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Pearls in Psoriasis Part 2: Dr Armstrong on Mental Health and COVID-19

April Armstrong, MD, and Lawrence Green, MD, discuss the impact of the COVID-19 pandemic on mental health among patients with psoriasis, as well as clinicians. 

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.


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

I’m joined by Dr April Armstrong today, and she’s going to talk about psoriasis, mental health, and COVID‑19. Dr Armstrong is associate dean of clinical research and professor of dermatology at the University of Southern California Keck School of Medicine.

April, thanks for joining us to talk about this timely topic.

Dr April Armstrong: Thanks for having me, Larry.

Dr Green: You’ve done a lot with psoriasis and mental health recently, including the manuscript you published in JAMA Dermatology. I want to focus a little bit on COVID‑19. We know that psoriasis is associated with a lot of mental health comorbidities. What do you think are the biggest concerns for these patients during the current COVID‑19 pandemic on top of all the psoriasis that they have?

Dr Armstrong: Based on my conversations with my patients, as well as conversations from my colleagues, there are a few things that our patients are really expressing with regards to what is impacting them from a mental health perspective.

Number one is just whether having psoriasis or psoriatic arthritis (PsA) themselves would predispose them to greater risk of contracting COVID. This is a very important concern for our patients. Based on the current literature, we actually don’t have data showing that having psoriasis and PsA, just having those diseases alone predispose one to having greater risk of contracting COVID.

Most of the risk actually comes from the comorbidities that patients with psoriasis may have. For example, cardiometabolic comorbidities, or those that are older. Those are the comorbidities that typically predispose someone to have potentially a worse course if they were to contract SARS‑Cov-2 virus.

The other concern that really is impacting our patients and is on the top of their mind and that is giving them a lot of anxiety is whether being on systemic medication, such as biologics, may put them at higher risk for contracting the virus or put them at a worse course. Fortunately, the National Psoriasis Foundation has recently formed a task force to help address those questions.

To date, while they are still evaluating the data constantly, and the data is evolving as we see, but to date, we don’t have strong evidence that being on the biologics in patients who otherwise don’t have a lot of comorbidities predispose them to having a worse course for COVID.

The recommendation as it currently stands by the National Psoriasis Foundation (NPF), as well as AAD, is that in most patients who are on a biologic is to continue them, but obviously to exercise good protective measures.

Then, I will say that the third point is that they’re feeling very isolated during this time both physically, as well as from a social perspective. I think it’s especially important that we are cognizant of that and reach out to our patients to ensure that not only their skin is well‑controlled, but if there’s anything that we can offer to help them from that perspective, I think will be very helpful for our psoriasis patients.

Dr Green: I’m sure you have and I have seen many more calls from patients who are very worried and have anxiety or maybe even depressive symptoms about psoriasis, or are taking a biologic or even patients with mild psoriasis during this COVID‑19 pandemic.

Do you do anything when you see them, when they come in for a visit, or when you call them back specifically to lessen their anxiety or depression?

Dr Armstrong: Yes. When I see my patients, and these days it’s still mostly virtually, I do ask them how they’re doing currently, and I try to get at the source if they’re feeling anxious or depressed, what the source of that may be, whether it’s related to their skin or whether it’s beyond that.

Certainly, when they have specific questions about whether their medication could potentially predispose them at higher risk, I would actually address that very specifically. I address that with the recommendation that NPF and AAD have put out so that they are reassured that it’s not just my opinion but are current thoughts by a group of people who are obviously very versed and passionate in this area.

Some of my patients still may not decrease their fear or anxiety at this time, but I know that I will have another opportunity, for example, to follow up with them, and even just sowing the seed of reassurance based on what we have is helpful for some patients.

Dr Green: Yeah. If you have to share things with family members at all, any tips you work with family members of our psoriasis patients or spouse, for example, of someone who’s a little worried to help the patient be a little less anxious?

Dr Armstrong: One thing that’s really positive about needing to do teledermatology during this time is that it’s much easier for patients’ family members to join a particular clinical encounter. Certainly, many of my patients have ability to having their spouse or family member to join.

One thing that I try to emphasize to the family member if they’re on the same encounter with the patient’s permission is to especially be supportive during this time, understand that what the patient is going through in terms of their fears and their apprehensions about their disease or their therapy is completely natural.

I also find that if the family member is there during the discussion and hear the discussion that I have with the patient, they are much more likely to be an advocate for me when I’m not with the patient, which is the majority of the time, to help remind the patient with regards to some of the recommendations.

Dr Green: That’s great. Before we close, let me ask you one last thing. We’re all under a lot of stress, not just our patients, the last several months, and seems it’ll be continuing for a while. Do you have suggestions for us as dermatologists on how to maintain mental health and happiness ourselves?

Dr Armstrong: Yeah. I often think about the analogy on the airplane where they give you instructions on if the oxygen bag is deployed, to make sure that you put on yourself first before you put on a child. I think that we need to be in a good mental health state in order to take care of other people.

Based on happiness research, which is something that I read aside from dermatology research, the two things that make people truly happy are, number one, connection, and number two, purpose. In the current world where physical connection may not be possible or as readily possible during this time, I think that being connected to others virtually, as we have, and then being part of that virtual community can be very helpful.

One example that I will give in my own department, we’re all on this text message group, and I felt like I became more connected with my fellow colleagues during this time, because we share our different thoughts about different issues, and how we can support each other better to do that. Having that connection is important.

Then number two, purpose. I don’t think I need to tell our group what a tremendous good that we do for the society, but I think recognizing that and understanding that we are in a time where we can serve our purpose through different ways, and that we are playing such an important role in the society is really important.

Dr Green: I think those are all great tips and showing that we’re all in this together and being together. That’s something I certainly will internalize and hope to use, staying in touch with everyone. In fact, doing this podcast and talking with you is very special and helpful as well.

Thank you for your time. Thanks for going over psoriasis, mental health, and COVID‑19, and great tips for us to help us as clinicians and dermatologists during this time. I hope, April, that I get to see you in real life soon, and we can reconnect and talk about this in real life over a glass of wine or whatever it is, as long as we’re together in real life.

Thanks, April, and look forward to seeing you also at the National Psoriasis Foundation Medical Advisory Board meeting, which you’re incoming chair. Thanks again for taking on that responsibility, and we’ll see you soon.

Dr Armstrong: Thank you, Larry.

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