In this cross sectional study from a large UK centre, screening for mental illness in individuals with psoriasis has demonstrated a high burden of depression and anxiety. 85% of the cohort report that their psoriasis had affected their quality of life. Quality of life scores correlate with depression scores, emphasing the importance of managing individual's mental health alongside their psoriasis to improve overall quality of life

Adesanya, Elizabeth

Bechman, Katie

Galloway, James

Hayes, Joseph F

Henderson, Alasdair

Langan, Sinéad M

Mansfield, Kathryn

Mathewman, Julian

Smith, Catherine H

English

UCL Discovery

© The Author(s) 2023. Published by Oxford University Press on behalf of British Association of Dermatologists. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. 1 Electronic screening for mental illness in patients with psoriasis  1  2 Katie Bechman,1 Joseph F. Hayes,2 Julian Mathewman,3 Alasdair Henderson,3 Elizabeth 3 Adesanya,3 Kathryn Mansfield,3 Catherine H. Smith,4 James Galloway1 and Sinéad M. Langan3 4  5 1 Centre for Rheumatic Diseases, King’s College London, London, UK 6 2 Division of Psychiatry, University College London, London, UK 7 3 Department of Non-communicable Disease Epidemiology, London School of Hygiene & 8 Tropical Medicine, London, UK 9 4 St Johns Institute of Dermatology, NIHR Biomedical Research Centre, Guys and St Thomas 10 NHS Foundation Trust, King’s College London, London, UK 11  12 Correspondence: Katie Bechman 13 Email: katie.bechman@kcl.ac.uk 14  15  16 Funding sources: KB is funded by the NIHR Clinical Lectureship Programme. This study is funded 17 by the National Institute for Health and Care Research (NIHR) Research for Patient Benefit 18 programme (Reference: PB-PG-0418-20025). The views expressed are those of the authors and 19 not necessarily those of the NIHR or the Department of Health and Social Care. SML is 20 supported by a Wellcome Trust Senior Research Fellowship in Clinical Science (205039/Z/16/Z). 21 The findings and conclusions in this report are those of the authors and do not necessarily 22 represent the views of the funders. SML is an investigator on the European Union Horizon 23 2020-funded BIOMAP Consortium (http://www.biomap-imi.eu/). Funders had no role in the 24 study design, collection, analysis, and interpretation of data, in the writing of the report, or in 25 the decision to submit the article for publication. This research was funded in whole or in part 26 by the Wellcome Trust (G205039/Z/16/Z). For the purpose of Open Access, the author has 27 applied a CC BY public copyright licence to any Author Accepted Manuscript version arising 28 from this submission. 29 ACCEPTED MANUSCRIPTDownloaded from https://academic.oup.com/bjd/advance-article/doi/10.1093/bjd/ljad141/7177592 by University College London user on 31 May 20232  Conflicts of interest: None to declare. 1 Data availability: All data are held on a restricted server at King’s College Hospital NHS 2 Foundation Trust behind the Trust firewall and in line with Trust policies like all other clinical 3 data. Data held on the IMPARTS server is only accessible to staff members working on the 4 IMPARTS programme, and data processors by approval. Information relevant to patient care is 5 added to the patient’s electronic care record. Data may be used to monitor the delivery of the 6 IMPARTS programme, for clinical audit and service evaluation. Aggregated IMPARTS data may 7 be used to publish research at various levels. 8 Ethics statement: IMPARTS programme ethical approval (IMPARTS Research Database REC 9 reference: 12/SC/0422). All applications to use data collected routinely under the IMPARTS 10 programme are scrutinized by a patient‐led oversight committee to ensure that the use of data 11 is appropriate and in line with ethics committee approval. 12  13  14 Dear Editor, Individuals with psoriasis have an increased risk of depression, anxiety, and severe 15 mental illness.1,2 National guidelines recommend assessing for mental health alongside 16 psoriasis disease severity and disease impact (NICE). Systematic screening for depression and 17 anxiety symptoms in tertiary centres has identified a significant burden of disease3 and has led 18 to increased use of mental health care and improvement in psoriasis and quality of life.1,4  19  20 This cross‐sectional study examined the use of screening for mental illness in a large centre 21 serving London and Southeast England. Individuals with a confirmed psoriasis diagnosis 22 attending Guy’s and St Thomas’ NHS Foundation Trust and King’s College Hospital, London 23 (January 2017 to January 2020) were invited to answer a series of questions about their health 24 at every outpatient visit. A touchscreen tablet-based programme, Integrating Mental and 25 Physical Healthcare: Research Training and Services (IMPARTS) was used to collect 26 patient‐completed screening questionnaires including the Patient Health Questionnaire (PHQ-27 9)5, Generalized Anxiety Disorder scale (GAD-7)6 and Dermatology Life Quality Index (DLQI)7. 28 IMPARTS is a multifaceted platform of clinical and research services that integrates mental 29 ACCEPTED MANUSCRIPTDownloaded from https://academic.oup.com/bjd/advance-article/doi/10.1093/bjd/ljad141/7177592 by University College London user on 31 May 20233  healthcare into routine care3 Completed questionnaire data automatically populates the 1 patient’s electronic health record with advice on mental health referral if questionnaire scores 2 suggest a possible mental health condition. We performed statistical analyses using Stata. We 3 assessed cross-sectional correlations between screening questionnaires using Spearman’s 4 correlation coefficient. We used linear regression, adjusting for age, sex and year of visit and 5 clustering for repeat questionnaires by individual patients to examine the relationship between 6 DLQI and mental health.  7  8 Engagement in screening for mental illness rose gradually over time with substantial month-to-9 month variation (Figure panel A). In total 285 individuals provided data. Of these, 217 provided 10 data at more than one visit (median number of visits 3, interquartile range [IQR] 2-4) over a 11 median time of 1.5 years (IQR 0.9-2). Median age was 42 years (IQR 31-53), with a slight male 12 predominance (n=147, 52%). On the first recorded visit, a third of the cohort screened positive 13 for psoriatic arthritis (Psoriasis Epidemiology Screening Tool).  14  15 At first visit, 84% (n=238) of the cohort reported that their psoriasis had affected their quality of 16 life (DLQI score >2). Quality of life impairment was reported as very large (DLQI score 11-20) by 17 32% (n=90) or extremely large (DLQI score 21-30) by 17% (n=47). The depression screen, 18 defined by a positive answer to either of the first PHQ9 questions, was present in 35% (n=100). 19 The anxiety screen, defined by a GAD7 score >5 was positive in 29% (n=82). Severe depressive 20 symptoms (PHQ-9 >=20) were reported by 22% (n=60) and severe anxiety symptoms (GAD-7 21 >=15) were reported by 23% (n=64).  22  23 When examining across all visits, quality of life impairment was frequently reported (78% of 24 visits had a DLQI score >2). Median DLQI score was 8 (IQR 2-16). Depression screen was positive 25 on 30% of visits and anxiety on 25% of visits. Median PHQ-9 score was 1 (0-5) and GAD-7 was 2 26 (0-10). Severe depression and anxiety symptoms were more frequently reported by women 27 than men [PHQ-9: women 24%, men 15%, GAD-7: 25% versus 14%], as was severe quality of life 28 impairment [47% versus 33%].  29 ACCEPTE MANUSCRIPTDownloaded from https://academic.oup.com/bjd/advance-article/doi/10.1093/bjd/ljad141/7177592 by University College London user on 31 May 20234   1 Across all visits, the DLQI score moderately correlated with the PHQ-9 score (Rho 0.52) (Figure 2 panel B) and weakly correlated with the GAD-7 scores (Rho 0.41) (Figure panel C). In linear 3 regression, depression and anxiety were associated with DLQI scores (PHQ-9: β=0.48, 95% CI: 4 0.38 to 0.56, p<0.001, GAD7: β= 0.29, 95% CI: 0.21 to 0.36, p<0.001). For each one unit increase 5 in PHQ9, DLQI score increased by half a point (R-squared 0.27), and for each one unit increase 6 in GAD7, DLQI increased one third of a point (R-squared 0.18). 7  8 Our study has demonstrated increasing engagement in the screening of psychological wellbeing 9 over time, and the burden of depression and anxiety in people with psoriasis. We 10 demonstrated a strong relationship between mental health and quality of life. Our findings 11 emphasise the importance of holistic care and managing individual’s mental health alongside 12 their psoriasis to improve overall quality of life.   13  14 References 15 1. Elizabeth I Adesanya, Julian Matthewman, Yochai Schonmann, Joseph F Hayes, Alasdair 16 Henderson, Rohini Mathur, Amy R Mulick, Catherine H Smith, Sinéad M Langan, Kathryn E 17 Mansfield, Factors associated with depression, anxiety and severe mental illness among 18 adults with atopic eczema or psoriasis: a systematic review and meta-analysis, Br J 19 Dermatol., 2022;, ljac132, 20 2. Egeberg A, Thyssen JP, Wu JJ, Skov L. Risk of first-time and recurrent depression in patients 21 with psoriasis: a population-based cohort study. Br J Dermatol. 2019 Jan;180(1):116-121 22 3. Lamb RC, Matcham F, Turner MA, et al. Screening for anxiety and depression in people with 23 psoriasis: a cross-sectional study in a tertiary referral setting. Br J Dermatol. 2017 24 Apr;176(4):1028-1034 25 4. Kromer C, Mohr J, Celis D, et al. Screening for depression in psoriasis patients during a 26 dermatological consultation: A first step towards treatment. J Dtsch Dermatol Ges. 2021 27 Oct;19(10):1451-1461 28 5. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity 29 measure. J Gen Intern Med. 2001;16(9):606-613. 30 6. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety 31 disorder: the GAD-7. Arch Intern Med. 2006 May 22;166(10):1092-7. 32 7. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)--a simple practical measure for 33 routine clinical use. Clin Exp Dermatol. 1994 May;19(3):210-6. 34  35   36 ACCEPTED MANUSCRIPTDownloaded from https://academic.oup.com/bjd/advance-article/doi/10.1093/bjd/ljad141/7177592 by University College London user on 31 May 20235  Figure legend 1 Figure 1 (a) Monthly IMPARTS engagement in absolute number of visits between 2017 and 2 2020; (b) Scatter plot of DLQI and PHQ9 score with regression prediction line; (c) Scatter plot of 3 DLQI and GAD7 scores with regression prediction line. 4  5  6  7   8 ACCEPTED MANUSCRIPTDownloaded from https://academic.oup.com/bjd/advance-article/doi/10.1093/bjd/ljad141/7177592 by University College London user on 31 May 20236   1 Figure 1 2 173x230 mm ( x  DPI) 3 ACCEPTED MANUSCRIPTDownloaded from https://academic.oup.com/bjd/advance-article/doi/10.1093/bjd/ljad141/7177592 by University College London user on 31 May 2023

Electronic screening for mental illness in patients with psoriasis

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Electronic screening for mental illness in patients with psoriasis

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