1. Dubai regional meeting
LEO Psoriasis Academy 2018
Dubai regional meeting
GCC Derma Summit:
Saturday 22 September, :00 AM–12:00 PM

2. Patient profiling and communication strategies to aid successful psoriasis management
Dr Anthony Bewley

3. Practical tools to aid successful psoriasis management

4. Identifying patients who are in need of additional support
Large, multinational study to help understand different patient types who might benefit from individualised interventions
Countries participating in the study
Identifying patients who are in need of additional support
Bewley A, et al. J Eur Acad Dermatol Venereol. 2014;28(6):

5. Research insights: Study design
Ethnographical study of 56 patients with psoriasis
42 respondents studied for 1 day
14 respondents studied for 2 days
Countries: UK, France, Germany, Spain, Italy, USA, Canada
Stage 1 –
Qualitative
Qualitative stage-guided development
of the quantitative questionnaire
and sample
Online methodology, 40 minutes
3822 patients with psoriasis*
Patient criteria
18 years old or over
Suffer from psoriasis and/or psoriatic arthritis
Stage 2 – Quantitative UK
France
Germany
Spain
Italy
USA
Canada
Total
608
571
488
577
358
609
611
3822
*Includes the 1884 patients currently using prescription treatments for psoriasis that are reported in Bewley A, et al. J Eur Acad Dermatol Venereol. 2014;28(6):

6. Research insights: Understanding patients
Burden of disease
Self-manager
40%
Why me? 28%
Help me! 16%
Actively engaged 16%
High
Low
Engagement with treatment
Based on insights from Bewley A, et al. J Eur Acad Dermatol Venereol. 2014;28(6):

7. Research insights: Identification of patient profiles
In this multi-national study, patients received questionnaires on the burden of their disease1
This led to an understanding of how the burden of disease connected to the patient’s engagement with treatment
Patterns were identified, which began the development of the distinct patient profiles:
Self-manager
Actively engaged
Why me?
Help me!
These profiles are not psychometrically determined, but are a means by which to facilitate patient decision making and thus improve their QoL
QoL, quality of life
Bewley A,et al. J Eur Acad Dermatol Venereol. 2014;28(6):

8. Research insights: Basis of the profiles
Profiles utilise key intrinsic, behavioural and attitudinal characteristics
Intrinsic characteristics
Patient history with psoriasis
Burden of disease/ treatment (QoL)
Differentiating behaviours
Treatment choice
Frequency of HCP visits
Differentiating attitudes
QoL impact
Satisfaction with current medication
Receptivity to new treatments
Trust in HCPs
HCP, healthcare professional; QoL, quality of life

9. Research insights: Characterising the profiles
Self-manager
Tend to have the most positive outlook on life
Psoriasis has least impact on QoL
Not as likely to be current users of prescription medicine; would avoid using treatments unless necessary
Least receptive to new treatments
Refer to psoriasis information least frequently
72% have mild psoriasis
Actively engaged
40% use prescription medicine; 40% use non-prescription medicine
Have the most positive relationship with their HCPs
Tend to trust their HCPs the most
Tend to have a good level of satisfaction with topicals
The most adherent cluster (54%)
56% have moderate psoriasis; 33% mild
POSITIVE EXPERIENCE
LOW DISEASE IMPACT
HIGH DISEASE IMPACT
Why me?
Psoriasis not as severe as ‘Help me’ cluster; however, not coping well
50% use prescription medicine; 33% use non-prescription medicine
Not as satisfied with topicals; would try to avoid prescription medicine unless necessary
Least trusting of their HCPs
Least adherent cluster (41%)
53% have moderate psoriasis; 35% mild
Help me!
Tend to have the most negative outlook
Highest percentage of body affected by psoriasis
Psoriasis has highest impact on QoL
Tend not to have a good relationship with their HCPs
Most receptive to new treatments
Refer to psoriasis information the most frequently
57% have moderate psoriasis; 32% severe
NEGATIVE EXPERIENCE
HCP, healthcare professional; QoL, quality of life
Based on insights from Bewley A, et al. J Eur Acad Dermatol Venereol. 2014;28(6):

10. Patient profiles: A useful clinical tool
Patient profiling should improve the quality of consultations and make limited consultation time more effective
Understanding changes to a patient’s profile over time will enable you to modify their management accordingly
What are your patient’s ideas, concerns, expectations (ICE)?
How much do they already know about their psoriasis?
What concerns does your patient have about their condition or treatment?
What do they expect from treatment and are they likely to adhere to it?

11. Case-study activity

12. Patient case study: Christina6
Christina (45 years) has suffered from psoriasis for >20 years
She attends regular consultations and trusts her dermatologist
Over the last 6 months, her psoriasis has flared very badly (which is unusual)
Her psoriasis impacts her choice of clothes
She is usually cheerful, but now feels quite depressed
She struggles to find time to apply creams, even though she knows they have previously worked well

13. Answer key questions about your patient to assist in profiling
Burden of disease
Engagement with treatment
Self-manager
Actively engaged
Why me?
Help me!

14. Questions about Burden of disease Psoriasis disease impact Never
Occasionally
Often
A lot
Psoriasis stops you from doing everyday tasks…
You feel unhappy about your skin…
Your psoriasis affects your relationships with people…
Your psoriasis affects your sleep patterns…
Your psoriasis affects your confidence…
Your psoriasis stops you from socialising, going out or playing sports…
Your psoriasis flares…
Your psoriasis is itchy…
OVERALL your psoriasis affects your quality of life…

15. Questions about Engagement with treatment
Patient’s engagement with treatment
Disagree
Disagree a bit
Agree a bit
Agree
Your treatment makes a difference to your skin
You like your treatments
You follow the treatment regime recommended to you by your HCP
Your lifestyle doesn’t interfere with your regime
Treatment really works for your psoriasis
You understand how using your treatment helps you
You like going to see your doctor/nurse/HCP
You have time to use your treatments
OVERALL you are satisfied and engaged with your treatment plan
HCP, healthcare professional

16. Plot where your patient ‘scores’ on the two axes
Engagement with treatment
Burden of disease
Agree
Agree a bit
Disagree a bit
Disagree
Never
Occasionally
Often
A lot
Self-manager
Why me?
Help me!
Actively engaged

17. Patient case study: Christina6
Christina (45 years) has suffered from psoriasis for >20 years
She attends regular consultations and trusts her dermatologist
Over the last 6 months, her psoriasis has flared very badly (which is unusual)
Her psoriasis impacts her choice of clothes
She is usually cheerful, but now feels quite depressed
She struggles to find time to apply creams, even though she knows they have previously worked well

18. Plot where your patient ‘scores’ on the two axes
Engagement with treatment
Self-manager
Actively engaged
Agree
Agree a bit
Why me?
Help me!
Disagree a bit
Disagree
Burden of disease
Never
Occasionally
Often
A lot

19. Tailoring communication approaches for different patient profiles
The self-manager
Let them express their ideas
Develop treatment targets and goals
Explore hidden worries
Learn from them
Understand that they have good coping skills
The actively engaged patient
Understand that they may know a lot about their disease
Understand that they may challenge our authority
40%
16%
The ‘Why Me?’ patient
Impart more knowledge
Show empathy
Listen to what they want
Express feelings
Build support
Prioritise
Bring to acceptance
Do not focus on prognosis
The ‘help me’ patient
Support them
Information
Disease/treatment
Hand-holding
Develop rapport
Realistic goals
Make sure they have not given up
28%
16%
Based on insights from Bewley A, et al. J Eur Acad Dermatol Venereol. 2014;28(6):

20. Communication strategies to aid clinical consultations

21. Why does your communication style matter?
Psoriasis has a huge, lifelong impact on patients
Effective communication has a profound effect on patient adherence
Psoriasis is a long-term condition that requires patients to engage in self-management

22. Person-centred communication
‘Respecting and responding to patients’ wants, needs and preferences, so that patients can make choices in their care that best fit their individual circumstances’1 Studies demonstrate that person-centred care is associated with improved healthcare outcomes, particularly in patients with chronic diseases2
Institute of Medicine (US). Committee on Quality of Health Care in America. National Academy Press, 2001.
Epstein RM, Street Jr, RL. National Cancer Institute, NIH, 2007.

23. Two-agenda model for person-centred communication
disease
illness
HCP’s agenda:
Signs
Symptoms
Investigations
Patient’s agenda:
Feelings
Ideas
Function
Expectations
Differential diagnosis
Personal understanding
Integrated understanding
management plan
HCP, healthcare professional
Stewart MA, et al. Patient-Centred Medicine. Radcliffe, 1995.

24. The consultation
Introduce yourself and initiate the session
Clarify reasons for visit and any worries
Effective communication has a profound effect on adherence
Check and summarise what you have heard
Gather
information
Explain the process and ask for consent before examining a patient
Build a
relationship
The first
2 minutes
are key
Explore and plan
Share information wanted by the patient
Close the session
Develop goals and make decisions together
Silverman J, et al. Skills for Communicating with Patients. Radcliffe Medical Press, 1998.

25. How we communicate Non-verbal Verbal Approach
Maintain eye contact and a facial expression appropriate to the topic
Lean forward and nod appropriately, encouraging the patient to tell their story, do not interrupt
Acknowledge the patient’s views and feelings
Accept their opinions without judgement
Be supportive, genuine and sensitive to the patient
Moderate your speech; speed, volume and intonation
Allow the patient to express their feelings, thoughts or concerns without interruption
Actively listen with an intent to understand by clarifying and summarising points

26. Care Plan For Treatment plan
Patient number
Treatment plan
Things to think about before your next appointment
times each day
times each day 1
Has your psoriasis changed since your last consultation?
Have you been using your treatment? If not, what makes it hard for you to do this?
Has treatment met your expectations?
Do you have concerns related to your condition or treatment that impact your life?
times each day 2 3
times each day 4
Your next appointments
You might like to write notes or questions here and show this to your doctor/nurse at your next appointment
Date
Time
Date
Time
Between appointments
You can contact your clinic using the details below
Doctor / nurse (name)
Phone number
You can also get help or advice from
If you are worried or have medical concerns, seek medical advice; do not wait for your next appointment
© August 2017 LEO Pharma A/S. All rights reserved.
All LEO trademarks mentioned belong to LEO Pharma A/S.

27. How do you engage different patient types?

28. Psoriasis Academy learning tools
Poor consultation style
Good consultation style
Anxious patient
Angry patient
Disengaged patient

29. Summary
Multiple tools are available to dermatologists to explore patient well-being, e.g. the Person-Centred Dermatology Self-Care Index (PeDeSi)2
Research has identified four key patient profiles:
Different patient profiles have different medical and treatment needs
Understanding these needs may help to improve treatment adherence1 (e.g. through targeting of treatments, psychological assessments, educational programmes)
A person-centred approach can greatly improve patient understanding, the sharing of information and healthcare outcomes
Consider the various stages of the consultation and the communication skills required at each stage
Adapt your consultation style to meet the needs of different individuals
Individuals have different preferences for involvement in healthcare decisions
Self-manager
Why me?
Help me!
Actively engaged
Remember – the first 2 minutes of a consultation are key
1. Bewley A, et al. J Eur Acad Dermatol Venereol. 2014;28(6): Cowdell F, et al. Arch Dermatol. 2012;148(11):

30. Are there any questions?

31. Suicide ideation prevalence
Suicidal behaviour in dermatology
Several European studies have found that patients with dermatological conditions, such as eczema and acne, have an increased risk of developing clinical depression1-3
Other studies highlight a high prevalence of suicidal ideation and an increased likelihood of attempting suicide in these patient groups4-6
There are clear and significant associations between eczema, acne and psoriasis with suicidal thoughts:7-9
Suicide ideation prevalence
Eczema, N=2350 (OR, 95%CI)
1.87 (1.31–2.68)7
Acne, N=2995 (OR, 95%CI)
1.80 (1.30–2.50)8
Psoriasis, N=149,998 (HR, 95% CI)
1.44 (1.32–1.57)9
CI, confidence interval; OR, odds ratio
1. Cvetkovski R, et al. Contact Dermatitis. 2006;54(2)
2. Dalgard F, et al. J Am Acad Dermatol. 2008;59(5):
3. Onderdijk AJ, et al. J Eur Acad Dermatol Venereol. 2013;27(4):
4. Gupta MA, Gupta AK. Br J Dermatol. 1998;139(5):
5. Sundstrom A, et al. BMJ. 2010;341:c5812.
6. Picardi A, et al. J Am Acad Dermatol. 2006;54(3):
7. Halvorsen JA, et al. J Invest Dermatol. 2014;134(7):
8. Halvorsen JA, et al. J Invest Dermatol. 2011;131(2):
9. Kurd SK, et al. Arch Dermatol. 2010;146(8):

32. Severe psychological symptoms
Suicidal behaviour in dermatology
In patients with common skin diseases (n=3635), compared with controls (n=1359), Dalgard et al1 found a significantly higher prevalence of:
Clinical depression
Anxiety
Suicidal ideation
10.1%
4.3%
17.2%
11.1%
12.7%
8.3% vs vs vs
Female dermatological patients (n=299) consistently exhibit more severe psychological symptoms than male patients (n=201) (p<0.001)2
Severe psychological symptoms
1. Dalgard FJ, et al. J Invest Dermatol. 2015;135(4):
2. Zachariae R, et al. Acta Derm Venereol. 2004;84(3):

33. Psoriasis and suicide >10%
Patients with psoriasis are at an increased risk for suffering from psychological comorbidities such as suicidal ideation, compared to patients with other dermatological conditions1
A European meta-analysis of 26 studies comparing patients with psoriasis (n=264,568) with healthy controls (n=1,174,612), found that
Compared with control groups and patients with other dermatologic conditions, patients with psoriasis have higher rates of
Stress, physical limitations and social stigma further the mental health issues experienced by patients with psoriasis6
Depression
Self-harm
Anxiety
Suicidal thoughts3-5
of patients with psoriasis >10% are clinically depressed2
>10%
1. Gupta MA, Gupta AK. Br J Dermatol. 1998;139(5):
2. Dowlatshahi EA, et al. J Invest Dermatol. 2014;134(6):
3. Kurd SK, et al. Arch Dermatol. 2010;146(8):
4. Dalgard FJ, et al. J Invest Dermatol. 2015;135(4):
5. Singhal A, et al. J R Soc Med. 2014;107(5):
6. Hrehorow E, et al. Acta Derm Venereol. 2012;92(1):67-72.

34. Suicide ideation in psoriasis
Studies: Dalgard et al
68%
of patients with psoriasis reporting suicidal thoughts, stated that their skin was the cause of their considering suicide1
1.94
Suicidal ideation in patients with common skin disorders (N=4994)
Psoriasis
Non-melanoma skin cancer
Nevi
Atopic eczema
Leg ulcers
Benign skin tumours
Hand eczema
Acne
Control
Eczema
Skin infections
1. Dalgard FJ, et al. J Invest Dermatol. 2015;135(4):

35. Atopic dermatitis (AD)
Other dermatological diseases and suicide
Aside from psoriasis, the most studied dermatological conditions in relation to suicidal ideation are
Acne
Atopic dermatitis (AD)
There are several studies that reported a high prevalence of suicidal ideation in patients with acne
Studies from several countries show a similar prevalence of suicidal thoughts in severe AD
Study country (N)
Pakistan (50)1
Italy (466)2
North America (72)3
Germany (181)4
Denmark (95)5
Japan
(4400)6 20
Prevalence of suicide ideation (%)
Severe disease 8 7 6 21 19 6
Moderate disease
Overall, the results of these studies suggest that patients with moderate to severe cases of acne or AD may be at a higher risk of attempting and completing suicide
1. Khan MZ, et al. J Ayub Med Coll Abbottabad. 2001;13(4):7-8.
2. Picardi A, et al. J Am Acad Dermatol. 2006;54(3):
3. Gupta MA, Gupta AK. Br J Dermatol. 1998;139(5):
4. Dieris-Hirche J, et al. Acta Derm Venereol. 2017;97:
5. Zachariae R, et al. Acta Derm Venereol. 2004;84(3):
6. Kimata H. Suicide Life Threat Behav. 2006;36(1):

36. There are several risk factors for suicide, including
Male gender*
Adolescent and young adult
Widowed, divorced or unmarried
Substance abuse
Personal depression
Family history of mental health disorders
Severe or chronic physical illness
Unemployment .
*Though men are statistically more likely to commit suicide than women, it is known that female patients are more likely to develop psychodermatological problems than male patients with skin disorders1
1. Picardi A, et al. J Am Acad Dermatol. 2006;54(3):

37. Do not fear a direct question
“Just ask”
Do not fear a direct question ?
Discussing suicide does not make it more likely that the patient will consider it
It is actually more probable that discussing it will mean that the patient is relieved that they are able to be open and understood1
1. Am J Psychiatry. 2003;160(11 Suppl):1-60.

38. What are the benefits of asking?
Most people who commit suicide make contact with a primary care physician within a month of their death.1-2 A lack of knowledge of what signs to look for in patients may contribute to the lack of treatment seen in most people who commit suicide
Based on the literature, it is likely that a significant proportion of dermatological patients are at an increased risk of suicide
It is unlikely that an unplanned suicide attempt can be prevented; however, a planned attempt could be. Suicidal ideation is associated with a significantly increased likelihood of planned suicidal behaviour,3 meaning that an intervention in those at risk, leading to early detection and treatment, could result in a substantial benefit4-6
Those patients that do come forward to seek help with their suicidal thoughts are in the minority, meaning that the dermatological consultation may be a rare opportunity to recognise the signs of suicide ideation and attempt to prevent further suicidal behaviours4-6
1. Luoma JB, et al. Am J Psychiatry. 2002;159(6):
2. Andersen UA, et al. Acta Psychiatr Scand. 2000;102(2):
3. Paykel ES, et al. Br J Psychiatry. 1974;124(0):
4. Picardi A, et al. J Am Acad Dermatol. 2006;54(3):
5. Kessler RC, et al. Arch Gen Psychiatry. 1999;56(7):
6. Wang J, et al. Can J Public Health. 2003;94(3):

39. How to make patients feel safe
Try to speak with the patient alone, as long as they are capable. They may be less likely to discuss these thoughts in front of a family member1
Begin with broader, more open questions, being more specific as the conversation moves forward2
When asking the patient about their thoughts and feelings, maintain an empathic and non-judgmental attitude and tone. This will strengthen the therapeutic relationship and make it less likely that the patient will feel emotions like shame or guilt2
In order to keep the flow of conversation natural and keep the patient at ease, ensure that you are familiar with any screening questions you wish to ask
Gliatto MF, Rai AK. Am Fam Physician. 1999;59(6):
Picardi A, et al. Clin Dermatol. 2013;31(1):47-56.

40. How to communicate
In order to ascertain a patient’s mental state, it is important to ask questions1 1. 2. 3.
When asking patients about suicidal ideation, it can be helpful to begin with a milder or more general question such as
If the patient responds with feelings that concern you, such as hopelessness or loss of interest, inquire further with questions relating to death wishes or depression such as
If the patient’s answers suggest that they have had such thoughts, you should continue with asking them about plans for suicide
How have you been feeling emotionally?
How does life seem at the moment?
Have you ever thought about you would commit suicide?
Have you taken any actions towards killing yourself?
Do you ever wish you could go to sleep and not wake up?
Have you ever felt that your life is not worth living?
1. Picardi A, et al. Clin Dermatol. 2013;31(1):47-56.

41. imminence of that behaviour1
Being at risk or a cry for help
If you feel that a patient shows a risk of suicide, further assessment needs to confirm the
imminence of that behaviour1 1.
Have they made plans?
Detailed and more violent planned methods of suicide, such as using firearms or jumping from a great height, present a greater risk of completed suicide2
If you are not confident about assessing any of these, please refer to a liaison psychiatrist4
If you can confirm that the patient is not at immediate risk and is safe, ensure that they are listened to and feel comforted
Do they fall into any of the high risk categories?2
Severe or chronic illness
Drug/alcohol abuse
Mental health co-morbidities 2.
Family history of mental health disorders
Widowed, divorced or unmarried
Unemployed
Male gender
Adolescent or young adult
Do they have “safe stops”?3 For example:
Religion
Family
Friends 3.
Are they at any immediate risk?
Do they have the means to commit suicide?2 4.
Is the patient safe or can they be made safe?
Inform a family member of your concerns4 5.
1. Galynker I, et al. Psychiatric Annals. 2014;44(9):
2. Picardi A, et al. Clin Dermatol. 2013;31(1):47-56.
3. Dervic K, et al. Am J Psychiatry. 2004;161(12):
4. Gupta MA, Gupta AK. Am J Clin Dermatol. 2003;4(12):

42. Immediate risk
If you think a patient is at immediate risk of suicide: !
It is imperative that the liaison psychiatry team is contacted as well as a family member1*
An emergency psychiatric evaluation must be undertaken
*It should be noted that different countries may have a different protocol. Please refer to your managing body’s advice
1. Gupta MA, Gupta AK. Am J Clin Dermatol. 2003;4(12):

43. Conclusions
Suicide ideation is common among patients with dermatological disease
However, very few patients will be immediately forthcoming when bringing up this topic
Therefore, remember to ask questions and listen to the patient
Discussing these topics openly will put your patient at ease and provide comfort
It allows the patient to have an opportunity to be open and connect with their HCP
Most importantly, it can prevent a psoriasis-related mortality
It is even more common among those patients with psoriasis
HCP, healthcare professional

44. Conclusions
It is important to know how to assess the likelihood of suicide ideation in patients
Identify their risk
Have there been previous attempts?
Have they written suicide notes?
Are they socially isolated?
Have they made any plans for suicide?
Do they suffer from a comorbid affective disease, such as depression?
Have they had recurrent thoughts or considerations surrounding suicide?
It should be noted that the majority of patients will not be at risk
If the risk is not immediate, be sure to continue to monitor them and ensure their safety
If you believe the risk to be imminent then refer the patient to a psychiatrist as soon as possible

45. Just ask

46. Are there any questions?