Transcript
Announcer:
You’re listening to On the Frontlines of Psoriasis on ReachMD. And now, here’s your host, Dr. Steve Jackson.
Dr. Jackson:
This is On the Frontlines of Psoriasis on ReachMD. I'm Dr. Steve Jackson, and today I'm joined by Dr. Margo Gkini to discuss the psychological aspects of inflammatory skin diseases. Dr. Gkini is a consultant dermatologist at Barts Health NHS Trust in London, as well as an Honorary Senior Lecturer at Queen Mary University.
Margo, welcome to the program.
Dr. Gkini:
Thank you very much for the nice introduction. It's a real pleasure to be here with you today.
Dr. Jackson:
Let's start with the big picture, Margo. How should we think about psoriasis beyond a skin condition, particularly in terms of its psychological and emotional burden?
Dr. Gkini:
That's a very good question. When people were asked about psoriasis years ago, everybody would reply that it is “just a skin disease.” Now, and I would say during the last decade at least, we know very well that psoriasis is a systemic condition. It's a condition that is immune-mediated, chronic, and associated with multiple comorbidities. Some of the most common ones that everybody underlines are psoriatic arthritis and the cardiovascular comorbidities. But actually, the psychiatric and the psychosocial comorbidities are some of the most common ones, and sometimes some of the more underrecognized ones.
So psoriasis is more than skin deep, and conditions like depression, anxiety, suicidal ideation can be there. The impact on quality of life of our patients is massive, so we're talking about a systemic condition with a significant burden on our patients.
Dr. Jackson:
What kind of impact can the visibility and the chronic nature of psoriasis have on a patient's identity, their relationships, and their day-to-day quality of life?
Dr. Gkini:
What happens with all skin conditions—with all conditions that have cutaneous involvement—is the fact that there is a lot of stigma surrounding them. Why? Because the skin lesions are visible. Everybody can see them, everybody can spot them. So the visibility and the chronic nature of the condition really triggers the social stigma, which can have a significant impact on patients' self-esteem. So this can cause psychological distress. It can have an impact on interpersonal relationships, on intimacy, and on overall daily quality of life of patients. Many of our patients, for instance, need to take time off work. When we're talking about adolescents, they may need to skip school. They may not do well at their exams because of their skin condition.
So what happens is that psoriasis, along with other inflammatory conditions, can have an impact on the identity of patients. There is body image distortion. There is also social appearance anxiety. Patients are fearful of judgment. They're fearful of people staring at them. One of the most common things that our patients mention in our clinics is, "I would like my skin to be clear, and I just want to go out swimming," or, "I want to go to the pool, and I don't want anyone to stare at me, look at me, or ask me if I have something contagious."
Dr. Jackson:
So the stigma is there, and of course, this has an impact on mental health.
For those just tuning in, you're listening to On the Frontlines of Psoriasis on ReachMD. I'm Dr. Steve Jackson, and I'm speaking with Dr. Margo Gkini about the psychological impacts of inflammatory skin diseases.
Let's put this in the context of the clinical practice setting. What are some of the most common mental health challenges you see in patients, and how do they typically present?
Dr. Gkini:
Some of the common psychiatric comorbidities are depression and anxiety. And I'm saying depression and anxiety because many of our colleagues believe that it is either depression or anxiety; the reality is that the majority of the patients suffer from both conditions, and actually one of them is a bit more profound.
What is also interesting is that unfortunately, some of our patients may become suicidal. So suicidal ideation is something that we should be screening our patients for. From a practical point of view, what we should be doing as healthcare professionals and treating physicians is screening our patients for these psychiatric comorbidities. There are many different ways to do that. There are standardized questionnaires like PHQ-9 and GAD-7 for depression and anxiety respectively, or the classic HADS score that we have been using a lot in clinical trials, which is useful for screening for these two conditions. For suicidal ideation, there are questionnaires that we have been using a lot in clinical trials, but not so much in clinical practice.
A very easy way to screen someone for suicidal ideation is just asking a simple open question: "Have you ever thought of harming yourself?" If somebody has really thought about it, they will say yes, and actually, they will feel a relief that somebody asked them about that. Then you can delve into more about if there are protective factors, if there is direct risk for the patient of committing suicide, and more.
And in terms of quality of life, because we're not only talking about mental health, and we're also talking about the general wellbeing of patients, some standardized questionnaires, like DLQI questionnaires, are something that we do in our clinic to understand how patients feel in the different aspects of their life because of their condition.
Just one thing that I would like to underline is that yes, we're using the screening tools and the screening questionnaires, but they are not diagnostic. So when patients come in and we have in front of us our scores, it's really important to be empathetic, listen to them, and start our consultations by understanding them a bit more as individuals and not just a patient with psoriasis.
Dr. Jackson:
Now, let's bring all of this together before we close, Dr. Gkini. What roles do effective disease control and a whole patient approach play in improving outcomes?
Dr. Gkini:
I think a holistic approach is really crucial for our patients. Why? Because yes, we need to treat the skin. Yes, we need to treat the physical comorbidities like psoriatic arthritis, for instance. And last but not least, we should be treating the psychiatric and psychosocial comorbidities.
So when a patient comes in, what we tend to do in a specialist psoriasis clinic is treat the patients with an advanced treatment. This can be a biologic agent, a small molecule, or even conventional systemics like methotrexate or cyclosporine as first step. That's something that we tend to do in Europe. On the other hand, simultaneously, what we tend to do is to treat our patients by using some SSRIs in order to improve their mood. Sometimes, talk therapy may be an additional tool that really helps to support these patients.
So at the end of the day, what happens is this holistic approach leads to better outcomes. Why? Because we are able to manage the patient holistically, and this is associated with better outcomes in terms of patient-reported outcomes, clinician-reported outcomes, and overall satisfaction.
When you ask your patients, "How do you feel?" and “How happy are you after you have been treated by your physician?”, you're seeing that the scores are much higher compared to someone who just saw a doctor or a specialist nurse who offered them a treatment just for their skin. So they feel valued, they feel trusted, and they feel that somebody really takes their issues into consideration. And together, we are moving forward with a shared decision-making plan, and we are offering a holistic approach.
Dr. Jackson:
As those insights bring us to the end of our program, I want to thank my guest, Dr. Margo Gkini, for joining me to discuss the psychological aspects of inflammatory skin diseases. Margo, it was a pleasure having you on the program.
Dr. Gkini:
Thank you very much for the kind invitation. It has been a real pleasure taking part in this podcast, and I think it's really crucial to raise awareness about the psychiatric and psychosocial comorbidities in inflammatory diseases like psoriasis.
Announcer:
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