ABSTRACT

Dermatology is a discipline in which psychosomatic issues serve a key role in the understanding of the etiology and progression of skin diseases as well as determination of appropriate treatment protocols. It is paramount for all clinicians involved in treating skin disorders to take a holistic approach to the patient and address underlying psychosocial needs and psychiatric disorders in order to achieve the best outcomes. Optimal care of the dermatology patient should include careful screening for psychiatric issues and the mechanism for either referral to external mental health providers or on-site psychiatric liaison.

The best model of care appears to be an interdisciplinary clinic in which patients meet providers from multiple specialties as part of a treatment team, thus reducing the stigma associated with emotional issues. At University Hospitals Case Medical Center, we launched the first interdisciplinary psoriasis clinic in the country (The Murdough Family Center for Psoriasis). This clinic provides comprehensive, disease-specific care with a team of dermatologists, psychiatrists, rheumatologists, nutritionists and nursing. Our observation in the multidisciplinary psoriasis clinic is that patients who are reluctant to accept psychiatric referral, more readily agree when the psychiatrist meets with them as part of the treatment team.

The delivery of care model for this interdisciplinary clinic will be discussed in detail along with a description of the interaction between various specialists. Demographic data for our patient population will be presented. Diagnoses encountered and treatment modalities will also be discussed.

SUMMARY OF FINDINGS

• Psychiatry consulted on 25 % of patients at University Hospitals Case Medical Center site in 2008.

Comprehensive Psychiatric Evaluations

• 58 patients: 45 women, 13 men

• Most common primary psychiatric diagnoses were Major Depressive Disorder, Adjustment Disorders and Generalized Anxiety Disorder/ Anxiety NOS.

• All patients referred for comprehensive psychiatric assessment had an Axis I psychiatric diagnosis

• Recommended treatments: Combined medication and psychotherapy: 35 patients; Cognitive behavioral therapy: 20 patients.

• One patient required admission to psychiatry directly from clinic for suicidal ideation

• One patient required admission to chemical dependency treatment for alcohol dependence and withdrawal

General Observations

• Referrals of non-psoriasis patients by dermatology to UHCMC general med-psych consultation clinic increased after the start of collaboration in Murdough Center.

• Collaboration has also led to current and future research projects such as: fMRI differences in patients with psoriasis vs. normal controls, the effect of reiki and meditation on stress and scope of psoriatic lesions and depression, cardiac comorbidity and neuroimmunology in psoriasis patients.

The Murdough Family Center for Psoriasis: The Psychiatrist’s Role on an Interdisciplinary Care TeamJoseph A. Locala, MD and Sarah Parsons, DO

Department of Psychiatry

0%

10%

20%

30%

40%

Percentage of Patients Seen by Individual Providers (2008)

Dermatology Rheumatology Psychiatry Nutrition

The Murdough Family Center Team

ADDITIONAL RESOURCES

1. Murdough Family Center for Psoriasis website: www.murdoughpsoriasis.org

2. Locala JA. Current concepts in psychodermatology. Current Psychiatry Reports 2009, 11:211-218.

3. Gupta MA, Gupta AK Ellis CN, et al. Psychiatric evaluation of the dermatology patient. Dermatol Clin 2005, 23:591-599.

4. National Psoriasis Foundation Website: www.psoriasis.org

5. Listen to Dr Locala speak on NPR: Treating Stress and Skin Disease in Tandem

www.npr.org/templates/story/story.php?storyid=1128049050

50

100

150

200

250

300

2007 2008 2009

Database Patients Enrolled at UHCMC vs. Community

Total UHCMC Community

BACKGROUND

The Murdough Family Center for Psoriasis opened on April 25, 2007 at Bolwell Health Center of University Hospitals Case Medical Center. This project was made possible by a $5 million grant from the Murdough Foundation of Hudson, OH. The Center subsequently received a $6.37 million Center of Research Translation (Cort) grant from the NIH which allows the program to link physicians, researchers, community clinicians and public groups in the pursuit of new therapies to provide relief for patients. Although initially designed to treat patients from Northeastern Ohio, the Family Center draws numerous referrals from other states. A community database has been established to track patients from private dermatology offices throughout the region. Patients enrolled in the database are then eligible for studies through the Center. This community outreach network of physicians is called LIFEDERMNET (Leaders Initiative for Excellence in Dermatology Network).

The goals of the Center are as follows:•To discover the causes of psoriasis•To identify improved therapies for psoriasis•To make new treatments for psoriasis available to patients more quickly•To educate other physicians and the community about psoriasis and new findings regarding the disease

0

5

10

15

20

25

30

15-24 25-34 35-44 45-54 55-64 >65

Age (years)

Age Distribution of Patients (%)

Secondary Psychiatric Diagnoses

3

132

2

2

21 1 1 1

Depressive D/O Anxiety D/O Panic

OCD Alcohol Dep/Abuse Personality D/O

PTSD Social Anxiety Heroin Dep

Bereavement

Primary Psychiatric Diagnoses

26

13

7

2 1 1 1 1 1

Depressive D/O Adjustment D/O Anxiety, GAD

Bipolar D/O Panic D/O Pain D/O

Alcohol Abuse OCD ADHD

OPERATION OF THE MURDOUGH CLINIC

The Psoriasis Center functions as a true multidisciplinary clinic. Meeting monthly, patients have the opportunity for consultation with a dermatologist, psychiatrist, rheumatologist, nurse specialist and nutritionist. From the moment of intake, all facets of a patient’s care are addressed, from clinical management to research possibilities in each discipline. When the schedule permits, the entire treatment team performs the initial examination and history-taking together.

Patients are scheduled at intervals throughout an afternoon session. Coordination of services involves several stages:

• Initial triage – survey questionnaire is reviewed and plan for the visit determined• Treatment room- each patient is assigned a specific exam room for the afternoon• Coordination of care – a centralized board is maintained that indicates which services are expected for each patient/room• Communication – clinicians continually discuss the most logical order of providers based upon availability - frequent curbside consultations take place• Discussion – a final review of findings and plan occurs with all disciplines represented

Patients are able to efficiently meet in one session with experts in each domain of their psoriasis management. From a psychiatric standpoint, the stigma often associated with a separate psychiatric appointment is absent when the psychiatrist is a member of the clinic team. Brief psychiatric sessions to provide stress management techniques and education regarding emotions and psoriasis are possible. When more significant issues are identified, full psychiatric evaluations are performed in the same clinic visit.

STRATEGIC PLAN FOR THE PSORIASIS CENTER

CONCLUSIONS

•The implementation of a multidisciplinary clinic in dermatology has captured a patient population in need of psychiatric treatment which might not typically occur.

•Higher rates of psychiatric comorbidity reported in the literature for psoriasis patients have been confirmed in the clinical setting during participation in a subspecialty clinic.

•Collaboration with medical colleagues from vastly different specialties has fostered an interchange of ideas and served as a catalyst for research.

•Interaction with other medical disciplines has led to an influx of referrals of non-psoriasis patients to our Med-Psych Consultation Clinic.

•Multidisciplinary clinics are often the optimal setting for provision of care, however, limited resources, low reimbursement for services and logistical obstacles often thwart efforts to establish such a model.