Download Progress in developing and implementing stepped-care psychological support for people with psoriasis

Practice DEVELOPMENT
Progress in developing and
implementing stepped-care
psychological support for
people with psoriasis
Mark A Turner, Lucy Moorhead, Anna Simpson, Karina Jackson
Abstract
Psoriasis is an inflammatory, chronic, skin condition that can bring about significant difficulties in physical,
psychological and social functioning. The need for people with this skin condition to be assessed
and treated with an approach to care accounting for the mind and body is becoming increasingly
recognised in research and current policy. This article shares how one specialist centre collaborated
with a South London-based project to develop and implement systematic screening and various care
pathways to support people with psoriasis, psychological distress and problems in coping. The work
described includes a ‘stepped-care’ service model of psychological support drawing from existing and
newly developed resources. The article also includes reflections for nursing and recommendations for
dermatology services.
Key words
Psoriasis
Psychological distress
Screening
Stepped-care service model
Care pathways
Introduction
Psoriasis is an inflammatory, chronic skin
condition involving erythematous, scaly
plaques that can affect any skin surface;
most commonly the knees, elbows, scalp
and buttocks in a symmetrical fashion. It
Dr Mark A Turner is a Highly Specialist Clinical
Psychologist, Lucy Moorhead is a Clinical
Nurse Specialist and Karina Jackson is a Nurse
Consultant at St John’s Institute of Dermatology,
Guy’s and St Thomas’ NHS Foundation Trust,
London. Anna Simpson is a Project Coordinator
at Integrating Mental and Physical Healthcare:
Research Training and Services, King’s College,
London
22
affects up to 3% of the population with
its most common age of onset being
before 40 years of age, and men and
women are affected equally (Menter
et al, 2008). Many people with this
condition also develop co-morbidities
such as psoriatic arthritis and metabolic
syndrome (Christophers, 2007).
However, psoriasis can cause a
significant impairment in quality of life
across physical, psychological and social
functioning (de Korte et al, 2004). Indeed,
the burden of psoriasis goes well beyond
the physical and there is an increasing
awareness that people with this skin
condition require their assessment and
treatment to be more ‘holistic’, accounting
for the mind and body.
Research, National Institute for
Health and Care Excellence (NICE)
guidance, recommendations from the
British Association of Dermatologists
(BAD) and parliamentary policy (ie, the
All Party Parliamentary Group on Skin,
2013) all highlight the need to address
psychosocial distress in people with
psoriasis.
Dermatological Nursing, 2015, Vol 14, No 2
The purpose of this article is to
illustrate how one dermatology centre
has responded to this progressive
agenda. We will outline the process
adopted for the systematic screening of
psychological difficulties in our psoriasis
service and the corresponding steppedcare pathways, considering the role
of the nurse in the team approach. A
follow-on article will share data on the
prevalence and type of psychological
distress revealed through the screening
process.
Psoriasis and psychological distress
It has been shown that more than 10%
of people with psoriasis have clinical
depression and twice as many have
depressive symptoms (Dowlatshahi et
al, 2014). It has also been known for
some time that one in four people with
psoriasis report having experienced
suicidal ideation at some point in their
life because of their skin condition (Rapp
et al, 1997) and around 40% experience
high levels of anxiety (Richards et al,
2001). Furthermore, research shows
that levels of anxiety, depression and
worry do not necessarily decrease
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Practice DEVELOPMENT
following successful medical treatment
for psoriasis (Fortune et al, 2004). Data
also exists demonstrating that the extent
to which people with psoriasis are
psychologically distressed is not related
to more objective ratings of the severity
of their skin condition (Kimball et al,
2004; Sampogna et al, 2004).
Research also suggests that
psychosocial difficulties or stressors
can induce the onset and exacerbation
of psoriasis, perhaps more so than in
people with other skin conditions (AlAbadie et al, 1994; Schmid-Ott et al,
2009) and impede the effectiveness
of its medical treatment (Fortune et
al, 2003). Furthermore, there is some
evidence that psychological intervention
as an adjunct to medical treatment can
reduce psoriasis severity and improve
psychological wellbeing or dermatologyrelated quality of life, relative to medical
treatment alone (Fordham et al, 2014;
Fortune et al, 2002; Kabat-Zinn et al,
1998). However, it has been shown
that only 39% of significantly distressed
psoriasis patients have psychological
difficulties raised by their dermatologist
in routine consultations (Richards et al,
2004).
Therefore we believed that the
adoption of a systematic approach to
appropriately identify the psychological
needs of people with psoriasis would
improve holistic assessment. We also
recognised that such identification would
require us to devise care pathways
offering psychological support, which are
described hereafter.
NICE guidance relevant to psoriasis
Clinical guidelines (NICE, 2012) on the
assessment and management of psoriasis
recommend that the impact of this skin
condition on physical, psychological and
social wellbeing should be routinely
assessed, including impact on mood and
levels of distress. The same guidelines
recommend that people with psoriasis
are provided with information and
support including strategies to deal
with the impact on their psychological
wellbeing. Assessing the impact of
psoriasis on the person is also one of
six quality standards agreed for national
adoption (NICE, 2013). More broadly,
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NICE guidance on the treatment of
common mental health problems (NICE,
2011) and on treating depression in
adults with a long-term physical health
problem (NICE, 2009) both promote
the use of a ‘stepped-care’ approach
in which the level of intervention and
healthcare professional expertise is
matched to clinical need.
NICE (2009) has suggested the
following steps: Step 1; The recognition,
assessment and initial management of
all patients through the use of screening
questions, a validated measure, and
advice and increased contact with
practitioners, if necessary. Step 2; For
people with recognised depression,
including persistent subthreshold
depressive or mild to moderate
depression, increased levels of advicegiving, monitoring and contact with
practitioners and the option of ‘lowintensity’ psychological interventions
(eg, group-based peer support or
individually guided self-help based on
Cognitive Behavioural Therapy; CBT)
should be offered. Step 3; For people
with recognised depression (as above)
with inadequate response to initial
interventions and moderate and severe
depression — discuss the option of
antidepressant medication or ‘highintensity’ psychological interventions
(eg, individual or group-based CBT)
for initial presentations of depression
and a combination of these treatment
modalities for severe depression. Step
4; For people with complex and severe
depression, contact with specialist
mental health services working closely
and collaboratively with the physical
health services should be used.
British Association of Dermatologists (BAD)
working party report
The importance of offering stepped
care, specifically within the dermatology
setting, has been put forward by the
BAD working party report on minimum
standards for psychodermatology
services (Bewley et al, 2012). This
stepped-care service model strongly
encourages the involvement of
dermatologists and dermatology nurses
for offering psychological support at
level 1 (Figure 1). The suggested level 2
support for people who are moderately
distressed involves patient contact
with psychotherapy/CBT subsequent
to contact with a psychodermatology
multidisciplinary team (MDT). The level
3 support, for people who are highly
distressed and those with primary
psychiatric needs, suggests referral to
a regional psychodermatology service.
One of the main recommendations
from this report is that psychological
support remains largely embedded
within the dermatology setting and
this is in keeping with what has been
suggested for stepped-care support by
other experts working in the field of
psychodermatology (Thompson, 2009,
2014a, b).
Methods adopted in psoriasis clinic
In our centre we grasped the
opportunity to team up with a South
London-based project called ‘IMPARTS’.
Standing for Integrating Mental and
Physical Healthcare: Research Training
and Services, IMPARTS is a project
that assists physical health settings
like dermatology or rheumatology
departments to screen for psychological
problems in their respective patient
populations. The IMPARTS project
provides advice on the selection and
development of screening tools for
each specialist department. IMPARTS
also helps the physical health team
to devise and implement the most
appropriate and integrated care
pathways for their patients while offering
IT support. The IMPARTS team package
is completed with staff training in topics
relevant to psychosocial distress and
the development of bespoke selfhelp material to promote improved
psychological coping in specialist areas.
Screening tools selected
There is a range of validated
psychological health-screening
questionnaires available to use in
practice. We selected the patient health
questionnaire depression scale (PHQ9) and the generalised anxiety disorder
scale (GAD-7). The PHQ-9 and GAD7 were used so that we could ‘talk
the same language’ as Primary Care
Psychology and General Practice services
who are both used to using these
questionnaires for regular monitoring
and outcome assessment. These tools
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be marked as not relevant by the
patient and in these cases such items
are scored as 0. Quality-of-life cut-off
scores on the DLQI are: 0-1 (no effect),
2-5 (small effect), 6-10 (moderate
effect), 11-20 (very large effect), and
21-30 (extremely large effect).
Dermatology patient
Initial assessment in dermatology clinic
Low level distress
Moderate level distress
High level distress and
primary psychiatric disease
eg delusional infestation/suicidal
Psychological support
Level 1 skills
Dermatologist/Dermatology nurse
Psycho-dermatology
Multi-disciplinary team
Risk assessment
Psychologist
Dermatologist
Psychiatrist
Regional psychodermatology service
Level 3 skills
Dermatologist
Psychologist
Psychiatrist
Psychotherapy/CBT
Level 2 skills
Figure 1. The stepped-care provision of psychodermatology services from the BAD working party
report (Bewley et al, 2012).
are also NICE recommended for
screening physical health patients. We
also continued to use the dermatology
life quality index (DLQI)
Patient Health Questionnaire depression scale
(PHQ-9)
The PHQ-9 is a reliable and valid
9-item self-report questionnaire that
measures symptoms of depression
experienced in the last two weeks
(Kroenke et al, 2001). It belongs to the
patient health questionnaire, which is
an instrument for diagnosing mental
health problems commonly found
in primary care (Spitzer et al, 1999).
Scores for each item of the PHQ-9
range from 0 (not at all) to 3 (nearly
every day) and so the measure’s
full range is 0-27 with the following
symptom severity cut-off scores: 5
(mild), 10 (moderate), 15 (moderatesevere) and 20 (severe).
24
Generalised Anxiety Disorder scale (GAD-7)
The GAD-7 is a reliable and valid 7-item
self-report questionnaire that measures
symptoms of anxiety experienced in
the last two weeks (Spitzer et al, 2006).
Scores range from 0 (not at all) to 3
(nearly every day) for each item of the
GAD-7 and so the measure’s full range
is 0-21 with the following symptom
severity cut-off scores: 5 (mild), 10
(moderate), 15 (severe).
Dermatology Life Quality Index (DLQI)
The DLQI measures quality of life
specifically related to living with a skin
condition. It is widely used for both
clinical and research purposes and has
adequate validity and reliability (Finlay,
Khan, 1994). It has 10 items, each of
which is scored using the range 0 (not
at all/no) to 3 (very much or ‘yes’ in the
case of item 7) and so the measure’s
full range is 0-30. Eight items can also
Dermatological Nursing, 2015, Vol 14, No 2
Electronic screening
The selected questionnaires were
offered on an electronic tablet device
(iPad) to all patients attending the
specialist tertiary psoriasis clinic at each
attendance. Patients were initially given
an information sheet about the content
and use of the questionnaires as a
means of gathering informed consent.
An opt-out rather than opt-in consent
process was adopted because the
work was routine clinical practice, as
opposed to research. Clinic nurses also
confirmed that the patients were able
to use the tablet device as well as read
and understand the questionnaires’
items. If the patient required assistance,
due to English not being their first
language, unfamiliarity with the device
and/or physical disabilities, the patient
was invited to a quieter area and
offered assistance to maintain privacy
and dignity.
Patients completed the PHQ-9,
GAD-7 and DLQI questionnaires
at every clinic visit prior to seeing
the clinician. The questionnaire
data collected was available almost
instantaneously on the patient’s
electronic patient record. The speed of
this system enabled clinicians to review
the results prior to their consultation
with patients and address any relevant
issues within it. In the rare instances
that a patient declined to complete
the iPad’s questionnaires we offered
a paper DLQI solely to be completed
during their consultation.
Interpreting the questionnaire data
The interpretation of screening
data was in keeping with a protocol
collaboratively made with the IMPARTS
team. This protocol included algorithms
that converted scores from the PHQ-9
and GAD-7 into referral advice based
around what was most likely to be
clinically meaningful, in keeping with
the stepped-care model described
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Table 1.
Referral advice corresponding to cut-off scores on the PHQ-9 and GAD-7 used in the IMPARTS
integrated care pathways. In our protocol, referral advice for depression was only shown for those
who screened positive for ‘Probable Major Depression’ on the PHQ-9. Suicidal ideation was defined
as a score of ‘2’ or ‘3’ on item 9 of the PHQ-9 and this was always followed with additional
questions and appropriate actions, such as urgent contact with liaison psychiatry, if necessary.
Name of tool
Cut-off scores used in protocol
Referral advice
Patient Health Questionnaire
depression scale
(PHQ-9)
Suicidal ideation AND severe
depression (PHQ-9 = 20-27)
Urgent referral to liaison psychiatry/
phone GP
Suicidal ideation OR severe depression Referral to liaison psychiatry/
(PHQ-9 = 20-27)
phone GP
Generalised Anxiety Disorder scale
(GAD-7)
Moderate depression
(PHQ-9 = 15-19)
Team clinical psychologist OR
alert GP and advise IAPT
Mild depression
(PHQ-9 = 9-14)
Alert GP in letter;
advise IAPT referral
Severe anxiety
(GAD-7 ≥15)
Team clinical psychologist
Mild to moderate anxiety
(GAD-7 = 10-14)
Alert GP in letter; advise IAPT
referral
Dermatology patient
Step 1:
Screening AND staff recognition of reduced quality of life/problems in
coping/emotional health difficulties
Step 2:
Peer support
and self-help
Referrals to IAPT
Step 3:
Team psychologist
Inside GSTT general hospital setting
Step 4:
Urgent and non-urgent
referrals to liaison
psychiatry
Outside GSTT general hospital setting
Figure 2. The flexible stepped-care service model of psychological support developed and being
implemented in Medical Dermatology and more specifically the psoriasis clinic at Guy’s and St
Thomas’ NHS Foundation Trust (GSTT).
below. See Table 1. It is important to
note that the referral advice generated
from the PHQ-9 and GAD-7 was never
the sole source of information upon
which referrals were made. Specific
referral advice was not generated from
the DLQI, although its results were
still displayed electronically and used in
parallel to assist overall interpretation.
A clinical psychologist was
recruited to support and work
26
alongside the dermatology clinical
team. The psychologist assisted the
nursing and medical team to interpret
the questionnaire data and identify
people with psoriasis presenting with
problems in coping and/or psychological
distress. The knowledge and skill of the
medical and nursing team to identify
and act upon identified psychological
distress was achieved with regular
multidisciplinary discussion and brief
consultations with the psychologist
Dermatological Nursing, 2015, Vol 14, No 2
in the psoriasis clinic. Management
plans were formed using several care
pathways, as part of our stepped-care
model. One of the key distinctions
informing these plans was the extent to
which psychological distress was related
to coping with psoriasis or unrelated
psychosocial difficulties.
Our flexible stepped-care service model of
psychological support
In order to support those people
identified with psychological difficulties
in our psoriasis clinic, we have
developed and are implementing
the stepped-care service model
of psychological support shown in
Figure 2. The model is in keeping with
stepped care as outlined in NICE
guidelines (NICE, 2009) and we refer
to it as ‘flexible’ further to its use of
care pathways both inside and outside
of the hospital setting to which our
tertiary psoriasis clinic belongs. The
decision to use such care pathways
was made further to the extent of
the unmet need in our department in
the context of having only one team
psychologist, the reality of having
many patients who live too far away
to return for regular psychological
therapy, and the nationwide
availability of support in primary care
psychology, namely ‘Increasing Access
to Psychological Therapies’ (IAPT)
services. The model nonetheless
includes psychological support in the
dermatology department (Bewley et
al, 2012) at steps 1–3, in keeping with
guidance from Thompson (2009).
Step 1: Recognition and handling
Our step 1 includes the routine
use of screening for reduced
dermatology-related quality of life
and emotional health difficulties each
time a person with psoriasis attends
the outpatient clinic. This screening
has also been supported by staff
training on topics such as ‘identifying
anxiety and depression in people
with psoriasis’ and ‘Introducing IAPT’
and the team psychologist’s presence
in every psoriasis clinic. Such work
has optimised the recognition and
handling of emotional health difficulties
and problems in coping specific to
people living with psoriasis; it has also
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supported the use of various care
pathways described below.
Step 2: Peer support and self-help
Peer-support groups and self-help
are recognised step 2 methods of
intervention delivery (NICE, 2009).
More specifically, peer support between
people sharing a physical health problem
is suggested in this NICE guidance and
so we are aiming to develop this form
of intervention within our medical
dermatology department.
Our self-help material is based on a
cognitive-behavioural approach (available
at: http://www.kcl.ac.uk/ioppn/depts/pm/
research/imparts/Self-help-materials.
aspx ). We have tailored the material to
the experiences of people with psoriasis
and received input from patients and the
medical and nursing team to inform the
resource. This material, as well as that
based on more generic difficulties such
as sleep problems, was given to patients
as appropriate after consultation with
nursing staff or the team psychologist
during psoriasis clinic appointments.
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Self-help as a method of intervention
is important because many patients who
do not receive face-to-face psychological
therapy might still have at least some
symptoms of psychological distress
(Dowlatshahi et al, 2014) that should
not be left untreated. The widespread
provision of self-help interventions
requires multidisciplinary involvement
and so both medical and nursing staff
should be aware of what material is
available and where to direct patients
to access it (Thompson, 2014a). This has
been a key role for our nursing team.
Primary care psychology: increasing access to
psychological therapies (IAPT)
Increasing access to psychological
therapies, or ‘IAPT’ services, offers
psychological therapy options on a
national level. These services can be
referred to by GPs and other health
professionals, or indeed self-referrals
can often be made. IAPT services have
also been developed in a stepped-care
model and they offer support mainly
at steps 2 and 3. The IAPT service
makes decisions on who enters each
of these steps usually through a
telephone triage system. People can
be ‘stepped-up’ or ‘down’ according
to need. As part of our steppedcare model we routinely advise GPs
to refer patients to their local IAPT
services. We also give out self-referral
telephone numbers that can be found
through visiting NHS choices (see:
http://www.nhs.uk/Service-Search/
Counselling-NHS-(IAPT) services/
LocationSearch/396). Our rationale
for utilising these services in parallel
to developing psychological resources
in dermatology as part of our model
has been mentioned. A further point,
however, is that, as of yet, self-help/
computerised methods of intervention
cannot be used in substitute for
face-to-face delivery (Bundy et al,
2013). We aim to refer people with
psychological distress unrelated to
their psoriasis to IAPT services.
Step 3: Highly specialist clinical psychology
In every psoriasis clinic the team
psychologist carries out consultations in
the form of brief assessments and some
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intervention work. The psychologist’s
presence in the psoriasis clinic also
allows this member of the clinical team
to function as a pivot for the care
pathway leading on from step 1. Being
embedded in the psoriasis clinic also
serves the important purpose of destigmatising contact with psychological
services and gives access to patients
who would not otherwise come
into contact with a psychologist; it
also promotes and normalises the
mind-body link to this population.
This approach may be particularly
important in people with psoriasis
(and others with skin conditions) due
to the high risk of discrimination and
stigma they experience.
The team psychologist also
receives internal referrals from
nursing and medical staff in medical
dermatology outside of the time spent
in the psoriasis clinic. The psychologist
carries out specialist assessment
and treatment of those referred
based on cognitive-behavioural
approaches. This work includes the
measurement of clinical outcome
and patient satisfaction (Bewley et
al, 2012). There is an aim to refer
people with a complex interaction
between their psoriasis, coping, and
emotional health into step 3, given
the team psychologist’s presence in
the multidisciplinary team and special
interests.
Step 4: Liaison psychiatry
In some patients there is a need for
psychiatric review and management.
Psychiatrists are medically trained
doctors specialising in mental
healthcare. They therefore have a key
role in diagnostic assessment and
prescribing as a form of treatment,
in addition to holding knowledge of
community-based mental health services.
Psychiatry plays an important role in
the management of potentially suicidal
patients. Liaison psychiatry in our
hospital setting uses a system including
both urgent and non-urgent referrals.
For referrals where this system does
not match clinical need, psychiatry
embedded in accident and emergency
and/or community services (often called
assessment and brief treatment teams) is
28
utilised. In parallel we also keep general
practice up to date.
General reflections
The implementation of systematic
screening for anxiety and depression
(in addition to dermatology-related
quality of life) through electronic
questionnaire surveys has been widely
accepted by people attending our
psoriasis service, with a decline rate
of <5%. The use of technology over
paper questionnaires has also been
implemented without difficulty. The
process has been simplified as this
is a clinic specifically for people with
psoriasis and the approach in a mixeddiagnosis general dermatology clinic
would need further consideration.
In our experience, the
introduction of systematic screening
for psychological distress has led
to a number of positive outcomes;
the holistic needs of people
with psoriasis are being assessed
and addressed appropriately as
recommended in NICE guidelines;
there is improved staff learning and
understanding with a corresponding
reported increase in confidence and
competence in addressing patients’
psychological needs; there is also a
better understanding of the range
of psychological interventions and
support services available. These
changes have led to more appropriate
onward referrals through the adoption
of the stepped-care model.
An additional advantage of
implementing the screening
programme was the formal
identification of unmet patient
need and that, in turn, supported
the business case for a clinical
psychologist post dedicated to medical
dermatology.
Reflections for nursing
Nursing involvement with the
stepped-care model outlined above is
crucial. Indeed, nurses are well placed
to address the psychological needs
of patients with psoriasis, although
this is sometimes not fully addressed
in consultations. It was believed
by our team that exploration of
Dermatological Nursing, 2015, Vol 14, No 2
adjustment difficulties such as anxiety
and depression (including suicidal
thoughts), as well as patients’ methods
of coping, would require training
and the addition of a healthcare
professional specialising in this work.
The addition of a psychologist to our
team has allowed ongoing training and
support with the interpretation of
screening tools and the development
of care pathways from our psoriasis
clinic. These changes have enabled the
nursing team to truly offer holistic care
for their patients.
Recommendations for dermatology
services
Based on the work completed by our
service so far we would encourage
other dermatology departments
to scope their unmet need for
psychological support with service
evaluation work, adapt a steppedcare model, and build psychological
resources according to their setting.
The development of nursing skills
at steps 1 and 2 (NICE, 2009) is
particularly important given the finite
resource of team psychology. That
is, such nursing skills allow a team
psychologist more time to create selfhelp resources and focus on working
at step 3 in individual or group therapy.
It is noteworthy, however, that
what is deemed sufficient as a method
of self-help guidance is still not yet
known. It is nonetheless encouraging
that there has been some recent
academic interest in this for people
with physical health problems
(Matcham et al, 2014) and, more
specifically, in distress associated with
skin conditions (Thompson, 2014a).
Our self-help so far has been delivered
as stand-alone or ‘pure self-help’
with little or no ongoing support
from a clinician. Self-help supported
by guidance from a clinician, where
possible, may be a more effective
option (Thompson, 2014a), although
this might not necessarily be the
case (Matcham et al, 2014). Further
research is needed to look at the
relative effectiveness of different
methods of self-help for people with
dermatological conditions such as
psoriasis.
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We would emphasise that the use
of IAPT is not a substitute for building
internal resources, as this would not
fully answer the service problem of
requiring psychological support within
dermatology. Moreover, without such
integration, the mind-body link and
message of de-stigmatisation is not
fully made for patients with psoriasis.
Nonetheless, we also acknowledge
the usefulness of primary care
psychology services, particularly where
patients are less complex. Monitoring
the extent to which dermatology
patients access IAPT, either by GP or
self-referral, is also important. More
guidance on offering psychological
support to dermatology patients is
available from Thompson (2014b).
Summary
The present article has highlighted
research and policy pointing to a need
for changes in the landscape of health
care for people with psoriasis,
bringing together its physical and
psychosocial aspects. We propose
that our flexible stepped-care
service model is allowing us to start
addressing this need by drawing
from existing resources in primary
care and psychiatry while, in parallel,
developing additional support within
the dermatology department. DN
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