Addressing Mental Health Issues in AD

In this exclusive interview as part of the National Eczema Association’s Atopic Dermatitis (AD) Expert Series, Joy Wan, MD, MSCE, met with The Dermatologist to discuss mental health disorders in patients with AD, including why these patients are at high risk for experiencing mental health issues and what provider and patient barriers exist when it comes to discussing mental health.

The Dermatologist: What is known about the relationship between mental health disorders and AD?

Dr Wan: Over 20 years ago, researchers started looking at quality of life in children with AD. Back then, they found that AD had some significant effects on emotional and social functioning. In more recent years, many large epidemiologic studies have begun to link AD with a variety of mental health symptoms and disorders. AD in both children and adults has been linked with greater rates of depression, anxiety, and thoughts of or attempts at self-harm or suicide. In general, patients with AD have higher rates of mental health conditions compared with their peers without AD.¹ Some data suggest that AD is associated with attention-deficit/ hyperactivity disorder (ADHD).² Because we are talking about a skin condition that affects a large number of adult patients and up to 15% of children,³ these are important associations and relationships that we have to better understand.

The Dermatologist: Why are patients with AD at high risk for experiencing mental health issues, such as anxiety and depression?

Dr Wan: It is a complex web of factors and mechanisms that contribute to mental health issues in patients with AD. One of the more obvious factors might be that AD is a highly visible disease and it can be stigmatizing for many patients, which can have impacts on how patients view themselves and their self-esteem. AD is also a chronic disease for most patients, and it is associated with poor quality of life. It has been shown that, in general, having a chronic or debilitating disease puts patients at greater risk for having mental health issues.⁴ Itch, as we know, is one of the main features of AD and itch itself can worsen stress and disrupt sleep, which can in turn impact patients’ mental health.

In more recent research, scientists have explored the biologic mechanisms that might be at play. Although more research is needed to fully understand what is going on, there are some prevailing theories. One idea is that inflammation is often not limited to the skin in AD. Patients can have it systemically throughout their whole body.⁵ Higher levels of cytokine chemicals are circulating in the blood, and perhaps those inflammatory molecules also travel to the brain and impact the nervous system. There has been a more recent understanding of how inflammation in the brain can trigger some mental health conditions such as major depression. Another potential theory is that some patients with AD may have abnormal hormone and nervous system responses to stress in general.⁶ Perhaps that then leads to higher rates of anxiety or depression in these individuals.

It is important to note that not every patient with AD has the same risk of experiencing mental health issues. Studies have shown that having more severe and persistent AD increases a person’s risk of experiencing mental health symptoms.⁷ Large epidemiologic studies have found that children who have more severe AD have about a 2- to 6-fold risk of anxiety, depression, and ADHD.⁶ Timing of AD onset may also be a factor. Some studies suggest that earlier onset of AD may have an impact on developing ADHD.⁸ I am excited to see what future research will show us with respect to all these connections and how they interact.

The Dermatologist: In your clinical practice, do patients often raise mental health concerns?

Dr Wan: Concerns about mental and emotional health are common, particularly among patients who have severe disease. In my experience, some patients and parents raise these concerns to me, but probably not everyone. For a decent number of patients, we may not be aware that they are experiencing these symptoms. And patients might not know that the symptoms they are experiencing are related to having AD.

Research has found that up to 30% of children with eczema in the United States have symptoms that may indicate some impairment in their mental health.⁹ In that same study, about half of the kids with AD and severe mental health symptoms had not seen a mental health professional in the last year or even raised these issues with a general practitioner. This suggests that some mental health symptoms go undetected or untreated altogether. We need to be cognizant of this as providers and we should also do a better job of asking our patients targeted questions about these types of symptoms.

The Dermatologist: How do you assess or screen for mental health issues in patients with AD?

Dr Wan: One of the things that I try to do is open the door for a conversation about these concerns, if the patient or the family wants to raise any. For me, it is asking simple questions such as, “How are you doing?” “How is school going?” “How are you sleeping?” That will often elicit a response from families and patients and then we can have a deeper conversation about these issues.

Patient-Reported Outcomes Measurement Information System, or PROMIS, tools are fairly short surveys that the patient fills out, which ask about a variety of symptoms regarding mood, itch, and sleep, for example. In an ideal world, these would be integrated into our clinical practice and, even better, into our electronic medical record, where perhaps the patient could receive a link to fill out the survey before their visit. This is feasible, but it will take time, resources, and infrastructure to get us to that point in the future.

The Dermatologist: What provider and patient challenges or barriers exist when it comes to discussing mental health with patients who have AD?

Dr Wan: There is often limited time during an appointment. I feel like I have limited time to address all the things that need to be addressed in a visit, and the patient feels the same way, too, that perhaps they cannot get all their concerns out in a 15- or 30-minute visit. Sometimes some of the mental health issues may become backburner concerns that do not get brought up during a busy visit. Patients might feel uncomfortable bringing up some of these issues because of the stigmatizing nature of mental health disorders or perhaps they do not know how best to talk about it or whether they should discuss it with a dermatologist.

We, as providers, may also feel uncomfortable initiating some of these conversations because perhaps we do not know how to ask in a nonconfrontational, nonjudgmental way. Perhaps we are also hesitant to ask because we do not know what to do with the information we get, such as how to best provide the kind of support the patient may need or the most appropriate referrals. There is a lot to be said for shared decision-making and the benefits that can come from it.

The Dermatologist: What types of resources and additional members of the care team have you found to be helpful for your patients who may be experiencing mental health symptoms?

Dr Wan: Having interdisciplinary support and resources is helpful. Some dermatology clinics have an assigned psychologist. For example, we have a pediatric psychologist at our institution who is interested in dermatologic conditions and caring for our patient population. Identifying individuals who are experts in addressing and treating mental health concerns is one potential resource. As providers, we can become educated and trained on providing psychosocial support, particularly for patients with more mild symptoms. Understanding how to talk about these issues and ways to provide support is a beneficial tool to have as medical providers.

The Dermatologist: Do you find that mental health issues improve following optimal treatment for AD?

Dr Wan: Speaking from my experience as a clinician, I would say absolutely some patients benefit tremendously from a mental health standpoint after we get them on optimal treatment for their AD. I have had parents explain to me it is like having a whole new child after their child starts systemic therapy that erases their active eczema. As more novel therapies come out for AD that may have a direct impact on systemic inflammation, the story will unfold, and we will hopefully collect more data over time. There is the possibility that some of those treatments may help clarify the mechanisms driving mental health issues.

It is also important to be cognizant that some mental health conditions may still linger even after a patient’s skin is clear because there are issues surrounding stigma and perhaps anxiety about having a chronic condition that waxes and wanes. Some patients, even though they are clear, will tell me that they are anxious about their skin flaring again and their disease coming back even though, in the moment, their AD is well controlled. Because there are lingering concerns that can occur after AD treatment is optimized, we should still ask patients about their mental health, even when we feel like, from a skin standpoint, they are doing well.