- Email: [email protected]
Hypertension and asthma: Psychological aspects
Sot. Sci. Med. Vol. 29, No. I, pp. 79-84, 1989
0277-953618953.00 + 0.00 Copyright 0 1989 Pergamon Press plc
Printed in Great Britain. All rights reserved
HYPERTENSION AND ASTHMA: PSYCHOLOGICAL ASPECTS FRANCES M. FORD,’ M. HUNTER, t* M. J. HENSLEY,’ A. GILLIES,*~ S. CARNEY,‘~ A. J. SbiI?-&*t J. BAMFORD,~? M. LENzER,3t G. LISTER,3t S. hvAzDY3t and M. STEYN3t
‘Department of Psychology, *Faculty of Medicine and %eneral Practitioners (Newcastle), University of Newcastle, NSW 2308, Australia Abstract-Essential hypertensive and asthmatic patients, plus normal non-clinical controls, were compared on a number of psychological measures in order to identify the relationship between psychological distress, coping strategies and compliance behaviour. The hypothesised relationship between chronic clinical ailments and psychological distress was confirmed. The association between the presence of physical symptoms in the symptomatic condition, asthma, and greater psychological distress was also
confirmed. The coping strategies adopted by the patients did not discriminate between the two clinical groups. Compliance with medication was negatively correlated with measures of psychological distress. Compliance with an appropriate healthy lifestyle was not correlated with medication compliance, although it too was negatively correlated with other measures of psychological distress. Key
rclords-hypertension,
asthma, psychological distress, compliance
INTRODUCTION
threat and develop other, perhaps inappropriate, coping behaviours. Strain [12] has suggested that maladaptive coping behaviour is related to depression, anxiety, sexual and work inhibitions and noncompliance. In the present study a group of patients with a chronic asymptomatic condition (hypertension) have been age matched and compared with a group of patients with a chronic symptomatic condition (asthma) on a number of questionnaire scales designed to measure psychological distress, coping and compliance. The investigation was carried out in order to assess the relationships between the presence or absence of symptoms, the extent of psychological distress, coping styles and compliance behaviour.
Compliance with medication and with medical advice concerning lifestyle changes has been found to depend upon patients’ perceptions and beliefs about the severity of their illness, and about the appropriateness of the treatment and advice offered to them [l, 21. This poses a problem in chronic, asymptomatic conditions such as essential hypertension, where compliance with long-term medication may seem to the patients to be unnecessary because they do not feel ill. For essential hypertensive patients the perceptions of their own relatively sound health, plus any negative experiences attributable to the side effects of treatment will encourage non-compliance and indeed, this is what has been found in previous studies [3-71. The influences on compliance behaviour are likely to be different in symptomatic conditions such as asthma, where the experience of asthmatic attacks provides ample evidence to the patient of the need for the treatment regimen. However, the distress caused to patients by the asthmatic attacks and the consequent anxiety associated with the condition [S] may cause distress to the sufferers. In turn, such distress has also been found to encourage non-compliance [9, 101. Compliance behaviour can also be seen as one aspect of a more broadly based coping response. According to this interpretation patients perceive their illness as a threat and may react to it in a number of ways [ 111. They may actively approach it in order to achieve some understanding of its implications and learn the appropriate responses, including those associated with medication; or they may attempt to avoid or deny the existence of the
METHODS
Three groups of subjects were selected for the present study. The first group consisted of 3 1 patients with essential hypertension (17 males, 14 females, age range 25-60 years, mean age 47.9 years) diagnosed as hypertensive on the basis of blood pressure measurements of 150/90mmHg or greater. These patients were asymptomatic, free from organic disease, free from renal impairment and were not suffering from asthma or any other identifiable complicating illness. At the time of testing all the subjects in this group had been stabilised for a period of at least 3 months on a regimen of beta-blockers with or without a diuretic. All were being monitored regularly in general practice or at out-patient clinics and all had been fully appraised of the long-term implications of their condition. The second group consisted of 14 asthmatic patients (6 males, 8 females, age range 27-60 years, mean age 47.5 years) who had been diagnosed on the basis of evidence of reversible airway obstruction. A frequency table of their recent clinical symptoms is shown in Table 1. These subjects were
*Requests for reprints should be addressed to: Dr M. Hunter, Department of Psychology, University of Newcastle, NSW 2308, Australia. tThe Hunter Region Hypertension Research Group. SSM 29 I--F
79
FRANCESM. FORD et
80
Table I. Symptoms reported by asthmatic patients occurring the week prior to testing (n = 14)
Sleep difficulty Breathless with exertion Breathless at rest Cough Wheeze
Moderate
None
Slight
4
4
2
I
I
7
6 6 4
2 2 2
3 5 4
within Severe 4 5 3
I 4
Table A.
I. 2. 3. 4. 5. 6.
normotensive, with no history of hypertension and were free from any other identifiable complicating illnesses. The patients were symptomatic and were being treated with a variety of medications including theophylline, corticosteroids, beta-agonists and preventative agents. The subjects were aware that their medications could relieve and prevent symptoms but that they could also result in unpleasant side effects. The normal healthy control group consisted of 27 subjects (16 males, 11 females, age range 25-60 years, mean age 42.9 years) taken from the general population. All were normotensive, non-asthmatic, were not suffering from any long-term illness and were not being treated with any long-term medication. Most of the testing took place in the subjects’ own homes after initial contact by telephone or at a clinic. After signing a written consent agreeing to take part in the study the subjects completed three written questionnaires and then responded to questions in a structured interview. The first questionnaire consisted of 50 items in five subscales (anxiety; depression; hostility; interpersonal sensitivity and somatisation) taken from the Symptom Checklist 90 (XL-90) [13]. This questionnaire was developed and has been used as a measure of psychological distress. The subscales measure general anxiety, depression, anger/hostility, social anxiety/ social fears and physical complaints. The second questionnaire consisted of 14 items, comprising two subscales [avoidance and intrusion (denial)] of the Impact of Event Scale (IES) [14], a measure of evasive. non-confronting coping in response to an identifiable stressor; plus the six-item Active Approach Set (AAS) [15], a measure of positive coping style. The AAS was slightly modified to assess coping with a prevailing condition rather than a specific event. This questionnaire was not administered to the normal control group since they were not having to cope with an identifiable clinical conditon. The third questionnaire consisted of a Symptom Questionnaire for Hypertensive Patients [ 161, plus a list of symptoms associated with treatments for asthma [ 171.This provided a profile of symptoms and the side-effects of treatment for hypertension and asthma. This questionnaire was also considered inappropriate for administration to the normal control subjects. Finally, the structured interview consisted of questions concerning the subjects’ demographic profile (e.g. age, marital status, educational achievement, occupation), plus, in the case of hypertensive and asthmatic subjects, questions relating to the subjects compliance behaviour (see Table 2). The difficulty of relying on self-report measures of compliance has been discussed by others [18]. In order to control for
7. 8. 9.
10.
al.
2. Structured
Compliance
with
interview
questions behaviour
concerning
compliance
medication
What medicauons do you take? How often are you suppossed to take them? Do you always take them when you are supposed to? If you don’t take them when you are supposed to, do you take them at other times? In other words. do you ‘catch up’? Do you ever forget to take your medication? If so. how often do you forget (everyday/every 2 or 3 daysionce a week/only once or twice a month/less than that)? Do you often deliberately not take your medication? If so, why is this? How often does this occur m. say. a week (I 2.314’5 or more times)? Does anyone (e.g. spouse or partner) remmd you about taking your medication?
B. Comdiance
with
aoorotriare
liiestvle
~atte~n.r
Dih you smoke bhfdre diagno&? 2. Have you cut down or stopped smoking? 3. Number/day smoked before. Number/day smoke now. 4. Did you drink alcohol before diagnosis? 5. Have you cut down or stopped drinking alcohol? 6. Amount/day be-fore.. Amount/day now. 7. Were you overweight before diagnosis? 8. Are you now on a special diet? 9. Have you lost weight since diagnosis? IO. Previous stable weight. Current weight 11. Do you take any regular exercise or play any sport? I.
gross inaccuracies of self reported compliance, tablet counts were made where possible and for the hypertensive group, who were all taking beta-blockers, the two-step test of Master and Rosenfeld [19] was also carried out at the time of testing. RESULTS
Mean scores and standard deviations for all groups on the various psychological measures are shown in Table 3. Group mean scores and standard errors are illustrated in Fig. 1. Statistical analysis by analysis of variance revealed significant group differences in the subscales of anxiety [F(2, 71) = 11.97; P < 0.011; depression [F(2,71) = 6.92; P < 0.011; hostility [F(2,71) = 6.15; P < 0.011 and somatisation [F(2,71) = 8.09; P < 0.011. The group differences in interpersonal sensitivity [F(2, 71) = 3. lo] approach, but do not achieve, statistical significance at the 0.05 level. These data indicate that both the asthmatic and hypertensive patients show greater psychological distress than the normal control subjects, with the symptomatic asthmatic patients showing the greatest degree of psychological distress. Differences between the hypertensive and asthmatic groups in the subscales of avoidance [F( 1,44) = 0.801; intrusion (denial) [F(2,44) = 0.761 and active approach [F( 1,44) = 0.741 were not statistically significantly different, suggesting that the coping styles adopted by the two clinical groups are similar. Compliance with medication and with an appropriate healthy lifestyle was rated on a four-point scale [good compliance (4); moderate compliance (3); rather poor compliance (2); very poor compliance (l)] on the basis of the subjects’ responses to the
Hypertension and asthma
81
Table 3. Mean scores and standard deviations for hypertensive, asthmatic and normal health control subjects on the psychological and coping assessment scales Measuring
instrument
SCL-90 Subscale anxiety
x SD x SD * SD
Subscale depression Subscale hostility Subscale somatisation
:D Subscale interpersonal
sensitivity ;D
Hypertcnsivcs (n = 31)
Asthmatics (n = 14)
Healthy (n = 27)
7.07 5.89 12.03 9.39 4.74 4.40 9.19 6.61 6.68 7.05
12.29 8.13 16.07 Il.25 5.21 3.45 15.86 7.81 7.43 5.72
3.77 2.97 6.33 4.14 I .85 2.03 6.63 5.94 4.0 3.12
1.74 4.88 5.29 3.71 7.0 4.67
6.29 4.20 4.36 3.52 8.5 3.88
Impactof even,scale Subscale avoidance CD Subscale intrusion Active approach
;D x SD
set
structured interview questions and the additional information from tablet counts and in the hypertensive patients, the two-step test. Each subject was rated independently by two of the investigators (F.M.F. and M.H.) with an inter-rater reliability of 0.75. Points of disagreement were resolved by accepting either the mean or the more favourable rating, that is, the rating of greater compliance. The means and standard deviations for the compliance ratings and also for the numbers of side-
effects reported by the hypertensive and asthmatic subjects are presented in Table 4. There is no between group difference in medication compliance ratings (t = 0.44, P = 0.66). However, the lifestyle compliance ratings did show that the asthmatic patients were more compliant than the hypertensives (t = 2.08, P = 0.047). The comparison between ciinical groups for the number of reported symptoms and side-effects of treatment approaches, but does not reach, statistical significance with the asthmatics
20
16
16
q
14
Asthmotcs
BiY
Controts
12
10
-T
T
6
2
3
5
6
Fig. !l. Group mean scores and standard errors for the hypertensive, asthmatic and normal healthy control subjects on the psychological and coping assessment scales.
FRANCES
82
M. FORDet
al.
Table 4. Means and standard deviations for the compliawe ratings and also for the numbers of reported side-effects experienced by the hypertensive and asthmatic subjects Medication compliance rating (4 = very good; I = very poor)
Hypertensives Asthmatics
Lifestyle compliance rating (4 = very good: I = very poor)
Number of symptoms and side-effects reported
x
SD
x
SD
x
SD
2.9 3.07
1.14 I.21
2.68 3.31
1.05 0.86
3.13 5.50
2.72 4.03
reporting a greater number (r = 1.88, P = 0.08). The side-effects most frequently reported by the asthmatic subjects were increased appetite and weight gain, headaches, dry mouth, nausea, palpitations, faintness, sleepiness, agitation and sore throat. Those reported most frequently by the hypertensive subjects were headaches, agitation, loose bowel movement, sleepiness, palpitations, weight gain, nausea and weakness of the limbs. In order to further assess the relationship between compliance ratings and the other experimental variables in the two clinical groups a stepwise regression analysis was performed. For hypertensive patients, with medication compliance held as the independent variable, the only dependent variable to show a significant relationship was avoidance [R = -0.507; F( 1) = 10.021. When lifestyle compliance was held as the independent variable, the only dependent variable to show a significant relationship was interpersonal sensitivity [R = -0.516; F(1) = IOS]. For the asthmatic group, medication compliance yielded two steps, comprising the variables of interpersonal sensitivity [R = -0.711; F(1) = 1I.221 and the number of reported symptoms and side-effects [R = 0.554; F(1) = 14.81. No steps were elicited for lifestyle compliance with the asthmatic group. Perhaps the most striking feature of this analysis is the relationship between compliance and interpersonal sensitivity. This variable appears to bear an important relationship to compliance for both groups, although what is compiled with, either medication or an appropriate lifestyle, differs for the two groups. Nevertheless, the importance of the variable indicates that patients’ responses to their clinical condition are dependent in part upon perceived social attitudes to it and their sensitivity to these attitudes. The relevance of avoidance in the hypertensive group is also of interest since it suggests that this is a particularly inappropriate and unhelpful coping strategy in these patients, even though the degree to which it is used does not differ between the two clinical groups. Finally, in order to illustrate the relationship between the experimental variables overall, a correlation matrix showing the product moment correlations of the compliance ratings, the side-effects reported and the measures of psychological distress are presented in Table 5. As can be seen in this table there is a close relationship between nearly all the subscales of psychological distress and also between these subscales and the measures of coping. It can also be seen that there is no statistically significant correlation between the ratings for medication compliance and compliance with a healthy lifestyle [r(43) = O.lOl]. However, compliance with medication is negatively
correlated with depression [r(43) = -0.3291, hostility [r(43) = -0.3731 and also, with both avoidance [r(43) = -0.4401 and approach [r(43) = -0.3141 coping styles. Compliance with a healthy lifestyle is negatively correlated with interpersonal sensitivity [r(43) = - 0.3951. The number of side-effects reported by the clinical patients is positively correlated with anxiety. depression, hostility, somatisation, interpersonal sensitivity, avoidance and approach. DISCUSSION
There are three main conclusions to be drawn from the present investigation. Firstly, these data demonstrate that a chronic clinical condition, symptomatic or asymptomatic, is associated with severe psychological distress. This confirms the earlier findings of Sackett and others [3-6,8]. Moreover, our data suggest that the symptomatic condition, asthma, causes greater psychological distress than the asymptomatic condition, essential hypertension. This result is the more striking since the group sample sizes are not large. The differences in psychological distress between the two clinical groups cannot be attributed to the co-variables of age and sex in spite of the imperfect sex matching, since statistical comparison of these co-variables by analysis of co-variance yielded no significant differences. It would seem from these data that certain clinical conditions are more prone to psychological distress than others. Such a finding conflicts with the study of Viney and Westbrook [20] who were unable to distinguish between a variety of chronic illnesses in terms of measures of psychological distress. However, all the clinical conditions of their patients were symptomatic. We would suggest that the presence of symptoms in a chronic illness is an important variable in determining the severity of psychological distress. Secondly, the coping patterns of both our clinical groups were similar. Table 5 shows that all three coping styles are highly significantly correlated with each other. In addition, ail three are significantly and positively correlated with anxiety, depression and interpersonal sensitivity, confirming that psychological distress requires some sort of coping strategy. Avoidance and approach are also positively correlated with the number of reported side-effects of treatment, suggesting that the presence of unpleasant side-effects requires additional coping resources. The finding that the coping strategies, approach and avoidance, are positively correlated may at first appear contradictory. It seems intuitively unlikely that patients will both approach their clinical condition positively and also take steps to avoid confronting their situation. Nevertheless, anecdotal evidence
Hypertension and asthma
“O!S”J,“,
@ISOH
uo!ssaJdaa
83
taken from our interviews with patients suggests that many actively seek the best advice concerning their condition, but then completely fail to accept or comply with this advice and subsequently adopt an attitude of avoidance and denial. This suggestion is provided with some circumstantial support by the fact that both avoidance and approach are significantly negatively correlated with compliance with medication. In other words, patients may know why they should comply with their medication but they still do not. The resolution of this apparent paradox may be found in the model suggested by Mime [ 1l] where the threat posed by an illness (or even merely the diagnosis of illness) requires the patient to learn coping mechanisms. The learning process will involve a careful evaluation by the patient of the reasons, both for and against compliance. before a behavioural coping strategy is adopted. In this way the approach and avoidance coping strategies may vie for supremacy until a decision is made to comply with medication or not. A similar response pattern has recently been reported by Prochaska et al. [21] with respect to compliance with a programme for quitting cigarette smoking. These investigators found that when smokers attempted to quit smoking their ratings of the importance of arguments both for and against smoking rose in parallel. Once a behavioural response, quitting or not, had been adopted then the ratings of the relative importance of arguments for and against smoking was found to vary in accordance with the adopted response. According to this interpretation, the process of learning to cope may involve the adoption of sometimes conflicting response patterns until the cognitive and behavioural changes necessary for adapting to the situation are made. In terms of patient management the important implication here is that a positive, interested and enquiring response on the part of the patient to guidance provided by the doctor, is no guarantee that the patient will comply with the help and advice proffered. Thirdly, the data concerning compliance behaviour yield two distinct and uncorrelated response patterns, one relating to compliance with medication and the other to lifestyle compliance. Compliance with medication is negatively correlated with depression and anxiety. This confirms the hypothesised relationship between psychological distress and poor compliance with medication 19, lo]. Nevertheless, there are differences in medication compliance between the clinical groups indicated by the regression analysis. For the hypertensive subjects the greater their avoidance the less compliant their behaviour, suggesting that for these patients avoidance is a particularly unhelpful coping mechanism. For the asthmatic patients, the greater their interpersonal sensitivity and the greater their reported number of symptoms and side-effects of treatment the poorer their compliance with medication. This suggests that asthmatics are pushed towards non-compliance by their own social sensitivity and by the number of complaints associated with their clinical condition. However, the unpleasant symptoms and side-effects of treatment in the asthmatic subjects do not translate into significantly poorer medication compliance overall since there is no statistical difference between the asthmatic and
Fru~c~s
84
M. FORD et al
hypertensive subjects in their ratings for compliance with-medication (Table 4). In other words, in spite of the distress attributable to the symptoms and side-effects, the need for relief from physical symptoms will over-ride non-compliance in the asthmatic subjects. Compliance with an appropriate healthy lifestyle also appears to be resistant to change. The negative relationship between interpersonal sensitivity and both medication compliance for the asthmatics and lifestyle compliance for the hypertensives, shown in the regression analysis, suggests that patients who are self-conscious and lack self-confidence in social settings are particularly resistant to changing their behaviour in an appropriate manner. Consequently, the social components of making significant lifestyle changes, such as refusing a cigarette or jogging around the neighbourhood, may make these changes very difficult, particularly for hypertensive patients. Nonetheless, the value of adopting such changes has been demonstrated by studies that have shown the effectiveness of lifestyle changes in treating chronic conditions such as hypertension [22,23]. Perhaps in this regard the presence of physical symptoms can be effective in controlling behaviour, since the asthmatic subjects showed significantly greater compliance with a desirable lifestyle than the hypertensive subjects.
8.
9.
10.
11.
12. 13.
14.
15. 16.
17. Acknowledgement-We
are grateful
to MS
Helen Dickey
(R.N.) for her help during this investigation.
18.
REFERENCES
1. Rosenstock I. M. Why people use health services. Milbank Meml Fund Q. 44, 94-124. 1966. 2. Becker M. H. and Maiman L. A. Sociobehavioural determinants of compliance with health and medical care recommendations. Med. Care 13, 10-24. 1975. 3. Caldwell J. R., Cobb S., Dowling M. D. and De Jongh D. The drop-out problem in antihypertensive therapy. J. chron. Dis. 22, 579-592, 1970. 4. Sackett D. L. Magnitude of compliance and noncompliance. In Compliance with Therapeutic Regimens (Edited by Sackett D. L. ef al.). Johns Hopkins University Press, Baltimore, Md. 1976. 5. Johnson A. L., Taylor D. W.. Sackett D. L., Dunnett C. W. and Shimizu A. G. Self-recording of blood pressure in the management of hypertension. Ann. R. CON. Phys. Surg. Can., 10, 32, 1977. 6. Sackett D. L., Taylor D. W., Haynes R. B., Johnson A. L., Gibson E. S. and Roberts, R. S. Compliance with the therapeutic regimen. In Mild Hypertension: Natural Hisrory and Management? (Edited by Gross F. er al.). Pitman Medical, London. 1979.
19.
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23.
Luscher T. F., Vetter H.. Seigenthaler W. and Vetter W. Compliance in hypertension; facts and concepts. J. Hyperlens. suppl. 1 3, 3-9. 1985. Viney L. L. and Westbrook M. T. Patterns of psychological reaction to asthma in children. J. Abnorm. Child Psychol. 13, 477-484. 1985. Egan K. J., Kogan H. N., Garber A. and Jarrett R. N. The impact of psychological distress on the control of hypertension. J. Human Stress 9, 4-10. 1983. Blumenthal J. A., Williams R. S., Wallace A. G., Williams R. B. and Needles T. L. Physiological and psychological variables predicting compliance to prescribed exercise therapy in patients recovering from myocardial infarction. Psychosom. Med. 44, 519-527, 1982. Milne B. J. Coping with the diagnosis of hypertension: an illustration of a conceptual model. Nurs. Pap. 15, 34-42, 1983. Strain J. J. Psychological Interventions in Medical Practice. Appleton-Century-Crofts, New York. 1978. Derogatis L. R., Lipman R. S. and Covi L. The SCL-90: an outpatient psychiatric rating scale-preliminary report. Psychopharmac. Bull. 9, 13-28. 1975. Horowitz M., Wilner N. and Alvarez W. Impact of event scale: a measure of subjective stress. Psychosom. Med. 41, 209-218. 1979. Cohen L. and Roth S. Coping with abortion. J. Human Stress 10, 140-145, 1984. Bulpitt C. J., Dollery C. T. and Carne S. A symptom questionnaire for hypertensive patients. J. chron. Dis. 27, 309-321, 1974. Lelah T., Harris L. J., Avery C. H. and Brook R. H. Asthma in children and adults. Med. Care suppl. 15, 106-148, 1977. Roth H. P. Problems in conducting a study of the effects on patient compliance of teaching the rationale for antacid therapy. In Nenl Directions in Patient Compliance (Edited by Cohen S. J.). Heath & Coy, Lexington, Mass., 1979. Master A. M. and Rosenfeld I. Two-step exercise test: current status after 25 years. Mod. Concepts Cardiovasc. Dis. 36, 19, 1967. Viney L. L. and Westbrook M. T. Psychological reactions to chronic illness and related disability as a function of its severity and type. J. ps.vchosom. Res. 25, 513-523, 1981. Prochaska J. 0.. Vellicer W. F.. Di Clemente C. C. and Fava J. Measuring processes of change: applications to the cessation of smoking. J. Consult. C/in. Psychol. 56, 520-528, 1988. Jennings G., Nelson L., Burton D., Esler M., Leonard P. and Korner P. Increased physical activity lowers blood pressure and sympathetic tone. Paper presented at the Sixlh Scienrific Meering of rhe High Blood Pressure Research Council of Ausrralia. December 1984. MacMahon S. W., MacDonald G. J.. Bernstein L., Andrews G. and Blacket R. B. Comparison of weight reduction with metoprolol in the treatment of hypertension in young overweight patients. Lance! 1, 1233-1236, 1985.
0277-953618953.00 + 0.00 Copyright 0 1989 Pergamon Press plc
Printed in Great Britain. All rights reserved
HYPERTENSION AND ASTHMA: PSYCHOLOGICAL ASPECTS FRANCES M. FORD,’ M. HUNTER, t* M. J. HENSLEY,’ A. GILLIES,*~ S. CARNEY,‘~ A. J. SbiI?-&*t J. BAMFORD,~? M. LENzER,3t G. LISTER,3t S. hvAzDY3t and M. STEYN3t
‘Department of Psychology, *Faculty of Medicine and %eneral Practitioners (Newcastle), University of Newcastle, NSW 2308, Australia Abstract-Essential hypertensive and asthmatic patients, plus normal non-clinical controls, were compared on a number of psychological measures in order to identify the relationship between psychological distress, coping strategies and compliance behaviour. The hypothesised relationship between chronic clinical ailments and psychological distress was confirmed. The association between the presence of physical symptoms in the symptomatic condition, asthma, and greater psychological distress was also
confirmed. The coping strategies adopted by the patients did not discriminate between the two clinical groups. Compliance with medication was negatively correlated with measures of psychological distress. Compliance with an appropriate healthy lifestyle was not correlated with medication compliance, although it too was negatively correlated with other measures of psychological distress. Key
rclords-hypertension,
asthma, psychological distress, compliance
INTRODUCTION
threat and develop other, perhaps inappropriate, coping behaviours. Strain [12] has suggested that maladaptive coping behaviour is related to depression, anxiety, sexual and work inhibitions and noncompliance. In the present study a group of patients with a chronic asymptomatic condition (hypertension) have been age matched and compared with a group of patients with a chronic symptomatic condition (asthma) on a number of questionnaire scales designed to measure psychological distress, coping and compliance. The investigation was carried out in order to assess the relationships between the presence or absence of symptoms, the extent of psychological distress, coping styles and compliance behaviour.
Compliance with medication and with medical advice concerning lifestyle changes has been found to depend upon patients’ perceptions and beliefs about the severity of their illness, and about the appropriateness of the treatment and advice offered to them [l, 21. This poses a problem in chronic, asymptomatic conditions such as essential hypertension, where compliance with long-term medication may seem to the patients to be unnecessary because they do not feel ill. For essential hypertensive patients the perceptions of their own relatively sound health, plus any negative experiences attributable to the side effects of treatment will encourage non-compliance and indeed, this is what has been found in previous studies [3-71. The influences on compliance behaviour are likely to be different in symptomatic conditions such as asthma, where the experience of asthmatic attacks provides ample evidence to the patient of the need for the treatment regimen. However, the distress caused to patients by the asthmatic attacks and the consequent anxiety associated with the condition [S] may cause distress to the sufferers. In turn, such distress has also been found to encourage non-compliance [9, 101. Compliance behaviour can also be seen as one aspect of a more broadly based coping response. According to this interpretation patients perceive their illness as a threat and may react to it in a number of ways [ 111. They may actively approach it in order to achieve some understanding of its implications and learn the appropriate responses, including those associated with medication; or they may attempt to avoid or deny the existence of the
METHODS
Three groups of subjects were selected for the present study. The first group consisted of 3 1 patients with essential hypertension (17 males, 14 females, age range 25-60 years, mean age 47.9 years) diagnosed as hypertensive on the basis of blood pressure measurements of 150/90mmHg or greater. These patients were asymptomatic, free from organic disease, free from renal impairment and were not suffering from asthma or any other identifiable complicating illness. At the time of testing all the subjects in this group had been stabilised for a period of at least 3 months on a regimen of beta-blockers with or without a diuretic. All were being monitored regularly in general practice or at out-patient clinics and all had been fully appraised of the long-term implications of their condition. The second group consisted of 14 asthmatic patients (6 males, 8 females, age range 27-60 years, mean age 47.5 years) who had been diagnosed on the basis of evidence of reversible airway obstruction. A frequency table of their recent clinical symptoms is shown in Table 1. These subjects were
*Requests for reprints should be addressed to: Dr M. Hunter, Department of Psychology, University of Newcastle, NSW 2308, Australia. tThe Hunter Region Hypertension Research Group. SSM 29 I--F
79
FRANCESM. FORD et
80
Table I. Symptoms reported by asthmatic patients occurring the week prior to testing (n = 14)
Sleep difficulty Breathless with exertion Breathless at rest Cough Wheeze
Moderate
None
Slight
4
4
2
I
I
7
6 6 4
2 2 2
3 5 4
within Severe 4 5 3
I 4
Table A.
I. 2. 3. 4. 5. 6.
normotensive, with no history of hypertension and were free from any other identifiable complicating illnesses. The patients were symptomatic and were being treated with a variety of medications including theophylline, corticosteroids, beta-agonists and preventative agents. The subjects were aware that their medications could relieve and prevent symptoms but that they could also result in unpleasant side effects. The normal healthy control group consisted of 27 subjects (16 males, 11 females, age range 25-60 years, mean age 42.9 years) taken from the general population. All were normotensive, non-asthmatic, were not suffering from any long-term illness and were not being treated with any long-term medication. Most of the testing took place in the subjects’ own homes after initial contact by telephone or at a clinic. After signing a written consent agreeing to take part in the study the subjects completed three written questionnaires and then responded to questions in a structured interview. The first questionnaire consisted of 50 items in five subscales (anxiety; depression; hostility; interpersonal sensitivity and somatisation) taken from the Symptom Checklist 90 (XL-90) [13]. This questionnaire was developed and has been used as a measure of psychological distress. The subscales measure general anxiety, depression, anger/hostility, social anxiety/ social fears and physical complaints. The second questionnaire consisted of 14 items, comprising two subscales [avoidance and intrusion (denial)] of the Impact of Event Scale (IES) [14], a measure of evasive. non-confronting coping in response to an identifiable stressor; plus the six-item Active Approach Set (AAS) [15], a measure of positive coping style. The AAS was slightly modified to assess coping with a prevailing condition rather than a specific event. This questionnaire was not administered to the normal control group since they were not having to cope with an identifiable clinical conditon. The third questionnaire consisted of a Symptom Questionnaire for Hypertensive Patients [ 161, plus a list of symptoms associated with treatments for asthma [ 171.This provided a profile of symptoms and the side-effects of treatment for hypertension and asthma. This questionnaire was also considered inappropriate for administration to the normal control subjects. Finally, the structured interview consisted of questions concerning the subjects’ demographic profile (e.g. age, marital status, educational achievement, occupation), plus, in the case of hypertensive and asthmatic subjects, questions relating to the subjects compliance behaviour (see Table 2). The difficulty of relying on self-report measures of compliance has been discussed by others [18]. In order to control for
7. 8. 9.
10.
al.
2. Structured
Compliance
with
interview
questions behaviour
concerning
compliance
medication
What medicauons do you take? How often are you suppossed to take them? Do you always take them when you are supposed to? If you don’t take them when you are supposed to, do you take them at other times? In other words. do you ‘catch up’? Do you ever forget to take your medication? If so. how often do you forget (everyday/every 2 or 3 daysionce a week/only once or twice a month/less than that)? Do you often deliberately not take your medication? If so, why is this? How often does this occur m. say. a week (I 2.314’5 or more times)? Does anyone (e.g. spouse or partner) remmd you about taking your medication?
B. Comdiance
with
aoorotriare
liiestvle
~atte~n.r
Dih you smoke bhfdre diagno&? 2. Have you cut down or stopped smoking? 3. Number/day smoked before. Number/day smoke now. 4. Did you drink alcohol before diagnosis? 5. Have you cut down or stopped drinking alcohol? 6. Amount/day be-fore.. Amount/day now. 7. Were you overweight before diagnosis? 8. Are you now on a special diet? 9. Have you lost weight since diagnosis? IO. Previous stable weight. Current weight 11. Do you take any regular exercise or play any sport? I.
gross inaccuracies of self reported compliance, tablet counts were made where possible and for the hypertensive group, who were all taking beta-blockers, the two-step test of Master and Rosenfeld [19] was also carried out at the time of testing. RESULTS
Mean scores and standard deviations for all groups on the various psychological measures are shown in Table 3. Group mean scores and standard errors are illustrated in Fig. 1. Statistical analysis by analysis of variance revealed significant group differences in the subscales of anxiety [F(2, 71) = 11.97; P < 0.011; depression [F(2,71) = 6.92; P < 0.011; hostility [F(2,71) = 6.15; P < 0.011 and somatisation [F(2,71) = 8.09; P < 0.011. The group differences in interpersonal sensitivity [F(2, 71) = 3. lo] approach, but do not achieve, statistical significance at the 0.05 level. These data indicate that both the asthmatic and hypertensive patients show greater psychological distress than the normal control subjects, with the symptomatic asthmatic patients showing the greatest degree of psychological distress. Differences between the hypertensive and asthmatic groups in the subscales of avoidance [F( 1,44) = 0.801; intrusion (denial) [F(2,44) = 0.761 and active approach [F( 1,44) = 0.741 were not statistically significantly different, suggesting that the coping styles adopted by the two clinical groups are similar. Compliance with medication and with an appropriate healthy lifestyle was rated on a four-point scale [good compliance (4); moderate compliance (3); rather poor compliance (2); very poor compliance (l)] on the basis of the subjects’ responses to the
Hypertension and asthma
81
Table 3. Mean scores and standard deviations for hypertensive, asthmatic and normal health control subjects on the psychological and coping assessment scales Measuring
instrument
SCL-90 Subscale anxiety
x SD x SD * SD
Subscale depression Subscale hostility Subscale somatisation
:D Subscale interpersonal
sensitivity ;D
Hypertcnsivcs (n = 31)
Asthmatics (n = 14)
Healthy (n = 27)
7.07 5.89 12.03 9.39 4.74 4.40 9.19 6.61 6.68 7.05
12.29 8.13 16.07 Il.25 5.21 3.45 15.86 7.81 7.43 5.72
3.77 2.97 6.33 4.14 I .85 2.03 6.63 5.94 4.0 3.12
1.74 4.88 5.29 3.71 7.0 4.67
6.29 4.20 4.36 3.52 8.5 3.88
Impactof even,scale Subscale avoidance CD Subscale intrusion Active approach
;D x SD
set
structured interview questions and the additional information from tablet counts and in the hypertensive patients, the two-step test. Each subject was rated independently by two of the investigators (F.M.F. and M.H.) with an inter-rater reliability of 0.75. Points of disagreement were resolved by accepting either the mean or the more favourable rating, that is, the rating of greater compliance. The means and standard deviations for the compliance ratings and also for the numbers of side-
effects reported by the hypertensive and asthmatic subjects are presented in Table 4. There is no between group difference in medication compliance ratings (t = 0.44, P = 0.66). However, the lifestyle compliance ratings did show that the asthmatic patients were more compliant than the hypertensives (t = 2.08, P = 0.047). The comparison between ciinical groups for the number of reported symptoms and side-effects of treatment approaches, but does not reach, statistical significance with the asthmatics
20
16
16
q
14
Asthmotcs
BiY
Controts
12
10
-T
T
6
2
3
5
6
Fig. !l. Group mean scores and standard errors for the hypertensive, asthmatic and normal healthy control subjects on the psychological and coping assessment scales.
FRANCES
82
M. FORDet
al.
Table 4. Means and standard deviations for the compliawe ratings and also for the numbers of reported side-effects experienced by the hypertensive and asthmatic subjects Medication compliance rating (4 = very good; I = very poor)
Hypertensives Asthmatics
Lifestyle compliance rating (4 = very good: I = very poor)
Number of symptoms and side-effects reported
x
SD
x
SD
x
SD
2.9 3.07
1.14 I.21
2.68 3.31
1.05 0.86
3.13 5.50
2.72 4.03
reporting a greater number (r = 1.88, P = 0.08). The side-effects most frequently reported by the asthmatic subjects were increased appetite and weight gain, headaches, dry mouth, nausea, palpitations, faintness, sleepiness, agitation and sore throat. Those reported most frequently by the hypertensive subjects were headaches, agitation, loose bowel movement, sleepiness, palpitations, weight gain, nausea and weakness of the limbs. In order to further assess the relationship between compliance ratings and the other experimental variables in the two clinical groups a stepwise regression analysis was performed. For hypertensive patients, with medication compliance held as the independent variable, the only dependent variable to show a significant relationship was avoidance [R = -0.507; F( 1) = 10.021. When lifestyle compliance was held as the independent variable, the only dependent variable to show a significant relationship was interpersonal sensitivity [R = -0.516; F(1) = IOS]. For the asthmatic group, medication compliance yielded two steps, comprising the variables of interpersonal sensitivity [R = -0.711; F(1) = 1I.221 and the number of reported symptoms and side-effects [R = 0.554; F(1) = 14.81. No steps were elicited for lifestyle compliance with the asthmatic group. Perhaps the most striking feature of this analysis is the relationship between compliance and interpersonal sensitivity. This variable appears to bear an important relationship to compliance for both groups, although what is compiled with, either medication or an appropriate lifestyle, differs for the two groups. Nevertheless, the importance of the variable indicates that patients’ responses to their clinical condition are dependent in part upon perceived social attitudes to it and their sensitivity to these attitudes. The relevance of avoidance in the hypertensive group is also of interest since it suggests that this is a particularly inappropriate and unhelpful coping strategy in these patients, even though the degree to which it is used does not differ between the two clinical groups. Finally, in order to illustrate the relationship between the experimental variables overall, a correlation matrix showing the product moment correlations of the compliance ratings, the side-effects reported and the measures of psychological distress are presented in Table 5. As can be seen in this table there is a close relationship between nearly all the subscales of psychological distress and also between these subscales and the measures of coping. It can also be seen that there is no statistically significant correlation between the ratings for medication compliance and compliance with a healthy lifestyle [r(43) = O.lOl]. However, compliance with medication is negatively
correlated with depression [r(43) = -0.3291, hostility [r(43) = -0.3731 and also, with both avoidance [r(43) = -0.4401 and approach [r(43) = -0.3141 coping styles. Compliance with a healthy lifestyle is negatively correlated with interpersonal sensitivity [r(43) = - 0.3951. The number of side-effects reported by the clinical patients is positively correlated with anxiety. depression, hostility, somatisation, interpersonal sensitivity, avoidance and approach. DISCUSSION
There are three main conclusions to be drawn from the present investigation. Firstly, these data demonstrate that a chronic clinical condition, symptomatic or asymptomatic, is associated with severe psychological distress. This confirms the earlier findings of Sackett and others [3-6,8]. Moreover, our data suggest that the symptomatic condition, asthma, causes greater psychological distress than the asymptomatic condition, essential hypertension. This result is the more striking since the group sample sizes are not large. The differences in psychological distress between the two clinical groups cannot be attributed to the co-variables of age and sex in spite of the imperfect sex matching, since statistical comparison of these co-variables by analysis of co-variance yielded no significant differences. It would seem from these data that certain clinical conditions are more prone to psychological distress than others. Such a finding conflicts with the study of Viney and Westbrook [20] who were unable to distinguish between a variety of chronic illnesses in terms of measures of psychological distress. However, all the clinical conditions of their patients were symptomatic. We would suggest that the presence of symptoms in a chronic illness is an important variable in determining the severity of psychological distress. Secondly, the coping patterns of both our clinical groups were similar. Table 5 shows that all three coping styles are highly significantly correlated with each other. In addition, ail three are significantly and positively correlated with anxiety, depression and interpersonal sensitivity, confirming that psychological distress requires some sort of coping strategy. Avoidance and approach are also positively correlated with the number of reported side-effects of treatment, suggesting that the presence of unpleasant side-effects requires additional coping resources. The finding that the coping strategies, approach and avoidance, are positively correlated may at first appear contradictory. It seems intuitively unlikely that patients will both approach their clinical condition positively and also take steps to avoid confronting their situation. Nevertheless, anecdotal evidence
Hypertension and asthma
“O!S”J,“,
@ISOH
uo!ssaJdaa
83
taken from our interviews with patients suggests that many actively seek the best advice concerning their condition, but then completely fail to accept or comply with this advice and subsequently adopt an attitude of avoidance and denial. This suggestion is provided with some circumstantial support by the fact that both avoidance and approach are significantly negatively correlated with compliance with medication. In other words, patients may know why they should comply with their medication but they still do not. The resolution of this apparent paradox may be found in the model suggested by Mime [ 1l] where the threat posed by an illness (or even merely the diagnosis of illness) requires the patient to learn coping mechanisms. The learning process will involve a careful evaluation by the patient of the reasons, both for and against compliance. before a behavioural coping strategy is adopted. In this way the approach and avoidance coping strategies may vie for supremacy until a decision is made to comply with medication or not. A similar response pattern has recently been reported by Prochaska et al. [21] with respect to compliance with a programme for quitting cigarette smoking. These investigators found that when smokers attempted to quit smoking their ratings of the importance of arguments both for and against smoking rose in parallel. Once a behavioural response, quitting or not, had been adopted then the ratings of the relative importance of arguments for and against smoking was found to vary in accordance with the adopted response. According to this interpretation, the process of learning to cope may involve the adoption of sometimes conflicting response patterns until the cognitive and behavioural changes necessary for adapting to the situation are made. In terms of patient management the important implication here is that a positive, interested and enquiring response on the part of the patient to guidance provided by the doctor, is no guarantee that the patient will comply with the help and advice proffered. Thirdly, the data concerning compliance behaviour yield two distinct and uncorrelated response patterns, one relating to compliance with medication and the other to lifestyle compliance. Compliance with medication is negatively correlated with depression and anxiety. This confirms the hypothesised relationship between psychological distress and poor compliance with medication 19, lo]. Nevertheless, there are differences in medication compliance between the clinical groups indicated by the regression analysis. For the hypertensive subjects the greater their avoidance the less compliant their behaviour, suggesting that for these patients avoidance is a particularly unhelpful coping mechanism. For the asthmatic patients, the greater their interpersonal sensitivity and the greater their reported number of symptoms and side-effects of treatment the poorer their compliance with medication. This suggests that asthmatics are pushed towards non-compliance by their own social sensitivity and by the number of complaints associated with their clinical condition. However, the unpleasant symptoms and side-effects of treatment in the asthmatic subjects do not translate into significantly poorer medication compliance overall since there is no statistical difference between the asthmatic and
Fru~c~s
84
M. FORD et al
hypertensive subjects in their ratings for compliance with-medication (Table 4). In other words, in spite of the distress attributable to the symptoms and side-effects, the need for relief from physical symptoms will over-ride non-compliance in the asthmatic subjects. Compliance with an appropriate healthy lifestyle also appears to be resistant to change. The negative relationship between interpersonal sensitivity and both medication compliance for the asthmatics and lifestyle compliance for the hypertensives, shown in the regression analysis, suggests that patients who are self-conscious and lack self-confidence in social settings are particularly resistant to changing their behaviour in an appropriate manner. Consequently, the social components of making significant lifestyle changes, such as refusing a cigarette or jogging around the neighbourhood, may make these changes very difficult, particularly for hypertensive patients. Nonetheless, the value of adopting such changes has been demonstrated by studies that have shown the effectiveness of lifestyle changes in treating chronic conditions such as hypertension [22,23]. Perhaps in this regard the presence of physical symptoms can be effective in controlling behaviour, since the asthmatic subjects showed significantly greater compliance with a desirable lifestyle than the hypertensive subjects.
8.
9.
10.
11.
12. 13.
14.
15. 16.
17. Acknowledgement-We
are grateful
to MS
Helen Dickey
(R.N.) for her help during this investigation.
18.
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