Psoriasis: Guideline consultation - British Psychological Society response to the National Institute for Health & Clinical Excellence (NICE)

Our team of reviewers was pleased to see that throughout the draft guideline considerable recognition was given to the very high degree psychological distress and social interference associated with psoriasis. Assessment: In addition, the draft guideline document gives a strong steer on the need for regular assessment all aspects of well-being (including psychological well-being) and preferably at each point of contact between clinicians and patients. The guideline highlighted the very low levels of satisfaction with current care expressed by patients and emphasised the need to improve the quality of discussion and communication within consultations. This includes discussion about the impact of the psoriasis.The draft guideline outlines the need to develop new assessment tools. This formed the first research recommendation. In our response we suggested that new assessment tools needed to take account of additional key areas including: self-rated psoriasis severity, appearance-related distress, and coping, Psychological interventions: There was detailed consideration of the evidence base for cognitive-behavioural therapy (CBT) in the draft guideline. This was welcomed by the reviewers, however there were insufficient numbers of high quality studies on which to base recommendations for the management of psoriasis. Unfortunately this gap in the evidence was not then used as a reason to identify CBT as a key are for research within the list of research recommendations. We view this as a significant missed opportunity which would begin to address the high level of need for this population and strongly suggest that this is added to the published guideline as a research recommendation. Other psychological interventions (for example coping skills training) and arousal reduction techniques (such as mindfulness) were not included in the scope for guideline development. We would strongly argue that coping is crucial given the very high levels of smoking and alcohol use in this patient population which suggests that problematic coping responses are common. Most people with psoriasis are diagnosed as teenagers or young adults and unhelpful coping responses are likely to be maintained throughout adulthood without active intervention. Arousal reduction is also likely to be a fruitful area for further research given the increasing understanding of the relationship between stress and inflammatory responses. Thus whilst we accept that research findings into the effectiveness of psychological interventions are only just coming on stream, they are likely to be crucial in addressing the needs of this population and it was disappointing to find that this area was not identified as a key research recommendation. Self-Management: The major criticism the reviewers had of the draft guideline was that the main research recommendation in this area identified ‘psoriasis focused educational programmes’ despite the research evidence indicating little or no evidence for their efficacy. Instead we would strongly support research into theory-based self-management support interventions that take account of and address psychological factors such as beliefs, mood, and self-efficacy, factors which are known to influence self-management and which have been used as a basis for intervention development for other long-term conditions. There was helpful reference to the NICE Guideline 76 on Adherence which is strongly informed by evidence-based psychological theory and research. However, no valid and reliable method of assessing medication adherence for topical therapies currently exists meaning that an important outcome for evaluating self-management interventions is not available. Priority areas for future research identified by the team include: •Tailored cognitive and behavioural interventions (including CBT) and coping skills training for people with psoriasis•Basic research to increase understanding of cognitive and behavioural factors associated with successful psoriasis self-care activities such as medication adherence•Theory based psycho-educational interventions to optimise self-management for people with psoriasis•Basic theory-informed research to investigate the relationships between stress and psoriasis severity•Evaluation of arousal-reduction techniques to improve psychological and physical symptoms of psoriasis•Psychological interventions such as guided self-help for social anxiety and depression specifically developed for young people with psoriasis.