Barriers to Seeking Mental Health Services for Atopic Dermatitis Patients and Caregivers

Atopic dermatitis (AD) is a chronic, inflammatory skin condition associated with mental health (MH) burdens including depression, anxiety, and sleep problems in both paediatric and adult patients [1, 2]. Despite the established MH burden of AD, there remains a gap in diagnosis and treatment. A cross-sectional study of US households found that only 19.9% and 53.5% of paediatric AD patients with mild or severe mental disorders with impairment, respectively, had seen a MH professional in the last year [3]. This study aims to determine barriers to seeking MH services among adult AD patients and caregivers of children with AD. The National Eczema Association (NEA) conducted an online survey of adult patients with AD and caregivers of children aged 8–17 with AD from October to November 2022. Recruitment was conducted through NEA's website, email, social media, and EczemaWise app. Participants were given the definition for MH symptoms as: ‘…can be, but are not limited to, trouble sleeping, difficulty concentrating, poor appetite, feeling tired, little interest or pleasure in activities, and feeling hopeless.’ The definition of MH services was: ‘…can be, but are not limited to, programs, counseling, social support groups, treatment therapies, and/or assessments directed towards maintaining or improving an individual's mental health’. Participants provided electronic informed consent and were entered for a chance to receive 1 of 15 $100 Amazon gift cards. This study was deemed exempt by the Western Institutional Review Board Copernicus Group. Analyses were performed using R (4.4.1). Of the 1496 people who started the survey, 991 met inclusion criteria and 986 completed over 50% of the survey (986/1496; inclusion rate of 65.9%). The 986 participants had a median age of 33 years (IQR = 26–47), were mostly female (68.6%, n = 676), and White (66.4%, n = 655). There was no statistical difference in the extent of self-reported MH burden (the number of days with MH symptoms in the past month) between adults and children with AD. Adult patients had more moderate/severe AD, compared to children (as reported by caregivers), who had more clear/mild AD (p = 0.019). The majority of respondents held the belief that their or their child's MH was impacted by AD severity (79.8% of adults and 78.8% of caregivers). However, half (53.0%) of adults and 51.9% of caregivers had never sought MH services. Respondents who had never sought MH services reported the reasons (adult patients: n = 388; caregivers: n = 68) (Table 1). Many caregivers (39.7%) did not seek MH services for their child because they did not want to pressure them into using MH services. The largest barrier for both adults and caregivers was discomfort with discussing MH (adults: 25.3%; caregivers: 16.2%). The largest structural barriers were uncertainty in how to find an MH provider (18.9% of respondents) and assuming or knowing that insurance would not cover MH services (14.5% of respondents). Interestingly, 18.9% and 12.1% of respondents did not seek care because they did not think it would help or did not have confidence in the mental health system, respectively. Only 9.0% (n = 41) said they or their child did not need MH services. These findings underscore the opportunity and need for HCPs to normalise the burden of AD on MH, which may reduce stigma related to discussing MH concerns. Use of brief, open-ended questions and validated screening tools may invite patients to discuss MH concerns without a substantial time burden [4]. It may be helpful to provide basic education about how MH services may be helpful for patients and recommendations for how to access MH care [5, 6]. Recommendations for MH support may be offered in the context of shared decision making. Additionally, integrating MH professionals into AD care teams (with primary care, dermatology or allergy specialty clinics or as part of a multidisciplinary AD clinic) can increase access to support and may reduce stigma [7-9]. Limitations to this study include patient self-report and caregiver proxy report. Additionally, the convenience sample may not be representative of the general population, as participation required access to technology, connection to the NEA community, and willingness to complete the survey. The sample in this study was highly educated, with 49.9% (n = 492) of participants completing at least a four-year college degree. Considering the role of education in the propensity to seek MH care, the unmet need for MH care may be more pronounced among AD patients in the general population. In this national survey, over half of adults with AD and caregivers of children with AD had never sought MH services despite recognising an impact of AD on mental health. Discomfort discussing MH and uncertainty about how to access care were the most frequently reported barriers, alongside structural and attitudinal factors. These findings highlight a critical opportunity to reduce stigma, improve patient–provider communication, and facilitate access to MH resources through integrated, multidisciplinary AD care. Allison Loiselle, Jessica Johnson and Wendy Smith Begolka contributed to the study conception and design. Material creation and preparation were completed by Allison Loiselle and Jessica Johnson. Data collection and analysis were performed by Allison Loiselle and Courtney Chau. The first draft of the manuscript was written by Allison Loiselle, Courtney Chau, Jennifer LeBovidge and Lynda Schneider and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Allison Loiselle, Jessica Johnson and Wendy Smith Begolka contributed to the study conception and design. Material creation and preparation were completed by Allison Loiselle and Jessica Johnson. Data collection and analysis were performed by Allison Loiselle and Courtney A. Chau. The first draft of the manuscript was written by Allison Loiselle, Courtney A. Chau, Jennifer LeBovidge and Lynda Schneider and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. This study was reviewed and deemed exempt by the Western Institutional Review Board Copernicus Group. Respondents gave electronic consent. A.L. and J.J. work for the National Eczema Association, but have no other relevant disclosures. L.S. has served as investigator—Regeneron, DBV Technologies (Viaskin peanut patch), Emerald Innovations, Advisory Boards—DBV, Alladapt Immunotherapeutics, Triveni Bio, BioThea Pharmaceuticals, Ukko, Sanofi, Leo Pharmaceuticals, Regeneron, DAIT/NIAID, National Eczema Association. J.L. has served as a consultant for Global Parents for Eczema Research. W.S.B. has served as an advisory board member for Amgen, Pfizer and Sanofi receiving honoraria, and received research grants from Pfizer. The data that support the findings of this study are available from the corresponding author upon reasonable request.