Another concern is that patients with psoriasis or PsA may turn to alcohol and drugs more than individuals without the disease. Mental health intervention could help patients avoid substance abuse or dependence that could adversely affect treatment of their rheumatic disease.
A German survey on addiction among patients with psoriasis found that nearly 24% were high-risk drinkers and 41% smoked regularly, both significantly higher than the general population, while 11% were at risk of drug abuse.5 About 50% of psoriatic patients in another study had evidence of mental health problems such as depression, anxiety and alcohol dependence.6
Patients with anxiety disorder may catastrophize when their psoriatic condition flares, notes Dr. Husni. They might drastically view the experience as the world ending or their disease getting much worse or else exaggerate their responses to pain or treatment. “It could affect sleep and sleep can impact their disease,” notes Dr. Husni.
Screening for Mental Health Concerns
Questionnaire
The Patient Health Questionnaire-9 (PHQ-9), which assesses degree of depression, is one tool Dr. Husni uses in her practice at point-of-care visits to spot mental health concerns among patients with PsA and psoriasis. The questionnaire is filled out just before the office visit and opens the door for a conversation between the rheumatologist and patient.
Mental illness has emerged from the shadows in recent years to become a popular topic in society, but some still stigmatize it. Address the topic with sensitivity, advises Dr. Husni, especially on a first visit or at diagnosis, so the patient doesn’t feel overwhelmed.
For example, “I’d say, ‘I see that you scored really low on this mood questionnaire,” Dr. Husni says. “A lot of my patients tell me they struggle with low mood—has this been the case for you?’”
Telling Signs
Certain clinical clues also suggest a patient is depressed or anxious. If a patient constantly looks down during an office visit and offers one-word answers or barely speaks at all, that might be a sign of mental distress, even if the questionnaire score is unremarkable, says Dr. Husni.
“Regardless of the screening, if we see that there is really poor eye contact and erratic behaviors or the patient is being very despondent, we would probably ask additional questions about [their] mood,” says Dr. Husni.
Possible questions include:
- Is your low mood affecting your health?
- Do you have feelings of helplessness?
- Is there someone in your family or social circle that you can talk to about how you are feeling?
Patient Trust
A trusting relationship between doctor and patient opens communication lines for talking about mental health in relation to management of a patient’s rheumatic condition. A patient’s first visit might not be the best time to launch into a big discussion on anxiety or depression, notes Dr. Husni. However, it is important to validate the patient’s feelings when they acknowledge them and then find a right time to address it.
