PS06 The beast beneath the blisters: assessment of depression and anxiety in patients with immunobullous disorders in a tertiary referral centre

Abstract

Immunobullous diseases can be disabling in the acute phase, causing widespread painful or pruritic skin and mucosal lesions. The subsequent psychological consequences of these disorders have not been fully evaluated. We treated a 53-year-old woman for severe bullous pemphigoid affecting her skin and oral mucosa. Following resolution of disease, she was left with debilitating anxiety and depression. This case prompted us to look at the psychological impact of immunobullous disease in our cohort. We used the Patient Health Questionnaire (PHQ-9), General Anxiety Disorder (GAD-7) and Dermatology Life Quality Index to establish the psychosocial impact in patients attending the immunobullous specialist clinic at a large tertiary dermatology centre. An assessment of pain using a numerical pain-rating scale and a question regarding any pre-existing mental health conditions were included. Twelve patients with various immunobullous conditions were surveyed. Seventy-five per cent (n = 9) of patients were identified as having a mood disorder via their PHQ-9 and GAD-7 scores. The PHQ-9 scores indicated mild (50%), moderate (17%) and severe (8%) depression symptoms in these patients. Twenty-five per cent and 17% of patients had a GAD-7 score indicating mild and moderate anxiety, respectively. Three patients declared that they had a previous mental health diagnosis; however, only mild depression and mild anxiety were identified in two of these patients. Only one of these patients volunteered mental health symptoms during their consultation, indicating an unrecognized burden of disease in this community. Our findings support previous research indicating high rates of depression in patients with immunobullous disease. Furthermore, there is an established association between bullous pemphigoid and neuropsychiatric conditions, with identification of autoantigen expression in the central nervous system. Mood disorders have a significant effect on patients’ experience of disease, and are likely to have an impact on disease course and engagement with treatment. A large European study found that dermatologists underestimate the severity of mood disorders. Therefore, the incorporation of validated measures for assessment of mood disorders such as PHQ-9 and GAD-7 into clinical practice is essential to identify the high proportion of patients with immunobullous disease suffering from these disorders. Quality of life measures, which are commonly assessed, are not sufficient for holistic management of these patients. These findings support the invaluable role of a psychologist within dermatology centres, and appropriate referrals to these services will improve with assessment during clinic consultations.