Psychocutaneous Medicine Clinic: Wisconsin Experience

Abstract

Background:

Psychocutaneous medicine, also known as psychodermatology, is a subspecialty of dermatology and psychiatry that explores the interactions between the skin and the brain. For many patients, skin disease affects their quality of life and mental wellbeing. For others, psychiatric problems exhibit skin signs.

Objective:

Little data is available from psychocutaneous clinics worldwide. The aim of our review is to advance clinical knowledge about psychocutaneous medicine and help bridge the current gap between dermatology and psychiatry.

Methods:

A total of 808 cases referred to our psychocutaneous clinic from 2002 to 2018 were reviewed. A specific code in the Electronic Health Records allowed us to identify these patients. All the patients referred to the clinic were included in the study. The primary variable of interest was the patient’s final diagnosis, as made by the psychiatrist. Patient demographics (age, sex, marital status), number of visits, and treatments were collected.

Results:

Our data showed a high prevalence of skin picking disorder followed by depressive and anxiety disorders. Serious mental health disorders such as major depressive disorder and generalized anxiety disorder were common in our patients. 3/4 of our patients were women. Skin picking was more prevalent in women and alcohol dependence was more prevalent in men. No other significant gender differences in final diagnoses were found. 44.2% of patients needed one visit and were able to return to referring physicians for follow up.

Conclusion:

This is the largest collection of patients from a psychocutaneous clinic in the literature to date. Previous studies show that psychocutaneous clinics save healthcare dollars by decreasing the number of patient visits and improving the quality of life of dermatology patients. Introducing the results of this clinic could inform future integration of psychocutaneous clinics in dermatology practices and identify areas of need in training dermatology and psychiatry residents.

Introduction

The skin and the mind are close siblings in that they have common embryonic origins, and their interactions are of great interest. The skin is a sensory organ that conveys a lot about how we feel inside. It can display signs of wellness or disease, while also being our first line of defense against external threats. These multiple functions allow us to indirectly study the mind through the skin.

Literature shows a high prevalence of psychiatric problems in individuals with skin disorders and vice versa^1–3. A systematic review of psychocutaneous medicine clinics emphasized the importance of these clinics in improving patients’ quality of life and reducing overall health care costs. This review also pointed to the paucity of data from these clinics. Out of 932 psychodermatology articles reviewed, only 23 qualified as a psychocutaneous clinic report⁴.

Our review aims to promote awareness, understanding, and treatments for psychocutaneous disorders. We used de-identified data gathered from our one day a week clinic from May of 2002 to February of 2018. Despite being in the era of integrative medicine, psychocutaneous clinics have not been implemented in most dermatology programs. The unique and interdisciplinary nature of the psychocutaneous clinic provides better solutions to patients who are emotionally distressed due to their skin disease.

Patients and methods

Data was gathered from the 808 referrals to the clinic during its operation. The referrals were mostly from dermatologists and a smaller number from psychiatrists, internists, and other specialties such as surgery or infectious diseases. While most referrals were patients from the State of Wisconsin, occasionally referrals were from other states.

The University of Wisconsin institutional review boards (IRB) approved an exemption status for the study as a category 4 (secondary research for which consent is not required).

All patients referred to the Psychocutaneous clinic between May of 2002 to February of 2018 were included in the study.

The psychocutaneous clinic visits had a specific code in the Electronic Health Records (EHR), allowing us to identify the patients seen. Referral diagnosis was defined as the reason for referral extracted from EHR. The primary variable of interest was the final diagnosis of the patient as made by the psychiatrist at the last visit. The number of no-shows and visits as well as age, sex, marital status, and treatments offered were collected for descriptive statistics. In the final diagnoses we included major depressive disorder (MDD), mood disorder secondary to general medical condition or substance use with depressive features and unspecified depressive disorder under the category of “depressive disorders.” We included generalized anxiety disorder (GAD), anxiety disorder secondary to general medical condition or substance use, unspecified anxiety disorder, social anxiety disorder under “anxiety disorders” category. Additionally, we measured the percentage of serious mood disorders including major depressive disorder and generalized anxiety disorder in the patients with diagnoses of depressive or anxiety disorders.

Statistical Methods:

Separate two-sided tests of proportions were used to compare the no-show rate from the psychocutaneous clinic to dermatology and psychiatry clinics during the same period and from other consult liaison clinics. 10 clinics were used for comparison. P-values from these 10 tests were Holm adjusted. A two-sided test of two proportions or a Fisher’s exact test were used to compare gender differences in the rate of 24 different final diagnoses. P-values from these 24 tests were also Holm adjusted. The significance level was set at 5%. All analyses were conducted using R for statistical computing version 3.5.

Results

Demographics

The sample included 619 (76.6%) females and 189 (23.4%) males. 333 (41.2%) patients were married including 19 patients that were married but separated, 274 (33.9%) patients were single, 149 (18.4%) were divorced, 50 (6.2%) were widowed, and 2 patients had unknown marital status. The age range was 4–92 years old. The median age was 48. Regarding ethnicity, 788 (97.5%) were non-Hispanic white patients and 20 (2.5%) were nonwhite patients. This included 14 (1.7%) African American, 2 (0.25%) Hispanics, 2 (0.25%) Asians, 1 (0.12%) Middle Eastern patients, and 1 (0.12%) South Indian patient.

Referral diagnoses

Referral diagnosis was defined as the diagnosis made by the referring physicians. Table 1 shows the top 20 referrals’ diagnoses. The most frequent cause of referral was skin picking for 401 patients (49.6%). The next cause of referral was pruritus (itching) for 119 (14.7%) patients, followed by delusional disorder for 88 (10.9%) patients. Some patients had a couple of referral problems like acne and skin picking.

Table 1:

Most frequent referral diagnoses

Referral	Total	Percentage
Skin picking disorder	401	49.6%
Itch	119	14.7%
Delusional disorder	88	10.9%
Trichotillomania	42	5.2%
Psoriasis	27	3.3%
Hair loss	23	2.8%
Atopic dermatitis	23	2.8%
Acne	20	2.5%
Abnormal skin sensation	16	2.0%
Self-designated as Morgellon’s disease	14	1.7%
All burning sensations	13	1.6%
Pain problems (including Vulvodynia and Glossodynia)	12	1.5%
Hyperhidrosis	10	1.2%
Psychotic depression	8	1.0%
Rash	8	1.0%
Alopecia	7	0.9%
Nail biting	6	0.7%
Nonhealing ulcers	6	0.7%
Hidradenitis	4	0.5%
Pigmentary changes	4	0.5%

Final diagnoses

Table 2 shows the final mental health diagnoses. Skin picking disorder was the most frequent final diagnosis 417 (51.6%). Among skin pickers, 37 (8.9%) also had Trichotillomania, 10 (2.4%) had Onychotillomania, and one (0.2%) patient was picking at their skin, hair, and nails. Females showed a significantly higher rate of skin picking than males (p=0.032).

Table 2:

Final mental health diagnoses

Final diagnoses	Total	Percentage of total referrals
Skin picking disorder	417	51.6%
Depression	343	42.5%
Anxiety disorder	227	28.1%
Tobacco use disorder	174	21.5%
OCD	108	13.4%
Adjustment disorder	96	11.9%
Delusional disorder	85	10.5%
Sleep problems	83	10.3%
PTSD	63	7.8%
Trichotillomania	49	6.1%
ADHD	40	5%
Alcohol use disorder	31	3.9%
Bipolar disorder	29	3.6%
Eating disorder (active or history)	23	2.9%
No mental health issues	20	2.5%
Cannabis use disorder	19	2.4%
Opioid dependence/use	19	2.4%
Other specified OCD (onychotillomania, lip licking)	15	1.9%
BDD	15	1.9%
Borderline personality disorder	10	1.2%
Somatic symptom disorder	9	1.1%
Schizophrenia	6	0.8%
Dementia	6	0.8%
Schizoaffective disorder	4	0.5%

total referrals: 808; Abbreviations: OCD: Obsessive-compulsive disorder, ADHD: Attention-deficit/Hyperactivity disorder, PTSD: Post traumatic stress disorder.

The next most common final diagnoses were depressive disorders 343 (42.5%) and anxiety disorders 227 (28.1%). Psychiatric evaluation of referred patients showed multiple cooccurring final diagnoses and comorbidities; for example, 187 of 401 (47%) patients referred for skin picking had a depressive disorder. Among these patients, 143 (35.7% of total skin picker referrals) qualified for major depressive disorder (MDD). 107 (27%) of the patients referred for skin picking had an anxiety disorder, among this group 64 (16% of total skin picker referrals) qualified for generalized anxiety disorder (GAD). MDD and GAD are severe mental health issues, and it is important to notice their frequency in our patients with skin picking disorder.

83 (10.3%) patients had sleep problems including sleep apnea, insomnia, and restless leg syndrome. Six patients with delusional disorder had the diagnosis of secondary delusions due to using a combination of opioids and stimulant medications. Two patients with secondary delusions used a combination of opioids and benzodiazepines. Five patients had active cocaine use disorder among which only two qualified for secondary delusional disorder, and one was using both Adderall and cocaine.

Among substance use disorders, alcohol use disorder was the only diagnosis significantly higher in males than females (p=0.047).

Only 20 (2.5%) of the referred patients did not have a final mental illness diagnosis.

Comparing referral diagnoses with final diagnoses

Although 401 (49.6%) of the patients were referred for just skin picking, more than half of these patients (58.9%) had a final diagnosis that included other comorbid major mental health issues such as MDD, GAD, bipolar disorder, schizophrenia, and delusional disorder.

The second most common cause of referral was pruritus (itching) with 119 patients (14.7%). In this group, 49 (41%) patients had comorbid depressive disorder and 32 (27%) had comorbid anxiety disorder. One hundred twenty-four (15.3%) patients had physical causes of pruritus such as atopic dermatitis in their final diagnosis.

The third cause of referral was delusional disorders; with 88 (10.9%) patients. In the final tally, 75 of the 88 patients met the criteria for delusional disorder somatic type.

14 (1.7%) patients self-identified as having Morgellons disease, 11 women and three men. 12 of these patients were referred for delusional disorder and the other two were referred for psychotic depression. The final diagnoses included delusional disorder somatic type, severe depression with delusions, and mood disorder secondary to chronic pain with delusions.

Number of sessions needed and no-shows

357 (44.2%) patients only needed one consultation and were sent back to the referring provider with treatment recommendations. The rest were followed for longer periods depending on the diagnosis and response to treatment. The frequency of sessions was once a month on average, but more stable patients would return every 3–6 months.

The no-show rate was 8.5%. This was significantly higher than no-show rates for the psychiatry department 6.3% (p <0.001), and the dermatology department 5.6% (p <0.001), over the same period. However, we had comparable rates with other psychiatry consult liaison clinics.

Treatments offered and outcomes

For 357 (44.2%) patients with one-time consults the recommendations for further testing, medication management, and therapy were communicated to referring providers.

For patients that were followed in the clinic, we offered a combination of dermatology treatments (topical and systemic medications based on their primary dermatology diagnosis) and psychotropic medications (antidepressants, antianxiety, and neuroleptics based on the severity of symptoms) as well as therapy (Cognitive-Behavioral treatment, Behavioral modification, Mindfulness-based stress reduction, family therapy, interpersonal therapy, Relaxation training). The treatment was tailored to the patient’s individual needs.

Complete dermatology evaluation was also part of the clinic’s services and allowed for diagnoses such as contact dermatitis, dermatitis herpetiformis, epidermolysis bullosa acquisita in patients initially referred for pruritus.

Patients that were followed in the clinic received combined dermatology and psychiatry treatments.

Discussion

Our data shows a high prevalence of mental health issues and sleep problems in patients with skin picking, intractable itching, abnormal skin sensations, hair loss, and other chronic skin problems (i.e., psoriasis, dermatitis). While only 3 (0.37%) of the patients were referred for depression, 343 (42.5%) of patients had a depressive disorder [including 238 (29.5%) with MDD] as their final diagnosis. Similar results were seen for anxiety with no patients referred for anxiety but 227 (28.1%) had final diagnosis of anxiety disorder with 102 (12.7%) meeting the criteria for GAD. Furthermore, the number of patients diagnosed in the clinic with pruritus was higher than those referred for pruritus (124 vs. 119). Pruritus, especially in its chronic form, severely affects quality of life and has high morbidity for patients^5–8. Proper treatment of mental health issues should be an integral part of the treatment.

The prevalence of major mental health disorders in our patients points to an untapped area of dermatology. Previous studies have shown that about one-third of all dermatology patients have comorbid psychological issues^1,9, and the effects that psychological stress have on skin disease are well documented within the literature^10–12. With this considered, it is likely that only patients with severe problems were referred to our clinic but that many more dermatology patients with psychological problems exist.

The gender disparity in patients referred to our clinic agrees with past studies that have found more females than males referred to psychocutaneous clinics⁴.

Our clinic offered combined dermatology and psychiatry treatments. By allowing a patient to visit just one provider, it is reasonable to assume that this would save them time and lower overall healthcare costs.

Limitations to our results include that our clinic was a referral-only clinic, therefore patients were only referred to us when their dermatologists suspected mental health issues. Consequently, all but 20 patients had one or more mental health diagnoses. Because the clinic was only one day a week, this may have limited the number of referrals. Another limitation was that most of our patients were from the state of Wisconsin, hence the majority were non-Hispanic whites; future multicenter studies could be done to expand the results.

When we opened the clinic, we performed a need assessment survey. The survey, published in 2009, was the first of its kind. The results showed that 42% of the participant dermatologists felt that 1/3 of their patients would benefit from psychiatry interventions and that 43% did not ask about mental health issues in their patients. Once they recognized mental health issues, 83% did not feel comfortable prescribing psychotropic medications¹³. Proper screening and identification of patients in dermatology is an important part of building integrative services. We know that there is a positive impact of collaboration between dermatologists and psychiatrists/psychologists. This collaboration increases patients’ satisfaction with health care services and improves their quality of life. It also helps to save healthcare dollars^14,15. Despite this fact, psychocutaneous medicine clinics are not widely used.

The lack of uniform models for psychocutaneous clinics may be the root cause of why they are infrequently implemented. Currently three different models are used: In the first model a dual-trained provider in dermatology and either psychiatry or psychology follows the patients (i.e., our clinic). In the second model, two providers, one dermatologist and one psychiatrist or psychologist, see the patients at the same time (this causes problems with insurance reimbursements and may work better in single payer systems). In the third model, the dermatologist sees the patient first and then refers them to a psychiatrist or psychologist trained in psychocutaneous medicine. Many times, patients get upset and feel that the dermatologist is not taking their problem seriously, hence referring them to a psychiatrist. This leads to no-shows and noncompliance.

In the absence of uniform integrative clinics, we suggest a better model would be to educate and train the dermatologists to screen patients for mental health issues, start the treatment, and once they have a good rapport with their patients, refer the more complicated cases to psychiatry or psychology clinics.

European Society for Dermatology and Psychiatry (ESDaP) and The American Association for Psychocutaneous Medicine of North America (APMNA) are active in finding the best setting and a common language to help dermatologists and psychiatrists work together^16,17. ESDaP offers educational courses for dermatology residents, as well as their scientific meetings every two years. Their website https://psychodermatology.net has the information on their training courses and meetings. Similarly, APMNA (http://www.psychodermatology.us) has yearly meetings. Most APMNA members are active in psychocutaneous research and clinical practice in the US and work closely with European, South American, and Asian colleagues.

To increase training opportunities in the United States, we created the Wisconsin psychocutaneous clinic (http://www.mind-skin.com) which offers training workshops for dermatologists, as well as dermatology and psychiatry residency programs.

Conclusion

Psychocutaneous problems are frequent in dermatology patients. Notably, there was an underdiagnosis of depression and anxiety made by the referring providers.

Timely diagnosis and treatment of psychocutaneous problems will improve patients’ quality of life and decrease the number of dermatology visits.

Finally, since the number of psychocutaneous clinics is limited, training dermatologists to screen and start treatment or refer patients promptly is important.