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The Murdough Family Center for Psoriasis: The Psychiatrist’s Role
on an Interdisciplinary Care Team
Joseph A. Locala, MD and Sarah Parsons, DO
Department of Psychiatry
STRATEGIC PLAN FOR THE PSORIASIS CENTER
ABSTRACT
Dermatology is a discipline in which psychosomatic issues serve a key role in the
understanding of the etiology and progression of skin diseases as well as determination of
appropriate treatment protocols. It is paramount for all clinicians involved in treating skin
disorders to take a holistic approach to the patient and address underlying psychosocial
needs and psychiatric disorders in order to achieve the best outcomes. Optimal care of the
dermatology patient should include careful screening for psychiatric issues and the
mechanism for either referral to external mental health providers or on-site psychiatric
liaison.
1
1
1
7
26
20%
13
10%
0%
Dermatology
Rheumatology
Psychiatry
Nutrition
Depressive D/O
Bipolar D/O
Alcohol Abuse
Adjustment D/O
Panic D/O
OCD
Anxiety, GAD
Pain D/O
ADHD
Secondary Psychiatric Diagnoses
SUMMARY OF FINDINGS
OPERATION OF THE MURDOUGH CLINIC
The Murdough Family Center Team
The Psoriasis Center functions as a true multidisciplinary clinic. Meeting monthly, patients
have the opportunity for consultation with a dermatologist, psychiatrist, rheumatologist, nurse
specialist and nutritionist. From the moment of intake, all facets of a patient’s care are
addressed, from clinical management to research possibilities in each discipline. When the
schedule permits, the entire treatment team performs the initial examination and historytaking together.
• Psychiatry consulted on 25 % of patients at University Hospitals Case Medical Center site in
2008.
• Most common primary psychiatric diagnoses were Major Depressive Disorder, Adjustment
Disorders and Generalized Anxiety Disorder/ Anxiety NOS.
• One patient required admission to psychiatry directly from clinic for suicidal ideation
• One patient required admission to chemical dependency treatment for alcohol dependence
and withdrawal
• Referrals of non-psoriasis patients by dermatology to UHCMC general med-psych
consultation clinic increased after the start of collaboration in Murdough Center.
• Collaboration has also led to current and future research projects such as: fMRI differences
in patients with psoriasis vs. normal controls, the effect of reiki and meditation on stress and
scope of psoriatic lesions and depression, cardiac comorbidity and neuroimmunology in
psoriasis patients.
UHCMC
Community
Depressive D/O
OCD
PTSD
Bereavement
Anxiety D/O
Alcohol Dep/Abuse
Social Anxiety
Panic
Personality D/O
Heroin Dep
CONCLUSIONS
•The implementation of a multidisciplinary clinic in dermatology has captured a patient
population in need of psychiatric treatment which might not typically occur.
•Higher rates of psychiatric comorbidity reported in the literature for psoriasis patients have
been confirmed in the clinical setting during participation in a subspecialty clinic.
•Interaction with other medical disciplines has led to an influx of referrals of non-psoriasis
patients to our Med-Psych Consultation Clinic.
•Multidisciplinary clinics are often the optimal setting for provision of care, however, limited
resources, low reimbursement for services and logistical obstacles often thwart efforts to
establish such a model.
ADDITIONAL RESOURCES
1. Murdough Family Center for Psoriasis website: www.murdoughpsoriasis.org
25
2. Locala JA. Current concepts in psychodermatology. Current Psychiatry Reports 2009,
11:211-218.
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3. Gupta MA, Gupta AK Ellis CN, et al. Psychiatric evaluation of the dermatology patient.
Dermatol Clin 2005, 23:591-599.
10
4. National Psoriasis Foundation Website: www.psoriasis.org
5. Listen to Dr Locala speak on NPR: Treating Stress and Skin Disease in Tandem
5
Total
13
30
20
2009
2
•Collaboration with medical colleagues from vastly different specialties has fostered an
interchange of ideas and served as a catalyst for research.
General Observations
Age Distribution of Patients (%)
2008
3
• 58 patients: 45 women, 13 men
• Recommended treatments: Combined medication and psychotherapy: 35 patients; Cognitive
behavioral therapy: 20 patients.
2007
1
2
• Initial triage – survey questionnaire is reviewed and plan for the visit determined
• Treatment room- each patient is assigned a specific exam room for the afternoon
• Coordination of care – a centralized board is maintained that indicates which services are
expected for each patient/room
• Communication – clinicians continually discuss the most logical order of providers based
upon availability - frequent curbside consultations take place
• Discussion – a final review of findings and plan occurs with all disciplines represented
300
250
200
150
100
50
0
1
2
Comprehensive Psychiatric Evaluations
• All patients referred for comprehensive psychiatric assessment had an Axis I psychiatric
diagnosis
Database Patients Enrolled at UHCMC vs.
Community
1
1
2
Patients are scheduled at intervals throughout an afternoon session. Coordination of services
involves several stages:
Patients are able to efficiently meet in one session with experts in each domain of their
psoriasis management. From a psychiatric standpoint, the stigma often associated with a
separate psychiatric appointment is absent when the psychiatrist is a member of the clinic
team. Brief psychiatric sessions to provide stress management techniques and education
regarding emotions and psoriasis are possible. When more significant issues are identified,
full psychiatric evaluations are performed in the same clinic visit.
The goals of the Center are as follows:
•To discover the causes of psoriasis
•To identify improved therapies for psoriasis
•To make new treatments for psoriasis available to patients more quickly
•To educate other physicians and the community about psoriasis and new
findings regarding the disease
1
1
30%
The delivery of care model for this interdisciplinary clinic will be discussed in detail along
with a description of the interaction between various specialists. Demographic data for our
patient population will be presented. Diagnoses encountered and treatment modalities will
also be discussed.
The Murdough Family Center for Psoriasis opened on April 25, 2007 at Bolwell Health
Center of University Hospitals Case Medical Center. This project was made possible by a
$5 million grant from the Murdough Foundation of Hudson, OH. The Center subsequently
received a $6.37 million Center of Research Translation (Cort) grant from the NIH which
allows the program to link physicians, researchers, community clinicians and public groups
in the pursuit of new therapies to provide relief for patients. Although initially designed to
treat patients from Northeastern Ohio, the Family Center draws numerous referrals from
other states. A community database has been established to track patients from private
dermatology offices throughout the region. Patients enrolled in the database are then
eligible for studies through the Center. This community outreach network of physicians is
called LIFEDERMNET (Leaders Initiative for Excellence in Dermatology Network).
Primary Psychiatric Diagnoses
2
40%
The best model of care appears to be an interdisciplinary clinic in which patients meet
providers from multiple specialties as part of a treatment team, thus reducing the stigma
associated with emotional issues. At University Hospitals Case Medical Center, we
launched the first interdisciplinary psoriasis clinic in the country (The Murdough Family
Center for Psoriasis). This clinic provides comprehensive, disease-specific care with a team
of dermatologists, psychiatrists, rheumatologists, nutritionists and nursing. Our observation
in the multidisciplinary psoriasis clinic is that patients who are reluctant to accept psychiatric
referral, more readily agree when the psychiatrist meets with them as part of the treatment
team.
BACKGROUND
Percentage of Patients Seen by Individual
Providers (2008)
www.npr.org/templates/story/story.php?storyid=112804905
0
15-24 25-34 35-44 45-54 55-64
Age (years)
>65