Recognition of depressive and anxiety disorders in dermatological outpatients

Although mental disorders are frequent among dermatological patients, little is known about their recognition by dermatologists. This study aimed to assess dermatologists' ability to recognize depressive and anxiety disorders. All adult outpatients who visited four dermatologists on predetermined days (n=317) completed the 12-item General Health Questionnaire (GHQ-12) and the section on depressive and anxiety disorders of the Patient Health Questionnaire (PHQ). Dermatologists, masked to GHQ-12 and PHQ scores, rated patients' mental health status. The analysis was performed on 277 patients (87%) with complete data. With the PHQ as criterion standard, the dermatologists' assessment sensitivity was 33%, while specificity was 76%. In most cases of disagreement between the dermatologists and the PHQ, the GHQ-12 corroborated the PHQ classification. Anxiety disorders tended to be recognized better than depressive disorders. Among patients with a PHQ diagnosis, male gender tended to be associated with misclassification by dermatologists. Although limitations inherent in self-report psychiatric assessment should be considered, this study suggests that mental disorders often go unrecognized in dermatological patients. This issue might be addressed by implementing specific training programmes, using validated screening questionnaires for depression and anxiety, and developing rational consultation-liaison services.     

Psychiatric morbidity and skin disease: what dermatologists think they see

It has been suggested that skin disease and psychological disturbance may be linked. Recent work has focused on the fatal outcome associated with some dermatological disorders as a result of suicide. The impressions of dermatologists about how much psychological or psychiatric morbidity they see related to dermatological disease has not been addressed. The survey reported here revealed that most dermatologists recognized the relationship and demonstrated the perceived need for clinical psychology and psychiatric services for patients with dermatological disorders. It confirmed the impression that in a small number of cases, skin complaints are associated with attempted or completed suicide.     

Psychiatric morbidity in dermatological outpatients: an issue to be recognized

BACKGROUND: There is a high prevalence of psychiatric disorders in dermatological outpatients. OBJECTIVES: To estimate the magnitude of this problem and to identify a set of variables associated with the presence of psychiatric disorder. METHODS: All adults attending the outpatient clinics of a dermatological hospital on predetermined days were given a questionnaire comprising the Skindex-29 and the 12-item General Health Questionnaire (GHQ-12). RESULTS: In total, 4268 questionnaires were given at admission, and 3125 were returned. Of these, 546 were blank or incomplete, leaving 2579 respondents (response rate 60.4%). Using a stringent cut-off threshold (> or = 5) for psychiatric case identification with the GHQ-12, scored in the conventional way, the overall prevalence of psychiatric morbidity was 25.2% (95% confidence interval 23.6-27.0%). We found a higher prevalence of psychiatric disorders in women and in widows/widowers, controlling for age. Health-related quality of life was a much stronger predictor of psychiatric morbidity than physician-rated clinical severity. High prevalence rates (> 30%) were observed among patients with acne, pruritus, urticaria, alopecia and herpesvirus infections, and in subjects without objective signs of dermatological disease. CONCLUSIONS: Our study has depicted the situation that is actually faced by dermatologists in their everyday practice, where they are in a unique position to recognize psychiatric morbidity and to take appropriate measures. The GHQ-12, being easy for patients to compile and for physicians or nurses to score, may be a practical tool to increase identification of patients with substantial psychological distress or formal psychiatric disorder in order to provide more comprehensive and appropriate intervention.     

Physicians' and patients' perspectives on office-based dispensing: the central role of the physician-patient relationship

OBJECTIVE: To describe physicians' and patients' reasons for participating in office-based sales of dermatologic products. DESIGN: Survey data on the attitudes, opinions, and beliefs of dermatologists and their patients were analyzed. SETTING: A market research study of office-based selling. PARTICIPANTS: Thirty dermatologists involved in direct selling from the office, 20 dermatologists not involved in direct selling, 22 patients who purchase products from their dermatologists' offices, and 25 office managers. MAIN OUTCOME MEASURE: The hypotheses of this study were formulated after the market research study had been done. The main outcome measure was the physicians' and patients' reported reasons for patients purchasing skin care products from dermatologists rather than from retail stores. RESULTS: "Trust" was the most frequent reason cited by physicians for patient purchases, while "physician knowledge" was the most frequent reason cited by the purchasing patients. The most common location to display the products was the waiting room (20 [67%] of the physicians). The most common types of products sold included glycolic acid products (15 [50%]), moisturizers (13 [43%]), sunscreens (12 [40%]), and alpha-hydroxy acid products other than glycolic acid (9 [30%]). CONCLUSION: The interaction between physicians who sell products in their offices and their patients is highlighted by 2 key elements of the physician-patient relationship: trust and physician knowledge.     

Increased psychiatric morbidity in female outpatients with skin lesions on visible parts of the body

Psychiatric disorders are frequent among patients with skin diseases. We aimed at identifying factors associated with psychiatric morbidity in dermatological outpatients. All adults attending the outpatient clinics of a dermatological hospital on predetermined days were given the 12-item General Health Questionnaire. The dermatologists indicated the diagnosis and location of skin lesions and rated the disease severity. A total of 1389 patients were asked to take part in the study. Of the 722 who accepted, 389 had a complete set of data and were included in the analysis. To verify the representativeness of our sample, we used the administrative registries to compare participants with the total population of patients who attended the clinics during the same period, and we examined the distribution of missing data. There was a tendency towards a younger age in the sample studied, but no evidence of substantial selection bias. The prevalence of psychiatric morbidity was 20.6%. We found higher probability of psychiatric disorders in women, controlling for age, clinical severity and localization of lesions. In women, but not in men, the prevalence of psychiatric morbidity was higher in patients with lesions on the face or hands. Given that the identification and appropriate management of psychiatric morbidity are important, it seems that the dermatologist should be particularly alert to the possibility of a concurrent psychiatric disorder in women with lesions on the face or hands.     

Effects of patient satisfaction with care on health-related quality of life: a prospective study

OBJECTIVES: To evaluate the effect of patient satisfaction on health-related quality of life among dermatological outpatients, independently of patients' sociodemographic, and clinical characteristics. DESIGN: Prospective cohort study. Satisfaction was evaluated with a standardized questionnaire three days after the visit by telephone interview. Quality of life and psychiatric disorders were measured with validated instruments (Skindex-29 and Ghq-12) before the dermatological visit and after four weeks. At the four week interview also self-reported medication adherence was assessed. SETTING: Outpatient clinics of a large dermatological hospital in Rome, Italy. PATIENTS: A consecutive sample of 1389 outpatients was approached, and 52% agreed to participate. Inclusion criteria were met by 424 patients, and 396 (93%) of them completed the study. MAIN OUTCOME MEASURES: Improvement in health related quality of life. RESULTS: At multivariate analysis satisfied patients have approximately twice the odds for an improved quality of life on the emotions scale (OR = 1.99; 95%CI 1.1 to 3.7; P = 0.03) and on the functioning scale (OR = 2.2; 95%CI 1.1 to 4.7; P = 0.03). Patients with psychiatric disorders at baseline were less likely to have an improved quality of life on the functioning scale (OR = 0.3; 95%CI 0.2 to 0.8; P = 0.01). CONCLUSIONS: This is the first prospective study showing that patient satisfaction and psychiatric disorders have a significant effect on quality of life improvement among dermatological patients, independently of patient characteristics. Particular attention should be devoted to improving physicians' interpersonal skills, the major component of patient satisfaction.     

Treatment outcome and incidence of psychiatric disorders in dermatological out-patients

OBJECTIVE: Epidemiological studies have shown that the prevalence of psychiatric disorders among dermatological patients is high. We aimed at estimating the short-term incidence of psychiatric disorders among patients with skin disease. METHODS: The 12-item General Health Questionnaire (GHQ-12) was used to identify subjects free from psychiatric morbidity at their first dermatological visit. The GHQ-12 was administered again after 1 month during a computer-assisted telephone interview. RESULTS: A total of 277 subjects was included in the study. At the follow-up interview, 21 (7.6%) were found to have significant psychiatric morbidity. Only lack of improvement was associated with increased incidence of psychiatric morbidity (13.6%), with an odds ratio of 3.1 (95% confidence interval 1.2-7.8), after adjustment for gender, age, educational level and clinical severity. CONCLUSIONS: Physicians should devote special attention to the risk of psychiatric complications in patients who have not improved with treatment.     

Dermatology in private practice in France in 2000

OBJECTIVES: Data regarding French dermatological practice are scarce. Our objective was to identify the skin disorders most commonly diagnosed by office-based dermatologists. We also documented the severity of these skin disorders, as reflected by the repercussions on patient's everyday life, and the way physicians managed patients. DESIGN: We carried out a one-day survey of visits to a randomly selected sample of 900 French office-based dermatologists. The randomization was stratified according to the five French different dialing area codes. RESULTS: Office-based dermatologists saw 6411 patients with 7839 skin disorders during the survey. The daily number of visits to French dermatologists was estimated at 47 000 and the annual number between 12 and 14 millions. Office-based dermatologists mostly managed warts, acne, nevus, dermatitis, malignancies and pre-malignancies, fungal infection and psoriasis. Repercussions on patients'everyday life were assessed by physicians as important or very important in 28 p. 100 of cases. Half of the patients received topical treatment, 20.5 p. 100 a systemic drug and 40 p. 100 a minor surgical procedure (including cryotherapy). CONCLUSION: Although dermatologists frequently see benign skin disorders such as warts or nevus, more severe diseases represent an important part of their activity.     

Poor agreement between self-reported and dermatologists' diagnoses for five common dermatoses

BACKGROUND: Few epidemiological studies assessing the prevalence of chronic dermatosis are available in France and most of these studies have used biased samples drawn from specific subpopulations. As several recent studies have mentioned that self-reported diagnosis either underestimates or overestimates disease prevalence, the validity of such data is questionable. OBJECTIVES: To evaluate the agreement between self-reported and dermatologists' diagnoses for five chronic dermatoses: acne, eczema, fungal infection, psoriasis and seborrhoeic dermatitis, and to analyse the factors associated with patients' diagnosis knowledge. PATIENTS/METHODS: A cross-sectional study was conducted on the national day of skin tumour screening in April 2003. A self-administered questionnaire was completed by patients and a standard form was completed by dermatologists after clinical examination. A total of 4,622 adults were examined by a dermatologist in 134 screening centres across France. The agreement between self-reported and dermatologists' diagnoses was analysed using the kappa index. Characteristics of patients who were aware of their diagnosis were compared with those of patients who were not, by using multivariate logistic regression models. RESULTS: The demographic characteristics of the sample differed from those of the French population. The self-reported prevalence was significantly lower than the actual prevalence for all diseases except eczema. Underestimations ranging from 23% to 35% were observed in nearly all subgroups of our population. The agreement between self-reported and dermatologists' diagnoses was low to moderate. Many cases of chronic skin diseases were diagnosed in patients who did not report them. Diagnosis knowledge was poorer in those above 54 years of age and better for patients treated for the condition and those with impairment of social life. CONCLUSIONS: We observed a low agreement between self-reported and dermatologists' diagnoses for five chronic diseases. Self-reports underestimated the actual prevalence of four of five common diseases.     

Assessing diagnostic skill in dermatology: a comparison between general practitioners and dermatologists

This retrospective study was conducted to assess and compare the diagnostic accuracy between referring general practitioners and dermatologists with regard to skin conditions. Six hundred and fifty-six consecutive general practitioner referrals to a private dermatology practice and a dermatology outpatient department were assessed. The concordance rate in diagnoses from a wide spectrum of dermatological diseases was compared between general practitioners and dermatologists. Referring general practitioners agreed with dermatologists' clinical diagnosis and histology (when available) in 42% of cases. The concordance between general practitioners and dermatologists in the setting of non-biopsied cases is 45%. One hundred and fifty-one of 656 (23%) conditions had histological confirmation. Overall, general practitioners agreed with the histological diagnosis in 24% of cases and dermatologists agreed with the histological diagnosis in 77% of cases.     

Psychodermatology. Practical guidelines on pharmacotherapy.

BACKGROUND--The importance of emotional factors in dermatologic disorders has been recognized for several decades. However, there have been few reports on the management of psychodermatologic disorders. Meanwhile, there has been tremendous progress in the pharmacologic treatment of these conditions. This article describes major categories of psychodermatologic disorders and provides practical management guidelines, emphasizing the use of selected psychopharmacologic agents. OBSERVATIONS--Psychodermatologic conditions can be divided into three broad subgroups: psychophysiologic disorders in which the severity of primary cutaneous disease is influenced by the patients' emotions; primary psychiatric disorders in which the skin conditions are self-induced and reflect underlying psychopathologic conditions; and secondary psychiatric disorders in which the patients experience psychologic problems as a result of disfigurement associated with the skin conditions. There are many ways to manage these psychodermatologic conditions, including psychotherapy, behavioral therapy, and psychopharmacotherapy. To determine which pharmacologic agent is most appropriate, the nature of the underlying psychopathologic condition such as anxiety, depression, psychosis, and obsession/compulsion should be identified. Furthermore, there are nonpsychiatric disorders encountered by dermatologists in which psychopharmacologic agents may be more efficacious than conventional therapeutics. CONCLUSION--We conclude that psychopharmacologic agents provide a useful option to the management of psychodermatologic disorders.     

Obsessive‐compulsive disorder in dermatology

Patients with obsessive‐compulsive (OCD) and related disorders – primarily trichotillomania, body dysmorphic disorder, and skin picking disorder – frequently present to dermatologists due to associated hair and skin symptoms. It is therefore crucial that dermatologists be familiar with these disorders. In this review article, we provide an update on clinical features, neurobiology factors, and treatment options for OCD spectrum disorders. Employing PubMed and Cochrane Library databases, a selective literature search was conducted using keywords related to dermatological disorders within the OCD spectrum. OCD and its related disorders share several phenomenological as well as pathophysiological similarities, thus warranting their classification within a separate nosological category of psychiatric disorders. Another similarity of OCD spectrum disorders is the frequent concurrence of hair and skin diseases. Besides symptomatic dermatological treatment, the combination of psychotherapy (behavioral therapy) and psychopharmacotherapy (SSRIs) may be helpful. Although recent insights into OCD have contributed to a better understanding and treatment thereof, more research is required, especially with respect to OCD spectrum disorders, for which large controlled treatment studies are still lacking.     

Expert opinions in dermatology

Apart from their medical responsibilities relating to the diagnosis, treatment and prevention of skin diseases, dermatologists may also be asked to provide expert medical opinions. In their role as medical experts, dermatologists provide their services not only to public institutions and courts but also to private clients. Expert dermatological opinions involve the application of medical knowledge and experience to an individual case as regards a specific legal question. The dermatological expert thus becomes an “assistant” to administrative and public agencies or courts. In addition to providing the required expert knowledge, the expert must maintain strict neutrality and avoid any bias. Expert opinions play a significant role in the field of occupational dermatology. In this context, it is important to make a distinction between scientific expert opinions – commissioned to determine whether the criteria for an occupational skin disease are met or to assess the degree of reduction in earning capacity – and the much more common “small expert opinions” relating to disease prevention (“dermatologist's procedure”). Moreover, expert medical opinions have become increasingly important with respect to medical malpractice issues, both in court proceedings and for investigations conducted by State Medical Chambers. For quality assurance of expert dermatological opinions, the Working Group for Occupational and Environmental Dermatology in particular offers certification courses. The same group also provides guidelines for expert opinions in occupational dermatology (Bamberg Recommendations).     

Suicide in dermatological patients

Sixteen patients, seven men and nine women, who committed suicide after presenting with dermatological problems to two dermatologists, are described. Most of the patients had either a body image disorder (dysmorphophobia) or acne. In addition, patients with longstanding and debilitating skin disease may become depressed enough to commit suicide and there is always an attendant risk of suicide in patients with established, severe psychiatric problems, who are referred to dermatologists with concurrent skin disorders. It is important to recognize that patients with dermatological non-disease, and particularly women with facial complaints, may be extremely depressed and at risk of suicide. Facial scarring, particularly in men, may be an 'at risk' factor for suicide, emphasizing the positive early therapeutic role of isotretinoin. Funding problems in regard to provision of this drug could have potentially fatal consequences. The provision of a liaison clinic within a dermatology department may have an important role in managing patients thought to be at risk of suicide.     

The clinical significance of drug interactions between dermatological and psychoactive medications

Dermatological disease is commonly associated with psychological morbidity because of its visible nature. The burden of living with a chronic dermatological illness can contribute to the development of psychiatric illness and conversely, such conditions can result in the exacerbation of preexisting dermatological disease. It may also reduce a patient's compliance to treatment, result in loss to follow‐up and a decreased level of functioning and quality of life. In dermatological patients who suffer from psychiatric symptoms, medical management used in their treatment may have significant interactions with systemic medications used to treat their dermatological condition. A well‐known example of this is lithium's ability to exacerbate psoriasis. Such interactions can result in suboptimal treatment of their psychiatric and/or dermatological condition. The present paper aimed to review the literature for documented interactions and the level of clinical significance between dermatological and psychoactive medications. Such information is clinically relevant to the practicing dermatologist in order to minimize adverse effects and drug–drug interactions in dermatological patients.     

Atopic dermatitis: impact on quality of life and patients' attitudes toward its management

This work studies atopic dermatitis in the following terms: impact on patients' life; patients' satisfaction and attitudes toward topical pharmacological treatment and medical recommendations (regarding hygienic and preventive strategies) and patients' and dermatologists' impressions of severity at the moment of consultation. To this end, an epidemiological, multicentre, cross-sectional study was carried out. In total, 191 dermatologists collected data from 322 patients (163 children, 159 adults). Poor agreement between specialists' and patients' criteria was found and patients with higher severity of affectation showed higher impacts on sleep/rest, emotional and school/ professional fulfillment (p<0.001). Moreover, reported compliance with pharmacological treatment and medical recommendations was high but patients' satisfaction with these recommendations was lower than with respect to pharmacological treatment. These results highlight that although reported compliance was high, there were still non-compliance attitudes and concerns about treatments that should be answered. Finally, a significant impact on patients' life was confirmed.     

Delusional parasitosis in dermatological practice

BACKGROUND: The accurate incidence of delusional parasitosis (DP) is difficult to assess. The aim of this study was to analyse the frequency of DP treated by dermatologists, and to evaluate the treatment modalities they applied. MATERIAL AND METHODS: A specially designed questionnaire was distributed to 172 dermatologists. A total of 118 doctors responded (68.6% of all subjects). The dermatologists were asked to answer questions concerning demographic data of the respondents and the frequency of DP observed in their everyday practice. Finally, methods of treatment used by the dermatologists to help patients suffering from DP were evaluated. RESULTS: During the whole working period the majority of dermatologists participating in the survey (84.7%) had seen at least one patient with DP in their practice. About one-third of the respondents (33%) had seen one or two cases of DP during the past 5 years, and 28% of the doctors treated from three to five such patients. Twenty-three per cent of dermatologists declared that they had diagnosed no cases of DP during the past 5 years. The rest of our respondents had seen more than five cases of DP during the past 5 years, and 7% of the doctors reported seeing more than 10 patients with DP within this period. Almost 20% of the dermatologists were currently treating a patient with DP. Our data show that 40.7% of the respondents always ask and 28.8% often ask for a psychiatric opinion about their patients with DP. More experienced dermatologists statistically more frequently (P<0.05) obtained a psychiatric opinion about their patients. Only a small group of dermatologists (15.3%) use their own pharmacological treatment. If they do so, they first use sedatives and anxiety-relieving drugs. CONCLUSION: DP is a quite common disorder, however not all dermatologists are sufficiently prepared to treat it. There is an urgent need for training on the dermatological approach to psychodermatoses.     

Dermatologists and office-based care of dermatologic disease in the 21st century

Most professional care of skin diseases is provided in physicians' offices. In the past 25 y, medical practice has changed substantially. Since 1973, the National Ambulatory Medical Care Survey has provided data about patients seen in physicians' offices. Using 1974, 1980, and 1989 data, we have previously analyzed these data as they pertain to skin diseases. To provide a more current assessment of dermatologists' practices and the care of skin diseases in office-based practice, we analyzed National Ambulatory Medical Care Survey data for 1999 to 2000. We used statistical methods for survey data to estimate the number and characteristics of visits to dermatologists and others for skin diseases. We compared the characteristics of dermatologists' office-based practices with those of other physicians. In 1999 to 2000, there were approximately 35 million visits annually to office-based dermatologists, double the number for 1974. Eight diagnostic groups account for 65% of all visits to dermatologists. Acne is still the most frequent primary diagnosis at visits to dermatologists, but since 1974 the proportion of all visits that were for acne has decreased by half. Compared to other office-based physicians, dermatologists are significantly more likely to own their practices (OR, 2.78; 95% CI, 1.52-5.02) and much less likely to see capitated patients (OR, 0.30; 95% CI, 0.17-0.53). Over 26 y, utilization of dermatologists' services has grown in proportion to the increase in the number of office-based dermatologists. The organization of their practices has changed little. Dermatologists dominate the care of many of the same diagnoses as they did 20 y ago.     

Use of psychiatric drugs in Dermatology

Patients with psychocutaneous disorders often refuse psychiatric intervention in their first consultations, leaving initial management to the dermatologist. The use of psychotropic agents in dermatological practice, represented by antidepressants, antipsychotics, anxiolytics, and mood stabilizers, should be indicated so that patients receive the most suitable treatment rapidly. It is important for dermatologists to be familiar with the most commonly used drugs for the best management of psychiatric symptoms associated with dermatoses, as well as to manage dermatologic symptoms triggered by psychiatric disorders.     

The primary care provider and the care of skin disease: the patient's perspective

OBJECTIVE: To ascertain the patient's perspective on dermatologic care provided by primary care providers (PCPs) or dermatologists. DESIGN: Cross-sectional survey of patients drawn from primary care and dermatology clinics. SETTING: Academic Veterans Affairs medical center. PATIENTS: Convenience sample of patients in either a primary care or a dermatology clinic. INTERVENTION: Survey questionnaire. MAIN OUTCOME MEASURES: Patients' confidence in having their skin problems cared for by PCPs and dermatologists and satisfaction with previous care rendered. RESULTS: A total of 137 patients in the primary care clinic (group 1) and 100 patients in the dermatology clinic (group 2) participated. Patients (N = 237) expressed confidence in their PCP's ability to treat rashes (62%), diagnose skin cancer (65%), perform skin biopsies (60%), "freeze" lesions with liquid nitrogen (50%), and perform cutaneous surgery (46%). Group 2 patients were significantly less likely to have confidence in their PCP than group 1 patients for all measures other than the use of liquid nitrogen. High levels of confidence were expressed in a dermatologist's ability for all 5 measures: 92%, 91%, 92%, 83%, and 85%, respectively. Patients were more confident in dermatologists' abilities to perform these procedures compared with PCPs (P<.001 for all comparisons). Of patients previously treated for skin disorders, there was a high rate of satisfaction with the treatment rendered by PCPs (81% for group 1 and 75% for group 2) and by dermatologists (92% for group 1 and 90% for group 2). However, patient satisfaction was higher for dermatology vs primary care for the treatment of skin disease (P<.001). Direct access to dermatologists was preferred. CONCLUSIONS: Although patients have confidence in their PCP to care for their skin disease, they have greater confidence in the care provided by dermatologists. Among patients previously treated for skin disease, satisfaction was higher with care rendered by dermatologists vs PCPs. Most patients prefer direct access to dermatologists should they develop a skin problem.