March 20, 2018

The Psychosocial Burden of Psoriatic Arthritis

How and why to assess and treat

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By M. Elaine Husni, MD, MPH, and Sara Davin, PsyD, MPH

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Patients diagnosed with psoriatic arthritis (PsA) experience significantly poorer health-related quality of life (QoL) than the general population and than those with psoriasis alone. Appropriate management from a multidisciplinary team of clinicians can lessen the psychosocial burden of this disease. We recently published a review of the literature regarding PsA and QoL and made recommendations based on our observations and clinical experiences to help physicians manage their patients with PsA.

Diminished QoL

Quality of life is significantly diminished in patients with PsA. Patients experience:

  • More comorbidities, with cardiovascular disease as the most common
  • Cosmetic effects that negatively impact self-image and emotional health
  • Pain, which has a bidirectional association with depression in patients with PsA
  • Sleep disorders, which are common in patients with PsA and contribute to diminished QoL and increased pain
  • Higher risk of depression, making adherence to treatment (and thus pain management and functional improvement) more difficult
  • Diminished physical function and productivity, which impacts self-worth and increases economic burden

Delays in diagnosis and treatment can significantly impact these QoL issues in patients with PsA. Delays in treatment mean more bone erosion and functional decline and further negative impacts on mental health and QoL. These delays are common given the lack of laboratory or imaging tests for the early diagnosis of PsA and how difficult the disease can be to diagnose, especially in early stages. The latest Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment guidelines recognize the major challenges inherent in early identification of PsA and call for better diagnostics and faster treatment as key research imperatives.

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Recommendations to assess and address QoL

Based on our literature review and clinical experiences, we recommend always assessing psychological parameters in addition to overall function in your patients with PsA. The patient interview is crucial and should include questions about the patient’s social functioning which can be a very revealing sign of impaired QoL. Further inquiry is warranted into symptoms that patients may tend to minimize on written assessment tools, such as mood.

Physicians should assess physical function, dermatology-specific measures, sleep and fatigue, depression and anxiety, and QoL in all PsA patients. Validated measures to assess psychosocial burden in patients with PsA include:

  • Short Form-36 (SF-36)
  • Psoriatic Arthritis Quality of Life (PsAQoL) instrument
  • Health Assessment Questionnaire (HAQ)
  • Pain Disability Index (PDI)
  • Dermatology Life Quality Index (DLQI) for patients with skin involvement (supplemented with an evaluation for itch)
  • Psoriasis Area and Severity Index (PASI)
  • Functional Assessment of Chronic Illness Therapy-fatigue (FACIT-fatigue) scale
  • Depression, Anxiety and Stress Scale (DASS-21)
  • Goldberg Anxiety and Depression scale-7 (GAD7)
  • EuroQol 5 domain (EQ-5D)
  • PsA Impact of Disease (PsAID) (a recently developed tool that needs further evaluation)

With a wealth of assessment tools at the rheumatologist’s disposal, a collaborative approach involving primary care, dermatology and behavioral health will allow the best assessment and treatment of psychosocial burden in patients with PsA. PsA is chronic, and assessment should be continuous. At Cleveland Clinic, patients complete questionnaires at each outpatient visit that focus on how they are living with their current immune-mediated diseases. Queries include level of pain, quality of life and mental health. This information is available to physicians during the visit to add the patient’s perspective to clinician evaluations of the exam and of laboratory and imaging results.

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QoL in clinical trials, management algorithms

This literature review is but a first step toward further research on QoL concerns in patients with PsA. We believe that future clinical trials must include evaluation of QoL concerns based on a core set of variables and assessment tools recently defined by a joint dermatology-rheumatology board. A recent, OMERACT-endorsed update to the PsA core domain set establishes evaluation of pain, global assessment, physical function, health-related QoL and fatigue as imperative to include in all studies, and emotional well-being, participation and economic cost as highly recommended. It’s also key that future care paths and management algorithms for the disease incorporate the psychosocial assessments mentioned above and the management of psychological, functional and physical concerns.

Dr. Husni is Director of the Arthritis and Musculoskeletal Treatment Center and Endowed Chair of Translational Functional Medicine Research at Cleveland Clinic. Dr. Davin is staff in the Center for Neuro-Restoration.

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