LAUSR

Approximately 30% of all dermatology patients experience a psychiatric disorder or some form of notable psychosocial morbidity.1 When the psychiatric concern is related to skin disease, dermatologists are in a unique position to identify the problem and help patients seek treatment. Psychodermatology is a growing field that includes both primary and secondary psychiatric conditions. Primary psychiatric conditions associated with skin findings include disorders where self-induced skin lesions result from an emotional disturbance (eg, acne excoriée).2 In contrast, secondary psychiatric disorders involve emotional disturbances that manifest in response to the psychologic stress caused by the skin condition (eg, major depression induced by severe psoriasis).2 This article will focus on these secondary conditions. We do not know how often dermatologists screen for secondary psychiatric concerns in at-risk patients. Dermatologists do have difficulty perceiving psychological distress in patients3 and some may feel uncertain about the diagnosis of psychiatric conditions secondary to skin disease.4 Patients may not volunteer mental health information, and dermatologists do not always pursue further action even when mental health problems are identified in a consultation.3 It is unclear if this is owing to lack of clear guidelines, lack of time in busy clinics, or the perception that secondary psychiatric disorders fall outside of the dermatology domain. Taken together, these studies3,4 suggest that both dermatologists and patients may benefit from a simple and quick screening tool to identify patients experiencing secondary emotional distress. This article aims to provide a simple approach for dermatologists to screen and refer patients with psychiatric conditions secondary to skin disease. It is not suggested that dermatologists manage psychiatric conditions. However, it is important to screen dermatology patients for mental health concerns because conditions with high disease burden such as psoriasis (particularly with comorbidities), severe atopic dermatitis, and hidradenitis suppurativa, which are associated with increased suicidal ideation.4 Patients with chronic facial lesions or facial scarring secondary to a dermatologic conditions are also at higher risk of depression and suicide, particularly when the lesions develop early in life.5 This is especially true of severe acne vulgaris in adolescence.5 Regardless of the specific diagnosis, depression is often related to the patient’s experience of the skin disease rather than the objective disease severity. Dermatologic conditions and any secondary scars can impact socialization, leading to isolation and depression. Less obvious symptoms, such as pruritus, can cause insomnia. Insomnia is an independent suicide risk factor and pruritic severity is directly correlated with degree of depression.6 A broader list of risk factors for depression and suicidal ideation is provided in the Figure. When these dermatologic-specific risk factors are paired with additional high-risk features, depression and suicidal ideation screening become increasingly necessary. A patient’s degree of suffering is subjective; therefore, objective documentation of skin disease severity and negative psychiatric history is insufficient. Moreover, dermatologic conditions can trigger new psychiatric illness, so a negative history does not preclude a patient from risk of depression and suicide. Although quality-of-life assessments are useful, depression and suicide screens are a separate entity. Based on standard psychiatric screening in a clinical setting when the risk of depression and/or suicide is suspected, we suggest that dermatologists ask the following 2 questions (Patient Health Questionnaire-2 [PHQ-2])7: Over the past 2 weeks, how often have you been bothered by either of the following problems? • Little interest or pleasure in doing things. • Feeling down, depressed, or hopeless. The patient’s answers should be documented in their medical record. Each question should be scored 0 if not at all; 1, several days; 2, more than half the days; 3, nearly every day. The total score ranges from 0 to 6, with 3 or greater considered positive and requiring follow-up.7 If the PHQ-2 is positive, dermatologists should ask the following 2 questions while the patient is still in their office to gain an idea of urgency for follow-up: • Do you ever think about ending your own life? • (If the answer to 1 is “yes”) Do you currently have a plan to commit suicide? If the patient screens negative for the 2 follow-up questions or screens positive for suicidal ideation but does not have a plan, dermatologists should refer the patient to his or her primary care physician by an urgent referral letter or a call to directly address the concern for depression. Dermatologists can provide the patient with resources such as the US National Suicide Prevention Lifeline (1-800-273-8255) or the Canadian Association for Suicide Prevention website that lists provincespecific crisis lines (https://suicideprevention.ca/needhelp/). If the patient screens positive for question 1 and 2, an additional urgent referral should be made to psychiatric emergency department for further assessment (Figure). The discussion with the patient and the referral recommendation should be documented. The PHQ-2 and brief follow-up screen may help catch the unrecognized patients who fall between the dermatology and psychiatry domains. The simplicity and brevity of the PHQ-2 makes it an appropriate option for VIEWPOINT