Psychological problems complicate dermatologic conditions

November 1, 2005

Researchers noted that theirs was the first study to investigate the connection between type A behavior and dermatology. They found this psychological construct, characterized by symptoms including over-involvement in work and a pervasive sense of urgency, present in 12 percent of patients.

Researchers analyzed 545 patients admitted as inpatients at the Istituto Dermopatico dell' Immacolata (IDI-IRCCS), a large dermatological hospital here. It often hospitalizes patients with mild or moderate conditions who can't access care in outlying regions.

Using assessment tools including Skindex-29 and interviews conducted by a mental health professional, researchers found that 38 percent of patients received a Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV diagnosis. The most common diagnoses were mood (20 percent) and anxiety (16 percent) disorders (Picardi A, et al. Psychother Psychosom. 2005;74:315-322).

Additionally, researchers noted that theirs was the first study to investigate the connection between type A behavior and dermatology. They found this psychological construct, characterized by symptoms including over-involvement in work and a pervasive sense of urgency, present in 12 percent of patients.

"The high prevalence of psychiatric disorders among dermatological patients has several implications, because psychiatric morbidity in dermatological patients has been found to be associated with emotional suffering, impaired quality of life, reduced compliance with dermatological treatment (Renzi C, et al. Arch Dermatol. 2002 Mar;138(3):337-342), worse outcome (Fortune DG, et al. Arch Dermatol. 2003 Jun;139(6):752-756) and risk of self-harm (Gupta MA, Gupta AK. Br J Dermatol. 1998 Nov;139(5):846-850)," says Angelo Picardi, M.D., a psychiatric researcher at the clinical epidemiology unit of the IDI-IRCCS and at the Italian National Institute of Health, and lead researcher on the study.

Along with recommending use of diagnostic assessments such as DSM-IV criteria, the authors advise using more sensitive assessment strategies that encompass subclinical symptomatology in performing clinical studies.

Identifying, helping psych patients

"Many dermatologic patients with psychiatric comorbidity go a long time before they see a mental health professional. Hence, dermatologists play a key role in early detection and treatment," Dr. Picardi says.

Unfortunately, psychiatric disorders often go undetected in everyday dermatological clinical practice, he says.

"Possible ways to deal with this problem include implementing educational programs aimed at increasing dermatologists' ability to recognize depressive and anxiety disorders, as well as using psychiatric screening questionnaires - specifically validated in patients with skin diseases - such as the Primary Care Screener for Affective Disorders (PC-SAD), the General Health Questionnaire (GHQ)-12 or the Patient Health Questionnaire (PHQ)," Dr. Picardi says.

"This study represents another piece of evidence documenting that there's a very substantial amount of psychiatric morbidity in dermatology patients," says Richard G. Fried, M.D., Ph.D., a board-certified dermatologist and clinical psychologist (and clinical director of Yardley Dermatology and Yardley Skin Enhancement and Wellness Center, Yardley, Pa.).

Over a decade ago, he notes, researchers observed a high incidence of obsessive-compulsive disorder among such patients (Hatch ML, et al. J Am Acad Dermatol. 1992 Apr;26(4):549-551). Other studies show high incidences of depression and anxiety, Dr. Fried tells Dermatology Times.

"If anything," he says, "the trend is continuing. And it obligates dermatologists to be vigilant for psychiatric comorbidity. Skin disease can produce significant psychological effects, and, conversely, the psychological effects can exacerbate the skin disease."

With data illustrating the foregoing points increasingly plentiful, Dr. Fried adds, "The dilemma for the practicing dermatologist is what to do with it. For the university setting where one has as part of one's dermatology department a mental health arm, one can easily refer patients for evaluation and treatment."

It becomes more problematic for the average practicing dermatologist, who frequently lacks such resources.