Anxiety, Depression Linked to Patient Overestimation of Psoriasis Severity


The study underscores the importance of interpreting patient-reported disease severity scores in the context of mental health factors.


A cohort study of patients with psoriasis found that discordance in physician and patient disease severity assessments was associated with poorer mental health status.

“Although data are limited in psoriasis, studies have identified discordance between physician and patient measures of disease severity in chronic inflammatory diseases, for example, among one-third of patients with rheumatoid arthritis,” noted the study investigators.

Previous research has linked such discordance with patient dissatisfaction, lower treatment adherence, and worse disease outcomes. Therefore, the investigators indicated, it becomes necessary to evaluate potential underlying factors for these discrepancies so as to optimize care and shared decision-making.

A team led by Ewan Carr, PhD, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, evaluated psoriasis patients using self-assessment and clinical screening measures.

All patients had attended a large specialist service In London and Southeast England between May 12, 2016 — November 1, 2018. Data was analyzed between July 22 — October 22, 2019.

Psoriasis and Mental Health

Carr and colleages evaluated 502 individuals, thus amounting to 1985 total observations.

Of the population, a majority were male (68%) and white individuals (79%). The mean age was 47 years.

On each visit, psoriasis severity was assessed using identifical patient and physician global assessment scales. Patients were asked to rate their disease severity on a 5-point scale, with 1 indicating clear/nearly clear and 5 indicating very clear.

Physicians rated patients on the same scale, and discordance was measured by substracting the patient assessment from the physician assessment. 

Psoriasis severity was also evaluated using the Psoriasis Area and Severity Index (PASI).

Furthermore, probable major depressive disorder was screened using the Patient Health Questionnaire-2 (PHQ-2) and PHQ-9. Probable generalized anxiety disorder was screened using the Generalized Anxiety Disorder scale (GAD-7).

Thus, 9% of patients screened positive for depression, and 10% screened positive for anxiety.

The investigators also noted physician-patient discordance in 39% of the 1985 office visits.

More specifically, patients rated their psoriasis as less severe on 26% of visits. Patients overestimated severity on 13% of visits.

Those who were considered positive for depression or anxiety were more likely to overestimate their psoriasis severity compared with their physician (relative risk ratio: depression, 2.7; 95% CI, 1.6-4.5; anxiety, 2.1; 95% CI, 1.3-3.4).

“These findings remained statistically significant after adjustment for age, ethnicity, sex, body mass index, smoking, number of comorbidities, treatment modality, and presence of psoriatic arthritis,” the investigators reported.

However, they qualified their findings by noting that patients with anxiety and depression and more severe psoriasis (PASI score > 10) were more likely more to underestimate their disease severity.

Overestimation was more common if patients had PASI score ≤5.

“Thus, psoriasis severity may moderate the association of mental health status with patient-physician discordance,” Carr and team suggested.


The team acknowledged that their study did not account for stage of and experience with treatment regimens, which may have had an impact on mental health status. Furthermore, they believed that more work is needed to better understand what truly constitutes a meaningful level of discordance between patient and physician.

Nonetheless, they emphasized the implications of their findings, especially as they relate to addressing and screening for mental health in clinical practice. They encouraged the interpretation of patient-reported disease severity score in the context of comorbid anxiety and depression.

“The recognition, monitoring, and management of depression and anxiety in psoriasis by multidisciplinary health care teams (preferably encompassing clinical psychology expertise) has the potential to alleviate the substantial mental health burden in psoriasis while aligning clinician and patient perceptions of disease and treatment goals,” the investigators concluded.

The study, “Association of Patient Mental Health Status With the Level of Agreement Between Patient and Physician Ratings of Psoriasis Severity,” was published online in JAMA Dermatology.

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