Summary
Psoriasis is considered a skin disease, but it is increasingly recognised as a systemic disease associated with multiple comorbidities, including physical and psychological difficulties. There is clinical evidence that stress and psychological distress can play a role in the onset and exacerbation of psoriasis. Cardiovascular disease (CVD) risk has been found to be more common in psoriasis patients, attributable to both the disease itself and modifiable factors. Assessing the psychological impact of psoriasis on an individual, identifying cardiovascular risk, and providing relevant support for both, are NICE priorities. Assessing patients’ CVD risk and screening for psychological difficulties during their psoriasis clinical consultation provides the opportunity to intervene to improve patient care through primary prevention of CVD, and improvements in psychological wellbeing and quality of life through psychological support. The existing Leeds Teaching Hospital Trust-based psoriasis service carried out a pilot project to provide a holistic service, incorporating psychological screening and support with CVD risk assessment and support. A case has been made for a permanent holistic psoriasis service.
Method
Prior to the patient seeing the nurse specialist at the clinic, a healthcare support worker used the QRisk3 model to assess their CVD risk. The patient was given a letter explaining their risk score and offered supported conversations and British Heart Foundation (BHF) leaflets on lifestyle and behaviour change to reduce risk. The Qrisk3 score was included in a letter to the patient’s GP. The patient completed two questionnaires to screen for psychological distress. Two dedicated clinical nurse specialists explained the psychological support service and referred those who wished to use it. They also saw the patient for their usual psoriasis care, treatment and follow up. The pilot psoriasis psychology service was offered to all patients attending the clinic during the test period, including those whose screening did not pick up specific psychological difficulties related to their skin conditions. A dedicated psychologist triaged referrals. The remit of the psoriasis psychology input was that the psychological problems were related to the patient’s psoriasis. Where the issues were related to other causes, patients were signposted/referred on to other support. A patient satisfaction survey was developed and given to patients after their appointment.
Results
Out of 200 patients booked to attend the psoriasis clinic, 165 attended during the period of the pilot project. Prior to the pilot, there was no capacity to offer NICE recommended systematic screening for new patients, so the GP had to do this when the patient presented at the surgery. CVD risk is more common in psoriasis patients, but this group is often younger and engages less with primary care. NICE guidance recommends that treatment with a lipid-lowering therapy should be offered to people who have a 10% or greater risk of developing CVD within 10 years. The Qrisk3 algorithm calculated the patients’ CVD risk and found that: 20% had a 10-year risk of CVD above 10% (scores from 45% down to 10.7%); 60% of patients with a >10% risk took information and advice in person at the clinic; six of the patients whose Qrisk3 was >10% had not been identified as having CVD risk previously, so they were not on any lipid lowering therapy; even some in low-risk groups took information. All patients who completed a satisfaction questionnaire felt they had been given enough information about CVD and their individual risk score. The success of the CVD addition to the triage clinic led to managerial support for it to continue for the remainder of the financial year. Plans to fund it permanently were included in a business case. NICE Guidance GG153 states the importance of providing assessment and support for psychological distress within the psoriasis population. There is increasing evidence that this can improve both physical and mental health outcomes. However, prior to the pilot project, there had been no dedicated psoriasis psychology provision. Of the 165 patients who attended the triage clinic, 52% scored in the moderate-to-severe range on the PHQ-9 measuring symptoms of depression; 40% scored within the moderate-to-severe range on the GAD-7 measuring symptoms of anxiety and 17% were in the severe range; 28% accepted a referral to the psoriasis clinical psychology service (age range 22-73 years). Several patients in the no, low or little anxiety category still took information. A total of 42 referrals were made to the psoriasis clinical psychology service. Of these, 21 went on to attend psychology appointments. The mean DLQI score for these patients showed 52% within the ‘extremely large effect on someone’s life’ category. The mean PHQ-9 score for these patients showed 30% of the scores in the severe range. The mean GAD-7 score showed 45% in the severe range. The remaining 16 patients had a series of psychology sessions. Two of the key therapeutic approaches used in the sessions were cognitive behaviour therapy and compassion focused therapy. A recent systematic review and meta-analysis of the effects of a range of psychological interventions on patient‐reported outcomes in patients with psoriasis showed improvements in both psychological distress and psoriasis severity. This is consistent with findings from the pilot project. Over 75% of the patients in this group showed a reduction in scores on all measures, indicating reduced levels of psychological distress and improved quality of life in relation to their skin condition.
Sustainability and Spread
A business case supported by the outcomes from the pilot project has been submitted to the LTHT for the provision of a holistic psoriasis service to meet NICE guidelines for holistic care and NICE Primary Prevention guidance. Verbal indications are that both innovations will be approved, although COVID-19 issues are likely to add significant delays. The project has been submitted to the LTHT Shine awards, wherein the Trust celebrates initiatives that improve patient care. The BHF leaflets will be displayed in areas accessible to more hospital users. Further publications and presentations to the British Association of Dermatologists are planned.
