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Pearls in Psoriasis: Dr Armstrong on Mental Health, Physician Satisfaction, and Psoriasis

In this podcast, Lawrence Green, MD, interviews April Armstrong, MD, on her latest study, which showed associations between patient satisfaction with their physicians and mental health among patients with psoriasis.

Dr Armstrong is the associate dean of clinical research and professor of dermatology at the University of Southern California (USC) Keck School of Medicine in Los Angeles, California.

Dr Green is the psoriasis section editor for the Center for Excellence at The Dermatologist, and clinical professor of dermatology George Washington School of Medicine in Washington, DC.

Read the Study


Dr Larry Green: Good day, everyone. This is Dr Larry Green, the psoriasis section editor for the Center for Excellence at The Dermatologist, and clinical professor of dermatology George Washington School of Medicine in Washington, DC.

Today, we’re very lucky to have on our podcast to join us is Dr April Armstrong. She’s going to talk to us about mental health comorbidities in psoriasis. Dr Armstrong is the associate dean of clinical research and professor of dermatology at the University of Southern California (USC) Keck School of Medicine.

April, it’s so great to have you here. I’m really going to enjoy speaking with you because I always enjoy speaking with you. Actually, I should add that not only are you at USC, but you are also the incoming chair of the National Psoriasis Foundation Medical Board, taking over for Abby Van Voorhees, MD, and also an incoming member of the board of directors for the American Academy of dermatology.

A very busy person, April, but we’re going to focus on your research. You do so much, but this is going to be a great podcast. We’re really going to talk about the association between the mental health of patients with psoriasis and their satisfaction with physicians, which is a manuscript which you authored that’s available online now at JAMA Dermatology since May. But, I’m sure it’s also going to be available in real hard copy print at some point when we’re lucky enough and JAMA Derm’s lucky enough to publish it.

Dr April Armstrong: Thank you so much for having me, Larry. I’m really excited to be here today, speaking with you, and the rest of the dermatology community.

Dr Green: We’ll have a lot of fun. Let’s start. Let’s get into the article in JAMA Derm. Why’d you decide to do this study?

Dr Armstrong: Well, we recognized that the communication between patients and their dermatologist is really important, and the quality of that communication can oftentimes affect our patient’s health outcomes.

What is relatively unknown in dermatology literature is how our patient’s baseline mental health may be associated with their satisfaction with a physician. That is the question that we were looking at is: do happier patients tend to be more satisfied with their communication with their doctors than depressed patients?

I shall say that I had the good fortune of working with my research fellow, Dr Reed on this particular project. Dr Reed was funded by the National Psoriasis Foundation.

Dr Green: That’s great, so I’m glad the National Psoriasis Foundation funded the study. Because it’s really something that we really could use knowing. So, let me ask you what would you say is the overall objective of the study? What’s the meat of what you’re trying to get at?

Dr Armstrong: We are trying to look at the associations between mental health comorbidities in patients with psoriasis and their satisfaction with their physicians. That’s the key question that we’re try to address.

Dr Green: Something that we need to know, because I’m sure all of us know that people with psoriasis are at increased risk for depression, and it is very depressing, of course, to have psoriasis on yourself. So, they’re like a vicious circle or cycle, however you want to look about that.

Dr Armstrong: Mm hmm.

Dr Green: So, tell me how you went about doing this study. How did you put together...basically the materials and methods so that we know the background for it?

Dr Armstrong: So, we used nationally represented data from MEPS database that basically looked at over eight million US adults who have psoriasis over a 14-year period of time. This database is special in that it does representative sampling of patients with psoriasis. So, we’re confident that we have a pretty good representative sample of patients with psoriasis over the last 14 years.

These patients with psoriasis have all completed a validated questionnaire that measures three things. One is their psychological distress. Two is symptoms of depression. Then, finally, three is satisfaction with their providers.

Just as baseline and this is probably not news to people is that when we looked at their level of psychological distress, about 27% of patients had a moderate to severe symptoms of psychological distress. Over 20% of them had moderate to severe symptoms of depression.

For how do we measure satisfaction? Well, the survey used a patient/physician validated communication composite score measure, which involved different components of how well the patients thought their physicians listened to them, how well their physicians explained the diagnoses and the management. Also, they felt whether their physicians or clinicians showed respect for their perspective and whether they spent enough time with the patients.

Those are the different ways in which we use the validated measures to go at this particular question that we’re trying to answer.

Dr Green: April, how did you determine the differences between psychological distress and depression. Because it seems to me that there’s a lot of overlap between the two. How is that measured in your study?

Dr Armstrong: Thanks for that question, Larry. As you alluded to, there is some actually overlap between psychological distress and symptoms of depression. So, the study used essentially validated measure for those terms.

And to measure psychological distress, the study used something called Kessler 6 measurement, which asks patients how often they have felt during the last 30 days about some of the following qualities. For example, nervousness, hopelessness, restlessness or fidgety, or being fidgety, and a feeling that nothing could cheer them up, and that everything was an effort. Then, finally, the degree that they felt that they may be worthless.

So, this is the psychological distress measure that those domains are the ones that particular measure focused on.

Now, for symptoms of depression, obviously, there are some overlap. It’s really the PHQ-2 questionnaire is what was used, and that really focused on little interest or pleasure in doing things as number one, and then number two, feeling down, depressed, or hopeless.

So, as you can see, there’s some distinctions, but some overlap as one would think. Also, the trend actually for the result that we showed for the two measurements mirrored one another.

Dr Green: Dr Armstrong, this is really interesting how you set this up and used these validated measures. What were the findings in the study?

Dr Armstrong: What we found is that patients with moderate to severe psychological distress were about two to three times more likely to report low satisfaction with their doctors, as compared to those patients who had no or little psychological distress.

When we looked at depression symptoms, patients with moderate to severe depression symptoms were about four times more likely to report low satisfactions with their doctors, as compared to patients who had no or mild depression symptoms.

Dr Green: So, it appears that if someone has psychological distress before they see us, or even more noticeably depression, they’re much more likely to be unhappy with us no matter what we’re trying to do help them.

Dr Armstrong: Yeah, that’s absolutely right. 

Dr Green: So, what would you say? How would you make sense of this? What would you say to us practicing dermatologists from looking at this data?

Dr Armstrong: As you said, Larry, what we found was that regardless of sociodemographic factors or comorbidities and our analysis had adjusted for those that patients with psychological distress and depressive symptoms are more likely to report lower satisfaction.

There are several ways in which we can try to think about making sense of this data. One is that even if clinicians delivered, let’s say consistent, high, quality care, some patients may perceive such care to be inferior, owing at least in part to their baseline mental health status. So, for example, a patient who is depressed at baseline may be more likely than another patient without depression to rate the clinician poorly.

What we noted is that while this is new in the field of dermatology, when we look at other fields, this type of finding seems to be supported in other fields. For example, in fields of cardiovascular medicine, what they found is that patients with chronic coronary disease for example, depressive symptoms were strongly associated with a negative perception of their clinician.

I think another factor that may be adding another layer of interpretation to this is that in some patients, there could be possible cognitive impairments that’s associated with depression and other types of mental health comorbidities. That may affect their ability to engage with a clinician effectively or recall the information from the visit.

Dr Green: I think that’s really interesting, because no matter how many times we say something or think we have said to the patient what to do, how to take care of themselves, what we’re expecting, how they’ll get better, they may not be able to internalize that if they’re depressed or they have psychological distress. So, that’s something we have to take into effect, I guess, when we see the patient.

Dr Armstrong: Yes, absolutely.

Dr Green: So, let me ask you this. What about if we have patients doing well, and we want to put them on a biologic, and they’re using a biologic, yet they’re still depressed. So, is there any data that shows that they’re still going to be less happy with us?

Dr Armstrong: You know, that’s a great question. With most of our biologics, the average data, at least for that population is that typically when patients are placed on an effective therapy, whether be it biologic or other types of therapy, that their, overall, their mental health measures improve, so they get happier.

Now, if you have a patient to whom we have given what we think is an effective therapy for their skin, and their psoriasis is improving, but perhaps their mental health aspects are not improving as much, I think it’s really important to address other factors that may be contributing to their existing mental health comorbidity.

For those patients, it may be important to really look at other factors that may be affecting them in terms of their social environment, in terms of other underlying mental health comorbidities that may need to be addressed by other healthcare professionals.

Dr Green: I think that’s really interesting, April, and it’s an interesting finding. I look at it based on my clinical experience, and I’m sure people listening can relate to this as well. I’ve had many a time where patients doing well from a biologic or whatever therapy I’m giving them, but they don’t seem very happy and they don’t think they’re doing well enough.

Dr Armstrong: Mm hmm.

Dr Green: I think what you’re saying here is we should look at other comorbidities, specifically depression and psychological distress. That may play a role in why they’re as happy as we think they should be with their success.

Dr Armstrong: Absolutely. I think looking perhaps beyond what our anti-psoriasis medications can do and addressing those other factors, as you said, Larry, will be very important.

Dr Green: The people you looked at, was this people from all aspects of psoriasis, mild, moderate, and severe? So, even people, just mild psoriasis are included in this?

Dr Armstrong: That is correct. So, the study encompasses a spectrum of patients with different severities of psoriasis.

Dr Green: Right, because I can also think of patients in my clinical experience who have mild psoriasis, who I thought improved very well, who also were not happy with the success that they, that I thought they achieved. So, it all makes sense.

Dr Armstrong: Mm hmm.

Dr Green: I’m glad you include patients with mild because we would just think it would apply to severe. But, really, it applies across all types of psoriasis. I think that’s great.

Dr Armstrong: Mm hmm.

Dr Green: So, April, where do you think we can go from here?

Dr Armstrong: I think there are three things that we want to think about in terms of the next steps. Number one is probably very important to recognize this association between the patient’s baseline mental health status and their satisfaction. The reason for that is because a third of our patients with psoriasis, as previous literature have shown, have symptoms of depression and anxiety.

We really want to think about how to improve patient’s experience during their encounters with us. The reason is that when we have increased patient satisfaction with us, that’s typically then associated with greater adherence to their treatment, and as well as better health outcomes.

I would say number two is I really think about how we communicate with our patients who may have some of these mental health comorbidities. So, we probably want to be a little bit more adaptive in our communication style. Especially, research have shown that it’s important for clinicians to be more conscious of using a more positive and supportive communication style with some of these patients who may be suffering from these mental health comorbidities.

I will say, in addition to that, especially when we’re explaining a new therapy, talking about effectiveness and the potential adverse effects of the treatment, that we may want to be especially cognizant about providing the proper context for how we discuss this so that the patients can evaluate these treatments accurately.

Lastly, I want to bring up a point that I see is an important point with regards to change. In that as we know, we as clinicians, we’re evaluated oftentimes based on the results of the patient satisfaction surveys. So, I think that patient satisfaction surveys, where you have a small sample of patients that’s non-random sampling or low response rates, really need to be interpreted with skepticism and caution.

Also, comparing for example, one clinician’s performance based solely on patient satisfactions is potentially problematic because different clinicians may treat different patient populations with varying baseline mental health comorbidities.

Dr Green: That’s all very, very relevant for us as clinicians. Looking at having an adaptive style, and based on the patient’s mental health status, and trying to stay very positive is very different, I think, than we are often used to doing. We’re used to being scientific and sayings, “Hey, it looks like you went from a PASI 70 to a PASI 10. You’re doing great. Go home.”

Dr Armstrong: Mm hmm.

Dr Green: This something. It’s all very important to put it in perspective based on where the patient is. I think that’s what you’re saying from this. I think it’s something that’s not hard to do, but it’s a way to alter the way we interact with some of these patients in a more positive way.

Dr Armstrong: Absolutely. I think that being adaptive is important and being consciously even more supportive than we usually are will be very helpful for patients.

Dr Green: So, let me ask you also. When, myself included, probably you, and every other dermatologist, most dermatologists out there are not going to evaluate a patient the way you evaluated for psychological distress and depression. How can we get a just a…psychological distress and depression so that we have a sense of where our patient is on the scale or in terms of how they’re feeling?

Dr Armstrong: That’s a great question. One of the things I like about one of the instruments is the PHQ-2, which is a two-question instrument and basically asks over the last two weeks how the patient has been feeling. The specific question for that is, “How often have you been bothered by the following problem?”

It’s two questions. Number one, so having little interest or pleasure in doing things. But I think that’s a pretty quick question. Number two is how often have you been bothered by feeling down, depressed, or hopeless.

I think that they can say is it several days, more than half of the days, or nearly every day. That will give us a good sense of how well they may be doing in terms of screening for symptoms of depression. Again, how often have they had little interest or pleasure in doing things. Number two, really, how many days in the last two weeks have they been feeling down, depressed, or hopeless.

Dr Green: April, I think that’s great. Those are great ideas that would help all us in clinical practice. That’s really simple things that we clinical dermatologists can ask people when we see people with all different types of psoriasis  mild, moderate, and severe  just ask about their lack of interest or pleasure in something and are they feeling depressed or down, so that we can get a sense of where they’re coming from.

If I can make a suggestion, April. I think this is fantastic and very applicable for all us clinical dermatologists. I love the research you’re doing, and I think another area we can certainly go in.

We’ll wait for the next set of research and manuscript from you is people with acne, specifically severe acne in teenagers. A lot of them seem to be depressed and maybe we can manage their acne better once we learn more about them.

Thank you, Dr Armstrong. Great, very helpful. Congratulations on doing such a very important study that will help our patients with psoriasis.

Dr Armstrong: Thank you, Dr Green for having me.

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