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Original Investigation
March 3, 2021

Association of Patient Mental Health Status With the Level of Agreement Between Patient and Physician Ratings of Psoriasis Severity

Author Affiliations
  • 1Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
  • 2St John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
  • 3Department of Psychological Medicine, King’s College London, London, United Kingdom
JAMA Dermatol. 2021;157(4):413-420. doi:10.1001/jamadermatol.2020.5844
Key Points

Question  Is a patient’s mental health status associated with discordance between patient and physician assessments of psoriasis severity?

Findings  In this cohort study of 502 patients with psoriasis, analysis of repeated cross-sectional data from a tertiary psoriasis service in London found discordance in patient and physician psoriasis severity ratings at 39% of the appointments. Twenty-six percent of the patients underestimated their psoriasis severity, and 13% of patients overestimated their psoriasis severity, compared with physician ratings.

Meaning  Although patient assessments of disease severity remain important for informing appropriate treatment decisions, the data from this study suggest that recognition of anxiety and depression among individuals with psoriasis is important for interpretation of the assessments.


Importance  The emerging paradigm of treat-to-target in psoriasis requires accurate monitoring of treatment response. The commonly used physician global assessment tool does not capture the patient’s perception of their disease. Patient assessments facilitate shared decision-making and foster patient-centered care; however, recent research reports a discordance between patient- and physician-reported psoriasis severity. Understanding the factors underlying this discordance may improve treatment satisfaction and disease outcomes.

Objectives  To evaluate the discordance between patient- and physician-reported measures of psoriasis severity and assess the association with patient mental health status.

Design, Setting, and Participants  A cohort study using repeated cross-sectional analysis of real-world longitudinal data was conducted at a large specialist psoriasis service serving London and Southeast England. A total of 502 patients attending the psoriasis service between May 12, 2016, and November 1, 2018, were included. Data analysis was conducted July 22 to October 22, 2019.

Main Outcomes and Measures  Psoriasis severity was assessed on each visit with identical 5-point physician and patient global assessment scales (clear/nearly clear, mild, moderate, severe, and very severe). Each patient completed validated self-report screens for depression and anxiety on each visit.

Results  Longitudinal data from 502 individuals with psoriasis (1985 total observations) were available. A total of 339 patients (68%) were men, 396 (79%) were White, mean (SD) age was 47 (13) years, and 197 patients (39%) had concurrent psoriatic arthritis, 43 (9%) screened positive for depression, and 49 (10%) screened positive for anxiety. There was discordance between physician and patient measures of disease severity in 768 of 1985 office appointments (39%); on 511 visits (26%) patients rated their psoriasis as less severe and on 257 visits (13%) patients rated their psoriasis as more severe compared with their physician. Individuals who screened 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.

Conclusions and Relevance  The findings of this cohort study suggest that discordance between patient and physician assessments of psoriasis severity is associated with patients’ mental health status. Recognition of anxiety and depression in individuals with psoriasis appears to be important when interpreting patient-reported outcome measures and informing appropriate treatment decisions.

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    1 Comment for this article
    Association of Patient Mental Health Status With the Level of Agreement Between Patient - Physician Ratings of Psoriasis Severity: A comment
    Esther Burden-Teh, BMBS PhD | Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham
    Jen Yates1 and Esther Burden-Teh2

    1. Institute of Mental Health, School of Medicine, University of Nottingham,
    Nottingham, UK
    2. Centre of Evidence Based Dermatology, School of Medicine, University of
    Nottingham, Nottingham, UK

    We are grateful to the authors for drawing attention to the importance of the relationship
    between mental health and psoriasis.

    The article suggests the physician’s assessment of psoriasis is the ‘correct’ reference; when
    a patient’s rating of their skin differed from that of the physician, the patient was by default
    incorrect (underestimating or overestimating their psoriasis). We feel this perspective
    presents a rather paternalistic
    view of doctor-patient relationships and does not
    acknowledge equality in the power-balance or patients as experts through lived experience.
    The mean age of patients (46.8 years) suggests substantial expertise of skin symptoms and
    treatment response.

    Whilst patients and physicians used the same rating scale to assess psoriasis, the constructs
    measured by each tool possibly differ. The interpretation of ‘mild’ psoriasis by physicians
    may focus on physical skin changes, whereas patients are more likely to assess their
    psoriasis holistically. For example, including symptoms and involvement of high impact sites.
    We acknowledge that the assessment tools used are standard measures, but they do not
    fully capture the diverse aspects of psoriasis that may lead to poorer quality of life and
    mental health issues.

    We would also like to propose an alternative interpretation on the direction of the
    relationship between mental health and discordance in severity score assessments. The
    authors conclude that mental health issues drive disagreement. However, potentially,
    differences in severity assessment, including a sense of not being heard, could lead to
    poorer mental health and thus explain the association.

    Finally, the authors raise concern that mental health issues may lead patients to report their
    psoriasis as more severe than the physician’s assessment, with implications for treatment.
    The positioning of this sentiment does raise concern, as it implies that patients with mental
    health conditions are not providing a trustworthy evaluation that is meaningful to them, and
    we would urge caution against this conclusion. Rather, this highlights a need for different
    person-based approaches to psoriasis management, such as keeping a photo diary.
    Incorporating mental health assessments and supporting mental well-being should be a
    normal part of psoriasis consultations. We agree mental health professionals should be
    embedded within psoriasis services, along with further training for all dermatology staff.
    Assessment tools to capture real lived experience and impact of psoriasis are needed in
    addition to objective assessments by physicians.

    We would like to thank and acknowledge colleagues at the Centre of Evidence Based
    Dermatology, University of Nottingham, for their comments and suggestions.