Depression

Depression is a common and disabling mental health issue that affects around one in six people over the course of a lifetime (Bromet et al 2011). Its core features are persistent low mood and a loss of enjoyment or interest in activities and experiences, which may be accompanied by a range of associated emotional, cognitive, physical and behavioural symptoms, for example sleep disturbances, changes in appetite, reduced energy, feelings of guilt and/or worthlessness, and suicidal thoughts (NICE 2009).

The risk of experiencing depression is substantially increased among people with any chronic physical health condition, with reviews identifying that its prevalence is approximately doubled in people with diabetes mellitus, hypertension, coronary artery disease and heart failure compared with healthy controls (NICE 2009). This elevated risk is evident for chronic skin conditions such as psoriasis (Dowlatshahi et al 2014).

An extensive evaluation of more than 100 studies found that several tools are effective in identifying depression in people with chronic physical health conditions (Meader et al 2011). One of these tools is the Patient Health Questionnaire-9 (PHQ-9) (Kroenke et al 2001), which is widely used in primary care services in the UK, has good psychometric characteristics and has been found to be feasible and acceptable as an assessment tool for patients with comorbid physical health conditions. However, rather than asking every question on the PHQ-9, nurses can use the brief PHQ-2 (Kroenke et al 2003) screening tool.

The PHQ-2 has been found to have excellent sensitivity for detecting depression, and it has been suggested to be the preferred method for quickly assessing depression (Meader et al 2011). It is also the recommended initial tool for assessing depression in people with chronic physical health conditions (NICE 2009). The PHQ-2 comprises the first two questions of the PHQ-9, which require a yes or no response from the patient:

A positive response to either or both of these questions indicates depression may be likely, and a thorough mental health assessment is required. If it is beyond the limits of the nurse’s competence to perform such an assessment, the patient should be referred to an appropriate healthcare professional (NICE 2009). Box 2 describes what is involved in performing a mental health assessment in patients with suspected depression.

Anxiety disorders

One of the most prevalent types of anxiety is generalised anxiety disorder (GAD). The core feature of GAD is excessive anxiety and worry about several events or activities, which occurs more days than not for a period of at least six months (NICE 2011). Unlike in phobic anxiety disorders, the symptoms of GAD are not focused on specific events or activities, and they may be accompanied by restlessness, fatigue, concentration issues, irritability, muscle tension and sleep disturbances (NICE 2011).

Nurses should be aware that having a chronic skin condition is a potential risk factor for anxiety disorders (NICE 2011). Where a person appears to be experiencing somatic features of anxiety, such as muscle aches, insomnia and sweating, or may be at risk of GAD, the nurse should use an appropriate brief screening tool such as the GAD-2 (Kroenke et al 2007).

The GAD-2 is a brief two-item scale that comprises the first two statements of the longer GAD-7 (Spitzer et al 2006) scale. The GAD-2 has been extensively evaluated and found to have high sensitivity and specificity for GAD (NICE 2011). It also performs adequately as a screening tool for other common anxiety disorders, such as panic disorder, social anxiety disorder and post-traumatic stress disorder (PTSD) (Kroenke et al 2007). In the GAD-2, the patient scores each of the following statements on a scale of 0 (not at all) to 3 (nearly every day) according to their frequency over a two-week period (Kroenke et al 2007):

If the patient scores three or more on the GAD-2, the nurse should consider the possibility of an anxiety disorder. If it is within the limits of the nurse’s competence, they can then perform a full assessment for anxiety disorders; if not, the person should be referred to an appropriate healthcare professional for this (NICE 2011). If the patient scores less than three, but the nurse is still concerned about the possibility of an anxiety disorder, they should ask the following question: ‘Do you find yourself avoiding places or activities and does this cause you problems?’. If the person answers yes to this question, an anxiety disorder should be considered and a full assessment should be conducted to determine the number, severity and duration of their symptoms, as well as the degree of distress and functional impairment that they are experiencing (NICE 2011). The seven-item GAD-7 (Spitzer et al 2006) scale is a valid tool that can be used as part of this full assessment (NICE 2011).

Assessing suicide risk

If a mental health issue has been identified during an assessment, it is necessary to determine the person’s risk of suicide. Suicidal thoughts are relatively common among people with depression and other mental health issues, and the nurse should ask sensitive but clear questions to examine such thoughts and any suicidal intention. The assessment should also include signposting the availability of social support and awareness of other sources of support, and ensuring that the patient knows what to do if the situation deteriorates.

The extent of the person’s risk of suicide will determine the nurse’s response. Where there is immediate or considerable suicide risk – for example if a person describes clear intentions, has made a plan or has a history of suicide attempts – urgent referral to specialist mental health services is required (NICE 2011).

If the nurse has concerns but is uncertain about the most appropriate approach to take, they need to discuss this with their colleagues immediately to determine how to address any risks and prevent harm. It is also important that the findings of the risk assessment are documented clearly in the patient’s records.

Getting their voice heard

People with chronic skin conditions need to cope with the physical discomfort this brings and the psychological burden associated with how it makes them feel. This may be compounded by the condition’s effects on their social relationships, employment and finances. Nurses should take a holistic approach to supporting patients with chronic skin conditions, acknowledging the importance of treating physical symptoms and the psychological effects that these symptoms have on the patient.

As with many chronic conditions, this approach should start with the nurse listening to the patient’s story and using open-ended questions to explore their experiences. The expertise that the patient brings regarding their condition should be acknowledged and respected, developing a plan of care that reflects this (Coulter et al 2015). For example, when describing how to use topical treatments, the nurse should assess what has been used before and whether it has had any benefit on the condition.

If the patient reports no benefit, the nurse should check whether the topical treatment was used correctly, or whether the treatment was too challenging to incorporate into the patient’s daily life. If such issues are raised, the nurse should consider amending the treatment if possible.

Accessing care at the right time

Timely diagnosis and effective interventions are essential to optimise patient outcomes and minimise the negative psychological effects of living with a chronic skin condition. Therefore, in addition to providing ongoing medical treatment and care, access to psychological and educational support should be ensured. This support will typically entail providing patient education and information on simple psychological techniques to manage symptoms such as itching, scratching and sleep disturbances.

A Cochrane review evaluated the findings of ten randomised controlled trials of psychological and/or educational interventions used to manage children with atopic eczema (Ersser et al 2014). It found some evidence that educational interventions can lead to reduced atopic eczema severity and improvements in quality of life, and that the use of relaxation methods may also reduce the severity of the condition.

Adhering to dermatological treatments

Chronic skin conditions that are mild or moderate in severity are generally managed by topical therapies, including emollients and topical corticosteroids. Patients with moderate or severe disease severity are more likely to be prescribed systemic therapies such as phototherapy, methotrexate or biologic medicines. However, evidence has demonstrated that adherence to treatment for skin conditions is low (Finlay 2017). There are several practical factors that may affect patients’ adherence to dermatological treatments, including:

Nurses need to be aware of these potential barriers to treatment and address them where possible. However, one systematic review by Vangeli et al (2015) acknowledged that while practical factors may influence patients’ adherence to treatment, psychosocial factors were the strongest determinants of adherence. These psychosocial factors included the relationship between the patient and healthcare professional, perceptions of treatment concerns, and depression. Therefore, developing effective relationships with patients, considering their mental health and well-being, and supporting them to develop the skills necessary to adhere to their treatment, are all important in achieving optimal patient outcomes.