LAUSR

In Reply We thank Dr Nwabudike for replying to our publication on the Patient Health Questionnaire-2 (PHQ-2) in Dermatology.1 We address his inquiries in chronological order: 1. The confusion between emotional distress and depression is one of the key reasons we introduced the PHQ-2 into dermatology. The questionnaire is a brief version of psychiatry’s Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) criteria for depression, translating the 2 most heavily weighted criteria into a questionnaire format.2 The complete DSM-5 depression criteria are not necessary for dermatologists to remember. Our goal is for dermatologists to recognize and screen for possible depression, detect suicidal ideation, and act on this by following our algorithm. We do not suggest that dermatologists formally diagnose or independently manage psychiatric conditions. Screening questionnaires are inadequate to make a diagnosis, and specialists should try to avoid making diagnoses outside the scope of their practice. 2. We proposed the PHQ-2 as a screening tool because it is the most succinct questionnaire for use in busy clinics. There are more extensive questionnaires, but we believe that these would be challenging to integrate in a time-pressed system. Therefore, we recommend keeping the approach simple by using the PHQ-2 to standardize screening. 3. Indeed, psychophysiologic disorders are considered a tertiary group within psychodermatologic conditions,3 and we thank Dr Nwabudike for raising this point. In dermatology, these disorders occur when skin conditions are influenced by a person’s state of the mind; classically, these patients will experience a flare of their skin condition when they are under emotional stress.3 Although we believe that these patients are not the primary target of our algorithm, a subset of these patients may experience depression and suicidal ideation, and they could benefit from identification and appropriate action, as outlined in our algorithm. 4. We hope that dermatologists do not feel uncomfortable asking patients questions about mental health. Dermatologists completed comprehensive medical training before entering the specialty. We believe that this foundational training appropriately equips any physician to screen for depression and suicidal ideation. Dermatologists have additional practice from screening patients undergoing treatment with systemic isotretinoin. Some dermatologists have already adopted the PHQ-2 for this specific purpose.4 We are simply formalizing, standardizing, and expanding the concept so that it is applied in more patient situations. The goal of the PHQ-2 is to avoid in-depth discussion and perform very targeted screening. We do not mean to imply that the dermatologist is responsible for management if the screen result is positive. Instead, the patient’s family physician should be involved, as outlined in the algorithm.1 There is no indication for the dermatologist to personally refer the patient to a psychiatrist, so direct refusal of care is unlikely. We hope that with therapeutic rapport and a delicate approach, dermatologists will be successful in applying the algorithm.1 We thank Dr Nwabudike again for his interest, and we would be happy to provide more detail as necessary.