Conflict of interest: none declared.
Clinical dermatology ● Original article
A study of service provision in psychocutaneous medicine
Article first published online: 17 DEC 2013
© 2013 British Association of Dermatologists
Clinical and Experimental Dermatology
Volume 39, Issue 1, pages 13–18, January 2014
How to Cite
Lowry, C. L., Shah, R., Fleming, C., Taylor, R. and Bewley, A. (2014), A study of service provision in psychocutaneous medicine. Clinical and Experimental Dermatology, 39: 13–18. doi: 10.1111/ced.12235
- Issue published online: 17 DEC 2013
- Article first published online: 17 DEC 2013
- Manuscript Accepted: 23 MAY 2013
Psychocutaneous medicine concerns the recognition and treatment of psychological distress and psychiatric morbidity associated with dermatological diseases. A study in 2004 examining resources in the UK highlighted a number of deficiencies, and recommended that psychodermatology services be available, at least regionally, in the UK. Although there is now increased recognition of psychodermatology, this study of the availability of these services shows that provision has deteriorated since 2004.
To study the service provision of psychocutaneous medicine in the UK.
Consultants in dermatology units across the UK were asked to take part in an online survey, accessible via an emailed link. This consisted of 10 questions concerning availability of psychodermatology services and psychological support for patients within their local trusts, both in adult and in child and adolescent medicine. Basic percentages were used to analyse quantitative data and content analysis for qualitative data.
From 154 surveys, 127 responses were returned. The data indicated that despite frequently encountering patients who required psychological and psychiatric input, a large majority of UK dermatologists have inadequate access to appropriate support in their department. Importantly, this included the child and adolescent medicine and skin cancer departments, despite there being clear objectives for these services to be routinely available.
A lack of resources in psychocutaneous medicine was highlighted in 2004, and the situation has not improved, or is, if anything, worse. Essential access to psychiatric and psychological support for patients is not currently available in most dermatology departments across the country.
Skin disease is associated with psychological distress and psychiatric morbidity. Additionally, psychiatric disease can present with cutaneous symptoms. These factors are an important part of the dermatology workload. Accordingly, psychocutaneous medicine, also referred to as psychodermatology, is now a dermatology subspecialty. Although the range of psychological and psychiatric disorders probably lies on a spectrum, the aim of psychodermatology is broadly to identify and address the following: (i) primary psychiatric conditions presenting as skin disorders (e.g. delusions of infestation); (ii) psychiatric conditions associated with a primary skin disease that has a psychosocial impact (e.g. clinical depression and chronic plaque psoriasis); and (iii) psychological difficulties associated with skin diseases, and vice versa (e.g. maladaptive coping skills and poor eczema control; alopecia and low self-esteem).
Historically, such conditions have been managed in general dermatology outpatient clinics, usually with an emphasis on the medical model of cutaneous disease. However, psychological factors can affect everything from disease onset to disease severity, frequency of flares, compliance and outcome.[1, 2] Improved recognition of these features is essential for optimal management, and a multidisciplinary approach is often helpful. Psychodermatology has been part of the specialty training curriculum for dermatology trainees for several years, and the list of competencies required was extended in the 2010 curriculum, but access to training remains limited, and there has been no clear guidance on implementation.
A 2004 national study ‘Mapping psychodermatology in the United Kingdom’, found marked deficiencies in the provision of psychodermatology services in the UK. Lack of funding and interest, longer consultation times, and inadequate training were cited as obstacles. Of 202 consultant dermatologists who responded to the 2004 study, only 15 dermatologists across 9 hospitals had access to a psychodermatology service. The report recommended that more attention be given to this field, in particular to training. The situation has not been reviewed since then.
In 2011, the British Association of Dermatology (BAD) set up a psychodermatology working party of psychologists, psychiatrists, dermatologists and BAD representatives. The aim was to review the available resources and develop a protocol that allows better access to psychological services and an adequate standards for minimal service provision in each trust. In the current study, we aimed to determine whether the situation has improved since 2004.
The study used an online survey consisting of 10 stemmed questions (Table 1), devised by a consultant dermatologist with a special interest in psychodermatology and BAD representatives. The survey was created with an online questionnaire software tool (SurveyMonkey), and it was distributed in November 2011 via email (containing a link to the survey) to consultants in dermatology units across the UK, inclusive of all National Health Service (NHS) hospitals providing dermatology services. The questionnaire format comprised open and closed questions, including free-text sections for open-ended comments to provide both quantitative and qualitative data. Percentages were used to analyse the quantitative data and content analysis was used for the qualitative data.
|1||Please indicate which psychodermatology patients are seen in your department along with an estimated percentage that this group represents|
|2||What psychological support services are available in your department for dermatology patients in Question 1?|
|3||For patients with skin cancer, what support is available?|
|4||Where are patients requiring psychological/psychiatric intervention treated?|
|5||How is the consultation provided for dedicated or joint clinics delivered by dermatologists and psychiatrists?|
|6||How frequent is the clinic?|
|7||Are younger dermatology patients (up to age 16) with psychocutaneous disease seen in a dedicated Child and Adolescent Mental Health Services (CAMHS) clinic?|
|8||Do you have a designated consultant within the Trust who leads or has an interest in psychocutaneous medicine?|
|9||Have you had any formal training in psychocutaneous medicine?|
|10||Please provide any further comments.|
Of the 154 surveys sent out, 127 were completed. This constitutes a high overall return of 82%, following a low attrition rate after e-mailed reminders, and can therefore be regarded as a valid and representative survey response. The participating units were distributed across the UK as follows: England 82% (includes London, 11%), Wales 9%, Scotland 7% and Northern Ireland 2%. Figure 1 illustrates the types and proportion of psychodermatology patients seen.
For question 1, the consultants studied considered that approximately 16% of their patients have a psychological condition because of their skin disease, and 14% have a psychological condition that exacerbates their skin disease. They estimated that 3% of dermatology patients present with a primary psychiatric disorder, 5% have psychiatric disorders as a consequence of their skin disease and 7% have comorbid psychiatric problems. Additionally, about 5% of their patients present with cutaneous sensory disorders without clear organic aetiology.
The second question concerned psychological support, which was reported as not available by 41% of participants. Experienced dermatology nurses support 39% of departments. Only 8% of respondents have access to a psychologist or psychotherapist, and 6% to a dermatologist with an interest in psychocutaneous medicine (Fig. 2). Other sources of psychological support included liaison psychiatry colleagues, general practitioner counselling services, volunteer organizations, patient support groups (e.g. the charity group ‘Changing Faces’), temporary student psychologists on attachments, and psychologists within other hospital departments (e.g. genitourinary medicine, transplant unit).
Regarding psychological support for patients with skin cancer, 94% of respondents stated that this comes from experienced dermatology nurses. In addition to nursing support, 35% make use of patient support and advisory groups. Only 18% can access a psychologist or psychotherapy service for their patients with skin cancer, and 12% refer these patients to liaison psychiatry. Other sources of support mentioned were palliative care teams, Macmillan nurses and hospital chaplains.
For younger dermatology patients (up to 16 years of age) with psychocutaneous disease, 27% of respondents have clear access to a dedicated Child and Adolescent Mental Health Services (CAMHS) clinic, whereas 28% do not have any access; however, 44% did not know what services are available for younger patients.
Consultants were asked if they have had any formal training in psychocutaneous medicine themselves, as this has been a core component of the dermatology trainee curriculum for several years. A minority (17%) reported they have had such training, but the remaining 83% did not. Only eight trusts have a designated or lead consultant with a specialist psychodermatology interest.
The remaining questions examined where patients requiring psychological or psychiatric intervention are treated. and how trusts with psychodermatology clinics set up the consultation. The majority of respondents (59%) referred these patients to psychiatry departments, while 35% treat them in the dermatology clinic. Only 6% (n = 7) have access to a dedicated psychodermatology clinic (Fig. 3). Of these, three involve a joint consultation with a dermatologist and psychiatrist and/or psychologist together in the same room, and the others set up separate consultations with each specialist. These clinics range from weekly to a few times a year.
Content analysis of the free-text comments in questions 2 and 10 identified several themes.
- Theme 1: no local psychology support. Reasons included withdrawal of funding and closure of the psychology department. Alternatives mentioned were a private psychologist and supportive charities.
- Theme 2: psychology support is only accessible by referring to an outside service, either to a separate service in the trust or back to primary care. The convoluted path of referring to psychiatry departments in order to access psychology support was remarked upon, as well as reluctance on the patient's part; referral to a psychiatrist is often discussed with but rarely agreed to by patients.
- Theme 3: disproportionate time is required to deal with these patients if they are not seen in a specialist setting. A number of comments alluded to the need for dermatologists to act as ‘amateur psychologists’:
- ○‘It is time intensive and hard in the target driven NHS to give these patients the time they deserve…some can take up to an hour’.
- Theme 4: Lack of funding for psychodermatology services:
- ○‘We have long been concerned about the serious deficiency of psychocutaneous support and funding, both locally and nationally’.
- Theme 5: Obstacles to referring for outside support. Often patients do not fulfil criteria for access to specialist help, referrals are declined or waiting lists are too long. Some sample comments were:
- ○‘To refer to clinical psychology there is a 2-year ‘urgent’ waiting list.’
- ○‘CAMHS input very limited and you have to have a psychiatric diagnosis to fulfil referral criteria.’
- ○‘I have sent three referrals to the psychiatric services in the past six months…. all three were declined.’
- Theme 6: Inadequate training in psychodermatology. Some respondents had attended meetings (mostly the Psychodermatology UK Annual Meeting) or shadowed in specialist clinics. However many indicated that more training is essential and that increased opportunities would be welcome:
- ○‘I would like to undergo a more structured formal training.’
- ○‘When I tried to attend a course I was told it was for trainees only.’
The relationship between the mind and the skin is widely acknowledged, and there is a high prevalence of psychological and psychiatric morbidity among dermatology patients.[5, 6] Much of the research has focussed on chronic inflammatory conditions such as psoriasis, which are associated with higher incidences of depression, anxiety and suicidal ideation. However, many other skin conditions have an impact on the psyche and vice versa. A recent meta-analysis concluded that interventions such as cognitive behavioural therapy and habit reversal can be beneficial for skin conditions. However, psychological morbidity is probably underdiagnosed by dermatologists,[9, 10] which is not surprising considering the lack of training noted in this study's findings. The shortage of multidisciplinary input highlighted in this survey also supports the call for dermatologists to be appropriately trained.
Unfortunately, when dermatology patients clearly need specialist care, most are referred to an outside service. Patients often have negative perceptions of these services because of the stigma surrounding them, resulting in nonattendance, or as noted in this study, rejection of the offer. In-house provision would help to maintain rapport, enable integration of care, and promote the link between mind and skin. Such collaboration would enhance the work of the dermatology team, and might offer financial advantages.
For patients with primary psychiatric disorders presenting with cutaneous symptoms, a psychodermatology clinic is particularly effective. Our study identified only seven of these. The cost-effectiveness of managing patients with dermatitis artefacta (DA) in a psychodermatology clinic was presented at the BAD Annual Meeting in July 2012. The average cost of managing a patient with DA in the psychodermatology clinic was £1210 per patient per year, compared with £8063 per patient per year before the patient was seen in this clinic. Thus, for patients with DA, a psychodermatology clinic is cost-effective.
A number of medical specialties now acknowledge the importance of the biopsychosocial model and a holistic approach. Needs identified in fields including rheumatology and oncology have led to provision of psychological training and support, with subsequent improvement in disease activity measures.[13-15] Further examples exist of service innovation that has successfully integrated psychological interventions for chronic conditions such as diabetes, chronic obstructive pulmonary disease, and cardiovascular disease. A 2012 NHS confederation report provided a growing body of clinical and economic evidence to support investment in services to address the mental health of patients with long-term conditions. This is also applicable to chronic dermatology conditions, known to have psychological sequelae.
National Institute for Clinical Excellence guidance on cancer services for people with skin tumours, including melanoma, recommends that psychiatric and psychological assessment and support should be available for all patients with skin cancer. In the current study, we found that in dermatology, although there is access to dedicated nurses, more specialized psychology and psychiatry input is lacking. The situation is similar, if not slightly worse, for access to CAMHS where, according to the survey findings, less than a third of respondents have access to a dedicated clinic.
The NHS programme ‘Improving Access to Psychological Therapies’ (IAPT) is in the middle of its roll-out and we anticipate that effective implementation may benefit dermatology patients. Launched in 2008 to increase availability of psychological therapies, the initial phase was targeted at adults with mental health problems. However, the plan is to extend the scope to include children, adolescents and adults with physical conditions across England. The goal is to ensure access to psychological therapies for ‘all…who would benefit from it’ by March 2015. Completion should see expansion of services and funding for many additional practitioners in psychological therapies. It is still uncertain whether dermatology patients will gain directly; nonetheless, the introduction of IAPT recognizes the fundamental link between psychological wellbeing and physical health.
Our study has a number of limitations. Dermatologists who have a special interest in psychodermatology or have strong feelings about these resources may be more motivated to take part or add free-text comments, opening the study to information bias. The percentages in question 1 are estimates, and therefore cannot be assumed to be a reliable reflection of the proportion of each patient group. Some questions invite responses that are subjective, and depend on the knowledge or viewpoint of the respondent.
It is apparent that the current dermatology service model is not meeting the psychological needs of many of the patients. Access to psychiatric and psychological support for dermatology patients is inadequate, and has not improved since 2004. Neither has there been significant progress in the provision of psychodermatology training, despite an obvious demand. Many patients would benefit if dermatologists were able to work with associated specialists to develop tailored services of this kind. Following these concerns, guidance commissioned by the BAD will be published shortly.
- Skin disease often has a marked psychosocial effect, and there is a high prevalence of psychological and psychiatric morbidity among dermatology patients.
- Psychodermatology resources are lacking in the UK.
- Recognition and management of these patients in the appropriate specialist setting is cost-effective, and improves long-term outcome.
- Despite its inclusion as a core component of the UK dermatology curriculum, the vast majority of consultants in this country have not had formal training in psychodermatology.
- Only a fraction of UK dermatology departments have access to dedicated psychodermatology clinics or psychological support.
We are grateful to T. von Hospenthal, British Association of Dermatologists, who helped enormously with the development of the questionnaire.
- 3Joint Royal Colleges of Physicians' Training Board. SpR training core curriculum in dermatology. Available at:http://www.jrcptb.org.uk/trainingandcert/ST3-SpR/Pages/Dermatology.aspx
- 4Mapping psychodermatology in the United Kingdom. Poster presented at the British Association of Dermatologists Annual Meeting 2004., , .
- 10The knowledge, awareness, and practice patterns of dermatologists toward psychocutaneous disorders: results of a survey study. Int J Dermatol 2010; 49: 784–9., , et al.
- 12Br J Dermatol 2012; 167(Suppl. 1): 21–69., , .
- 16NHS Confederation/Mental Health Network. Investing in emotional and psychological wellbeing for patients with long-term conditions and medically unexplained symptoms. Available at: http://www.nhsconfed.org/Publications/Documents/Investing%20in%20emotional%20and%20psychological%20wellbeing%20for%20patients%20with%20long-tern%20conditions%2018%20April%20final%20for%20website.pdf
- 17National Institute for Health and Clinical Excellence. Improving outcomes for people with skin tumours including melanoma, 2006. Available at: www.nice.org.uk/CSGSTIM
- 18National Health Service. Improving Access to Psychological Therapies. Available at: http://www.iapt.nhs.uk.
- 19Department of Health. IAPT three-year report. The first million patients. Available at: http://www.iapt.nhs.uk/silo/files/iapt-3-year-report.pdf