- Email: [email protected]
Depression and pulmonary function in outpatients with asthma
ARTICLE IN PRESS Respiratory Medicine (2004) 98, 220–224
Depression and pulmonary function in outpatients with asthma Georgios C. Krommydasa,*, Konstantinos I. Gourgoulianisb, Nikiforos V. Angelopoulosc, Evangelia Kotrotsioud, Vasilios Raftopoulosd, Paschalis-Adam Molyvdasa a
Lung function lab, Physiology Department, Medical School, University of Thessaly, Larissa, Greece Pulmonary Department, Medical School, University of Thessaly, Larissa, Greece c Department of Psychiatry, Medical School, University of Thessaly, Larissa, Greece d Technological Educational Institute of Larissa, Larissa, Greece b
Received 22 April 2003; accepted 12 September 2003
KEYWORDS Asthma; Depression; Anxiety
Summary The purpose of this study was to examine the relation between depression, anxiety and pulmonary function in asthmatics. Thirty-eight adult asthmatic patients underwent psychometric evaluation with the DSSI/sAD questionnaire, filled in an asthma questionnaire and underwent spirometry. The majority of patients suffered from mild-persistent asthma. Twenty-six reported symptoms of anxiety and 25 reported symptoms of depression. A statistically significant reduction in FEV1 and FEV1/FVC values was observed in asthmatic patients with symptoms of depression. The mean value of FEV1 was 81.84(720.83) in patients without symptoms and 63.73(717.99) in patients with symptoms of depression. The mean values of FEV1/FVC were 0.85(70.11) and 0.75(70.10), respectively. These findings indicate a high frequency of depression and anxiety in adult asthmatic patients. A biological linkage between depression and impaired pulmonary function is proposed. & 2003 Elsevier Ltd. All rights reserved.
Introduction Anxiety and depression are closely related to asthma.1 Estimates of psychopathology in severe asthmatics range from 30% to 63%.2,3 Children with asthma have higher rates of depression than children with certain other chronic medical conditions.4 Exposure to stress and strong emotions can make asthma worse, while having asthma can give patient an increased vulnerability towards the *Corresponding author. Tel.: þ 30-2410-623057. E-mail address: [email protected] (G.C. Krommydas).
development of anxiety disorders.5,6 Whether these high rates of depression and anxiety observed in asthmatics are due to the consequence of the disease only or there is also a genetic link between asthma and psychiatric disorders is controversial.3 On the other hand, psychiatric symptoms in asthmatic patients have been shown to be a risk factor for increased asthma morbidity and mortality.7 The present study investigated the relation between asthma and anxiety, asthma and depression and particularly the possible impact of these psychiatric disorders on the pulmonary function tests.
0954-6111/$ - see front matter & 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmed.2003.09.018
ARTICLE IN PRESS Depression and pulmonary function in outpatients with asthma
Samples and methods Subjects We selected 40 asthmatic patients (14 women; age range: 17–65 year old.). Patients were consecutively recruited during a 3-month period among patients that visited the University outpatient pulmonology clinic and asthma diagnosis was made according to Global Initiative for Asthma (GINA) guidelines. Asthma was diagnosed by the Lung Function Laboratory of the Physiology Department of the University of Thessaly. Most patients had already a clinical asthma diagnosis made by a G.P. or a Pulmologist and they visited University Laboratory for the confirmation of the diagnosis and further investigation. Others attented the University outpatient pulmonology clinic. The diagnosis of asthma was based on clinical findings, spirometry, and provocation tests, as necessary (reversibility in FEV1 and/or airway hyperresponsiveness to histamine). We only included lifetime non-smoking patients, with no previous history of near fatal asthma attack or hospitalization for asthma. Subjects did not experience respiratory infections or spontaneous asthmatic relapses during the 4 weeks preceding study. Two patients refused to undergo the psychological evaluation. The finally 38 enrolled patients were receiving anti-asthmatic therapy on a regular basis or as needed. All these patients were on inhaled medication only. Degree of asthma severity was assessed according GINA guidelines.8 A brief asthma questionnaire based upon a scale proposed by Woolcock and Jenkins9 was used. Assessment of asthma severity was based on symptoms and use of anti-asthmatic drugs. For length of asthmatic history, we divided asthmatics into three groups: subjects with newly diagnosed asthma (duration of the disease p1 year), subjects with long asthmatic history and with prolonged history of asthma (duration of the disease 41 and p10 and 410 years; respectively). Before entering the study, each patient attended a screening interview by a psychiatrist (N.A) to rule out any form of present or past mental disorder according to the Greek version of ICD- 10.10 No subjects reported history of cognitive impairment, low instructional level, recent negative life events, and past or present endocrine or metabolic disorder, obesity or recent weight loss, drug or alcohol addiction. Presence of atopy was not a prerequisite for selection. Atopy was assessed by skin prick tests to a standard battery of eight common inhalant allergens.
221
Pulmonary function assessment Pulmonary function was measured by a flow-sensing spirometer connected to a computer for data analysis. Forced expiratory volume in the 1st second (FEV1), forced vital capacity (FVC) and the ratio FEV1/FVC were calculated. FEV1/FVC is an index of airway obstruction.
Psychometric evaluation Each patient underwent psychometric evaluation with the Bedford and Fould’s (DSSI/sAD) inventory.11,12 It consists of 14 questions, seven measuring anxiety and seven depression. The sAD scale is statistically a highly acceptable measure of general psychological disturbance.13 It is an indicator of the intensity of anxiety and depression. The total score for each subscale is the sum of its item scores (0– 21). The cut-off score for each subscale is 3. A score below 3 (p3) means no psychiatric symptomatology, a score between 3 and 6 indicates some sort of borderline symptomatology, while people that score above 6 should be regarded as psychiatric patients. Approximately 95% of healthy individuals give scores below the cut-off score, and should be regarded as free from psychiatric symptoms; 2.2% give score between 3 and 6 and they are regarded as having some sort of borderline symptomatology, while 1.4% score above six ð46Þ and could be regarded as having significant psychopathology. Thus a cumulative 5.1% of healthy persons score above the 4 þ threshold. On the contrary, percentages exceeding the 4 þ threshold on state of anxiety and depression among psychiatric patients are 71.3% and 69%, respectively.11 High compliance has been reported in both non-psychiatric patient and non-patient groups. British adult norms are used as a reference in this study, as the existing studies of validity and psychometric structures of sAD are based upon British patients.11,13 However, results from other countries, including Greece, highlighted the need for local norms in transcultural research.13
Variables and data analysis FEV1 values were expressed as percent of predicted values. In order to include persons with even minor manifestations of depression and anxiety, separate categorical variables for anxiety and depression that included the patients scoring below the cut-off score (p3) and above 3 were defined. Independent samples T-test was used to assess differences in
ARTICLE IN PRESS 222
G.C. Krommydas et al.
pulmonary parameters between these groups. Comparisons of proportions were evaluated by means of w2 :14 A P value less than 0.05 was considered significant. Statistics was processed by SPSS for Windows, 7.5 version (Standard Version, 1996, SPSS Inc., Chicago, IL, USA).
Results The subjects’ characteristics are shown in Table 1. The mean age of the patients was 47 year. Female were 14 individuals. Twenty-five out of 38 patients were atopic. The mean duration of asthmatic disease was 6.5 years with a range of 0.5–40 years. The mean values of FEV1 and FEV1/FVC were 71.8 and 0.81, respectively. According to asthma symptoms and also taking into account the use of drugs, 28 out of 38 patients were presented with either intermittent or mild-persistent asthma (less than 500 mg of BDP or equivalent). Seven patients were classified as having moderate-persistent asthma and two as severe-persistent (8). Twenty-six patients (68.5%) reported symptoms of anxiety and 25(65.8%) patients reported symptoms of depression (score43 in DSSI/sAD inventory) (Tables 2 and 3). Mean value for anxiety scale was 7.9(SD:5.1) and for depression 5.6(SD:4.5). Twelve (31.5%) and 18(47.3%) patients could be regarded as having significant psychopathology since their score was above 6 in the scales of depression and anxiety, respectively, compared with the 1.4% reported in healthy individuals. Asthmatic patients had a statistically significant higher score in psychometric evaluation in comparison with normals (Table 2). Symptoms of depression were found to be associated with a statistically significant reduction in the values of FEV1 and FEV1/FVC, when patients
Table 1
Subjects’ characteristics (n ¼ 38).
Patients with intermmitent/mildpersistent asthma (n) Sex, F/M Ltopy yes/no Age (yr) Mean Range Duration of disease (yr) Mean Range FEV1 (% pred) Mean Range
28
14/24 25/13 47 (17–65) 6.5 (0.5–40) 71.8 (44–119)
with no symptoms (score p3) were compared with patients with some kind of depressive symptoms (either mild or severe psychopathology-score 43). The mean value of FEV1 was 81.84(720:83) in patients without symptoms and 63.73(717:99) in patients with symptoms of depression. The mean values of FEV1/FVC were 0.85(70:11) and 0.75(70.10), respectively. On the contrary, patients with symptoms of anxiety had no statistical differences in the pulmonary measures compared with patients without any symptoms (mean value of FEV1 was 84:7570:91 in patients without symptoms and 71:6379:94 in patients with symptoms of anxiety, P:NS).
Discussion Psychological disturbances are positively related to the severity of asthma.1 The same happens in other chronic conditions. Frequent admissions to hospital, inability to work and limitations in other activities often lead to behavioral problems indicative of psychiatric morbidity.15 Although there is not a unique pattern attributable solely to asthma, sometimes the scores in psychometric evaluation are proven to be higher than in other severe chronic conditions, such as diabetes mellitus.4 Rates of anxiety and depression in this study were compatible with prior clinical studies, reporting increased rates of anxiety and depressive disorders in persons with asthma. Yellowlees et al.,2 studied adult patients with asthma and found psychiatric morbidity in 58% of the sample with anxiety disorders being the most common diagnosis. High levels of anxiety and marked emotional imbalance characterize asthmatic patients.16 Certain personality profiles are detected in adult asthmatics.8 Affective and anxiety disorders are more common in children with asthma.17 Lower rates, however, have been demonstrated in epidemiological samples. These differences could be attributed to selection bias in clinical studies, where sicker patients are more likely to volunteer to participate in research.18 Greek populations exhibit higher scores in sAD scales by contrast with the initial British norms.13 Lyketsos et al.,19 translated the sAD into Greek and collected data on 220 healthy women with means of anxiety of 3.2 and depression of 2.2, significantly higher than Greek men. However, the scores in the present study still remain considerably high. Indeed, percentages above the threshold were quite close to those obtained from British psychiatric patients and comparable to data from psychosomatic groups in
ARTICLE IN PRESS Depression and pulmonary function in outpatients with asthma
Table 2
223
Distribution of anxiety and depression scores in asthmatic patientsFDSSI/sAD (n ¼ 38).
Scale of anxiety (n ¼ 38) mean: 7.9, n p3 12 43 26 Total 38
SD
(5.1)
Scale of depression (n ¼ 38) mean: 5.6,
SD
(4.5)
Expectedn mean: (sA:0.9,SD:0.6.),
SD:
%
n
%
n
%
31.5 68.5 100
13 25 38
34.2 65.8 100
31 2 38
94.9 5.1 100
(sA: 1.3,
SD
1.5)
In healthy individuals. n Po0.05.
Table 3 Differences in pulmonary measures between asthmatic patients with symptoms of depression (score43 in DSSI/sAD) and patients with no symptoms of depression (scorep3 in DSSI/sAD).
FEV1 FVC FEV1/FVC
Patients with no symptoms (n ¼ 13) Mean 7 SD
Patients with symptoms of depression (n ¼ 25) Mean 7 SD
Pn
81.84 7 20.83 96.30 7 25.02 0.85 7 0.11
63.73 7 17.99 84.72 7 23.40 0.75 7 0.10
o0.05 NS o0.05
n
T-test.
Greece, including patients with hypertension, irritable bowel syndrome, psoriasis and inpatients with bronchial asthma.13 In the latter, the inpatients’ sAD mean of 13.4 on admission grossly exceeded control and norms scores.20 Depression and anxiety have been shown to be risk factors for increased asthma morbidity and mortality. Moderate to severe asthma, pessimistic attitude towards prognosis, high levels of denial and non-compliance lead to steroid dependency and deaths from asthma.1,7 Most studies refer to severe asthma.2–6 In this study, patients were presented with mild asthma. Nevertheless, they scored significantly high in the scales of anxiety and depression reminding of more severely ill somatic patients. If few crises during the year cause far less embarrassment compared to severe and difficultto-control asthma, the scores observed in the psychiatric tests could hardly be attributed to the chronic disease alone. Moreover, there is some evidence that even mild asthma is associated with anxiety and depression.18 This may be consistent with common underlying mechanisms. Defects in the function of the autonomic nervous system such as a-adrenergic and cholinergic hyperresponsiveness and b-adrenergic hyporesponsiveness even distal from the airways has been demonstrated in asthmatic patients, as well as in depression. Moreover, in depression, studies of central mediators in the brain also demonstrate parasympathetic hyper-
responsiveness and b-adrenergic responsiveness.21 Although a similar imbalance to the autonomic nervous in the central nervous system is yet to be found in asthmatics, these data raise the question of common biological pathways. It is supported that depression and asthma may each have similar relative transmitter imbalance that additevely worsen the severity of either or both in a given patient.22 Wamboldt et al.,3 suggested a possible genetic risk for both depression and asthma. However, this also may represent the contribution of medication and resultant side effects.23 In this study, patients were on inhaled medication and no constitutional effects were expected. The environmental link between psychopathology and asthma seems to be less strong in these cases in favor of a biological-genetic one, which could make asthmatics more liable to psychiatric disorders. In this study, a statistically significant difference was observed in FEV1 and FEV1/FVC values between asthmatic individuals with symptoms of depression and asthmatics with no depressive symptoms. No such difference was observed in persons with symptoms of anxiety. This could be attributed to a common biological pathway between asthma and depression, but not anxiety, or simply to the small size of the samples. Emotional disturbances have been associated with low scores in objective pulmonary measures. Asthmatic attacks and reduction in FEV1 have been intentionally induced in
ARTICLE IN PRESS 224
asthmatic patients through exposure to emotional stimuli.24 Gustaffson et al.,25 found a negative correlation between peak expiratory flow (PEF) in children and disturbed family cohesion in nonsteroid dependent cases. In another study of ours, asthmatic attacks were more frequent in children with mild asthma, whose parents had high scores of anxiety and depression in sAD scales. This finding was attributed rather to a biological link than the disease of the children.26 There is also some suggestion in the literature that treating the anxiety or depression of the asthmatic may actually improve the control of asthma.6,27 Subjects given biofeedback training for facial relaxation exhibited higher pulmonary scores and more positive attitudes towards asthma.28 This study focuses on the issue that the presence of depressive symptoms in adult asthmatics may indicate worse objective pulmonary measures. If so, this could also mean that a most aggressive therapy and psychological support are necessary in these patients. The findings of this study lend support to the hypothesis that there are further implications between depression and asthma and that common biological pathways may exist. However, this was a preliminary study. Further studies confirming our findings are necessary. These could probably include the use of psychiatric drugs and their possible impact on the course of asthma. The results of this study emphasized the relations between psychiatric parameters and pulmonary measures and support the provision of intervention services to asthmatics.
References 1. Harrison BDW. Psychosocial aspects of asthma in adults. Thorax 1998;53:519–25. 2. Yellowlees P, Haynes S, Potts N, Ruffin R. Psychiatric morbidity in patients with life threating asthma: initial report of a controlled study. Med J Aust 1988;146:246–9. 3. Wamboldt MZ, Weintraub P, Kiafchick D, Wamboldt ES. Psychiatric family history in adolescents with severe asthma. J Am Acad Child Adolesc Psychiatry 1996;35:1042–9. 4. Vila G, Nollet-Clemenson C, Vera M, et al. Prevalence of DSM-IV disorders in children and adolescents with asthma v. diabetes. Can J Psychiatry 1999;44:562–9. 5. Rumbak MJ, Kelso TM, Arheart KL, Self TH. Perception of anxiety as a contributing factor of asthma; indigent vs. non-indigent. J Asthma 1993;30:165–9. 6. Yellowlees PM, Kalucy RS. Psychological aspects of asthma and the consequent research implications. Chest 1990;97: 628–34. 7. Mrazek DA. Psychiatric complications of pediatric asthma. Ann Allergy 1992;69:285–90.
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8. Global Initiative for Asthma.National Heart, Lung and Blood Institute. Revised 2002. NIH Publications. 9. Woolcock AJ, Jenkins CR. Management of asthma: a decreasing role for bronchodilatorts. Mod Med S A 1991;16: 73–99. 10. The ICD-10. Classification of mental and behavioral disorders: clinical descriptions and diagnostic guidelines. World Health Organization 1992. 11. Bedford A, Foulds GA, Sheffield BF. A new personal disturbance scale: DSSI/sAD. Br J Soc Clin Psychol 1976;15:387–94. 12. Gillespie N, Kirk KM, Heath AC, Martin NG, Hickie I. Somatic distress as a distinct psychological dimension. Soc Psychiatry Psychiatr Epidemiol 1999;34:451–8. 13. Bedford A, Deary IJ. The personal disturbance scale (DSSI/ sAD): development, use and structure. Person Individ Diff 1997;22:493–510. 14. Glantz SA. Primer of biostatistics, 2nd ed. New York: McGraw-Hill; 1987. 15. Pless IB, Roghmann KJ. Chronic illness and its consequences: observations based on three epidemiological surveys. J Pediatr 1971;79:351–9. 16. Bell IR, Jasnoski ML, Kajan J, King DS. Depression and allergies: a survey of a non-clinical population. Psychother Psychosom 1991;55:24–31. 17. Bussing R, Burket RC, Kelleher ET. Prevalence of anxiety disorders in a clinic based sample of pediatric asthma patients. Psychosomatics 1996;37:108–15. 18. Bussing R, Halfon N, Benjamin B, Wells K. Prevalence of behavior problems in US children with asthma. Arch Pediatr Adolesc Med 1995;149:565–72. 19. Lyketsos GC, Blackburn IM, Mouzaki D. Personality variables and dysthymic symptoms: a comparison between a greek and a british sample. Psychol Med 1979;9:753–8. 20. Lyketsos GC, Karabetsos A, Jordanoglou J, et al. Personality characteristics and dysthymic states in bronchial asthma. Psychother Psychosom 1984;44:177–85. 21. Wright JR, Rodriguez M, Cohen S. Review of psychosocial stress and asthma: an intergrated biopsychosocial approach. Thorax 1998;53:1066–74. 22. Fritz GK, Rubinstein S, Lewiston NJ. Psychological factors in fatal childhood asthma. Am J Orthopsychiatry 1987;57: 253–7. 23. Rappaport L, Coffman H, Guare R, et al. Effects of theoffylline on behavior and learning in children with asthma. A J D C 1989;143:368–72. 24. Miller B, Wood B. Psychobiologic reactivity in asthmatic children: a cholinergically mediated confluence of pathways. J Am Acad Child Adolesc Psychiatry 1994;33:1236–45. 25. Gustafsson PA, Kjellman NI, Ludvigsson J, Cederblad M. Asthma and family interaction. Arch Dis Child 1987;62: 258–63. 26. Krommydas GC, Gourgoulianis KI, Angelopoulos NV, Andreou G, Molyvdas PA. Left-handedness and parental psychopathology in the course of bronchial asthma in childhood. Pediatr Asthma Allergy Immunol 2002;15:145–52. 27. Ago Y, Teshima H, Nagata S, Inoue S, Ikemi Y. Psychosomatic studies of allergic disorders. Psychosother Psychosom 1979; 31:197–204. 28. Kotses H, Harver A, Segreto J, Glaus KD, Creer TL, Young GA. Long-term effects of biofeedback-induced facial relaxation on measures of asthma severity in children. Biofeedback Self Regul 1991;16:1–21.
Depression and pulmonary function in outpatients with asthma Georgios C. Krommydasa,*, Konstantinos I. Gourgoulianisb, Nikiforos V. Angelopoulosc, Evangelia Kotrotsioud, Vasilios Raftopoulosd, Paschalis-Adam Molyvdasa a
Lung function lab, Physiology Department, Medical School, University of Thessaly, Larissa, Greece Pulmonary Department, Medical School, University of Thessaly, Larissa, Greece c Department of Psychiatry, Medical School, University of Thessaly, Larissa, Greece d Technological Educational Institute of Larissa, Larissa, Greece b
Received 22 April 2003; accepted 12 September 2003
KEYWORDS Asthma; Depression; Anxiety
Summary The purpose of this study was to examine the relation between depression, anxiety and pulmonary function in asthmatics. Thirty-eight adult asthmatic patients underwent psychometric evaluation with the DSSI/sAD questionnaire, filled in an asthma questionnaire and underwent spirometry. The majority of patients suffered from mild-persistent asthma. Twenty-six reported symptoms of anxiety and 25 reported symptoms of depression. A statistically significant reduction in FEV1 and FEV1/FVC values was observed in asthmatic patients with symptoms of depression. The mean value of FEV1 was 81.84(720.83) in patients without symptoms and 63.73(717.99) in patients with symptoms of depression. The mean values of FEV1/FVC were 0.85(70.11) and 0.75(70.10), respectively. These findings indicate a high frequency of depression and anxiety in adult asthmatic patients. A biological linkage between depression and impaired pulmonary function is proposed. & 2003 Elsevier Ltd. All rights reserved.
Introduction Anxiety and depression are closely related to asthma.1 Estimates of psychopathology in severe asthmatics range from 30% to 63%.2,3 Children with asthma have higher rates of depression than children with certain other chronic medical conditions.4 Exposure to stress and strong emotions can make asthma worse, while having asthma can give patient an increased vulnerability towards the *Corresponding author. Tel.: þ 30-2410-623057. E-mail address: [email protected] (G.C. Krommydas).
development of anxiety disorders.5,6 Whether these high rates of depression and anxiety observed in asthmatics are due to the consequence of the disease only or there is also a genetic link between asthma and psychiatric disorders is controversial.3 On the other hand, psychiatric symptoms in asthmatic patients have been shown to be a risk factor for increased asthma morbidity and mortality.7 The present study investigated the relation between asthma and anxiety, asthma and depression and particularly the possible impact of these psychiatric disorders on the pulmonary function tests.
0954-6111/$ - see front matter & 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmed.2003.09.018
ARTICLE IN PRESS Depression and pulmonary function in outpatients with asthma
Samples and methods Subjects We selected 40 asthmatic patients (14 women; age range: 17–65 year old.). Patients were consecutively recruited during a 3-month period among patients that visited the University outpatient pulmonology clinic and asthma diagnosis was made according to Global Initiative for Asthma (GINA) guidelines. Asthma was diagnosed by the Lung Function Laboratory of the Physiology Department of the University of Thessaly. Most patients had already a clinical asthma diagnosis made by a G.P. or a Pulmologist and they visited University Laboratory for the confirmation of the diagnosis and further investigation. Others attented the University outpatient pulmonology clinic. The diagnosis of asthma was based on clinical findings, spirometry, and provocation tests, as necessary (reversibility in FEV1 and/or airway hyperresponsiveness to histamine). We only included lifetime non-smoking patients, with no previous history of near fatal asthma attack or hospitalization for asthma. Subjects did not experience respiratory infections or spontaneous asthmatic relapses during the 4 weeks preceding study. Two patients refused to undergo the psychological evaluation. The finally 38 enrolled patients were receiving anti-asthmatic therapy on a regular basis or as needed. All these patients were on inhaled medication only. Degree of asthma severity was assessed according GINA guidelines.8 A brief asthma questionnaire based upon a scale proposed by Woolcock and Jenkins9 was used. Assessment of asthma severity was based on symptoms and use of anti-asthmatic drugs. For length of asthmatic history, we divided asthmatics into three groups: subjects with newly diagnosed asthma (duration of the disease p1 year), subjects with long asthmatic history and with prolonged history of asthma (duration of the disease 41 and p10 and 410 years; respectively). Before entering the study, each patient attended a screening interview by a psychiatrist (N.A) to rule out any form of present or past mental disorder according to the Greek version of ICD- 10.10 No subjects reported history of cognitive impairment, low instructional level, recent negative life events, and past or present endocrine or metabolic disorder, obesity or recent weight loss, drug or alcohol addiction. Presence of atopy was not a prerequisite for selection. Atopy was assessed by skin prick tests to a standard battery of eight common inhalant allergens.
221
Pulmonary function assessment Pulmonary function was measured by a flow-sensing spirometer connected to a computer for data analysis. Forced expiratory volume in the 1st second (FEV1), forced vital capacity (FVC) and the ratio FEV1/FVC were calculated. FEV1/FVC is an index of airway obstruction.
Psychometric evaluation Each patient underwent psychometric evaluation with the Bedford and Fould’s (DSSI/sAD) inventory.11,12 It consists of 14 questions, seven measuring anxiety and seven depression. The sAD scale is statistically a highly acceptable measure of general psychological disturbance.13 It is an indicator of the intensity of anxiety and depression. The total score for each subscale is the sum of its item scores (0– 21). The cut-off score for each subscale is 3. A score below 3 (p3) means no psychiatric symptomatology, a score between 3 and 6 indicates some sort of borderline symptomatology, while people that score above 6 should be regarded as psychiatric patients. Approximately 95% of healthy individuals give scores below the cut-off score, and should be regarded as free from psychiatric symptoms; 2.2% give score between 3 and 6 and they are regarded as having some sort of borderline symptomatology, while 1.4% score above six ð46Þ and could be regarded as having significant psychopathology. Thus a cumulative 5.1% of healthy persons score above the 4 þ threshold. On the contrary, percentages exceeding the 4 þ threshold on state of anxiety and depression among psychiatric patients are 71.3% and 69%, respectively.11 High compliance has been reported in both non-psychiatric patient and non-patient groups. British adult norms are used as a reference in this study, as the existing studies of validity and psychometric structures of sAD are based upon British patients.11,13 However, results from other countries, including Greece, highlighted the need for local norms in transcultural research.13
Variables and data analysis FEV1 values were expressed as percent of predicted values. In order to include persons with even minor manifestations of depression and anxiety, separate categorical variables for anxiety and depression that included the patients scoring below the cut-off score (p3) and above 3 were defined. Independent samples T-test was used to assess differences in
ARTICLE IN PRESS 222
G.C. Krommydas et al.
pulmonary parameters between these groups. Comparisons of proportions were evaluated by means of w2 :14 A P value less than 0.05 was considered significant. Statistics was processed by SPSS for Windows, 7.5 version (Standard Version, 1996, SPSS Inc., Chicago, IL, USA).
Results The subjects’ characteristics are shown in Table 1. The mean age of the patients was 47 year. Female were 14 individuals. Twenty-five out of 38 patients were atopic. The mean duration of asthmatic disease was 6.5 years with a range of 0.5–40 years. The mean values of FEV1 and FEV1/FVC were 71.8 and 0.81, respectively. According to asthma symptoms and also taking into account the use of drugs, 28 out of 38 patients were presented with either intermittent or mild-persistent asthma (less than 500 mg of BDP or equivalent). Seven patients were classified as having moderate-persistent asthma and two as severe-persistent (8). Twenty-six patients (68.5%) reported symptoms of anxiety and 25(65.8%) patients reported symptoms of depression (score43 in DSSI/sAD inventory) (Tables 2 and 3). Mean value for anxiety scale was 7.9(SD:5.1) and for depression 5.6(SD:4.5). Twelve (31.5%) and 18(47.3%) patients could be regarded as having significant psychopathology since their score was above 6 in the scales of depression and anxiety, respectively, compared with the 1.4% reported in healthy individuals. Asthmatic patients had a statistically significant higher score in psychometric evaluation in comparison with normals (Table 2). Symptoms of depression were found to be associated with a statistically significant reduction in the values of FEV1 and FEV1/FVC, when patients
Table 1
Subjects’ characteristics (n ¼ 38).
Patients with intermmitent/mildpersistent asthma (n) Sex, F/M Ltopy yes/no Age (yr) Mean Range Duration of disease (yr) Mean Range FEV1 (% pred) Mean Range
28
14/24 25/13 47 (17–65) 6.5 (0.5–40) 71.8 (44–119)
with no symptoms (score p3) were compared with patients with some kind of depressive symptoms (either mild or severe psychopathology-score 43). The mean value of FEV1 was 81.84(720:83) in patients without symptoms and 63.73(717:99) in patients with symptoms of depression. The mean values of FEV1/FVC were 0.85(70:11) and 0.75(70.10), respectively. On the contrary, patients with symptoms of anxiety had no statistical differences in the pulmonary measures compared with patients without any symptoms (mean value of FEV1 was 84:7570:91 in patients without symptoms and 71:6379:94 in patients with symptoms of anxiety, P:NS).
Discussion Psychological disturbances are positively related to the severity of asthma.1 The same happens in other chronic conditions. Frequent admissions to hospital, inability to work and limitations in other activities often lead to behavioral problems indicative of psychiatric morbidity.15 Although there is not a unique pattern attributable solely to asthma, sometimes the scores in psychometric evaluation are proven to be higher than in other severe chronic conditions, such as diabetes mellitus.4 Rates of anxiety and depression in this study were compatible with prior clinical studies, reporting increased rates of anxiety and depressive disorders in persons with asthma. Yellowlees et al.,2 studied adult patients with asthma and found psychiatric morbidity in 58% of the sample with anxiety disorders being the most common diagnosis. High levels of anxiety and marked emotional imbalance characterize asthmatic patients.16 Certain personality profiles are detected in adult asthmatics.8 Affective and anxiety disorders are more common in children with asthma.17 Lower rates, however, have been demonstrated in epidemiological samples. These differences could be attributed to selection bias in clinical studies, where sicker patients are more likely to volunteer to participate in research.18 Greek populations exhibit higher scores in sAD scales by contrast with the initial British norms.13 Lyketsos et al.,19 translated the sAD into Greek and collected data on 220 healthy women with means of anxiety of 3.2 and depression of 2.2, significantly higher than Greek men. However, the scores in the present study still remain considerably high. Indeed, percentages above the threshold were quite close to those obtained from British psychiatric patients and comparable to data from psychosomatic groups in
ARTICLE IN PRESS Depression and pulmonary function in outpatients with asthma
Table 2
223
Distribution of anxiety and depression scores in asthmatic patientsFDSSI/sAD (n ¼ 38).
Scale of anxiety (n ¼ 38) mean: 7.9, n p3 12 43 26 Total 38
SD
(5.1)
Scale of depression (n ¼ 38) mean: 5.6,
SD
(4.5)
Expectedn mean: (sA:0.9,SD:0.6.),
SD:
%
n
%
n
%
31.5 68.5 100
13 25 38
34.2 65.8 100
31 2 38
94.9 5.1 100
(sA: 1.3,
SD
1.5)
In healthy individuals. n Po0.05.
Table 3 Differences in pulmonary measures between asthmatic patients with symptoms of depression (score43 in DSSI/sAD) and patients with no symptoms of depression (scorep3 in DSSI/sAD).
FEV1 FVC FEV1/FVC
Patients with no symptoms (n ¼ 13) Mean 7 SD
Patients with symptoms of depression (n ¼ 25) Mean 7 SD
Pn
81.84 7 20.83 96.30 7 25.02 0.85 7 0.11
63.73 7 17.99 84.72 7 23.40 0.75 7 0.10
o0.05 NS o0.05
n
T-test.
Greece, including patients with hypertension, irritable bowel syndrome, psoriasis and inpatients with bronchial asthma.13 In the latter, the inpatients’ sAD mean of 13.4 on admission grossly exceeded control and norms scores.20 Depression and anxiety have been shown to be risk factors for increased asthma morbidity and mortality. Moderate to severe asthma, pessimistic attitude towards prognosis, high levels of denial and non-compliance lead to steroid dependency and deaths from asthma.1,7 Most studies refer to severe asthma.2–6 In this study, patients were presented with mild asthma. Nevertheless, they scored significantly high in the scales of anxiety and depression reminding of more severely ill somatic patients. If few crises during the year cause far less embarrassment compared to severe and difficultto-control asthma, the scores observed in the psychiatric tests could hardly be attributed to the chronic disease alone. Moreover, there is some evidence that even mild asthma is associated with anxiety and depression.18 This may be consistent with common underlying mechanisms. Defects in the function of the autonomic nervous system such as a-adrenergic and cholinergic hyperresponsiveness and b-adrenergic hyporesponsiveness even distal from the airways has been demonstrated in asthmatic patients, as well as in depression. Moreover, in depression, studies of central mediators in the brain also demonstrate parasympathetic hyper-
responsiveness and b-adrenergic responsiveness.21 Although a similar imbalance to the autonomic nervous in the central nervous system is yet to be found in asthmatics, these data raise the question of common biological pathways. It is supported that depression and asthma may each have similar relative transmitter imbalance that additevely worsen the severity of either or both in a given patient.22 Wamboldt et al.,3 suggested a possible genetic risk for both depression and asthma. However, this also may represent the contribution of medication and resultant side effects.23 In this study, patients were on inhaled medication and no constitutional effects were expected. The environmental link between psychopathology and asthma seems to be less strong in these cases in favor of a biological-genetic one, which could make asthmatics more liable to psychiatric disorders. In this study, a statistically significant difference was observed in FEV1 and FEV1/FVC values between asthmatic individuals with symptoms of depression and asthmatics with no depressive symptoms. No such difference was observed in persons with symptoms of anxiety. This could be attributed to a common biological pathway between asthma and depression, but not anxiety, or simply to the small size of the samples. Emotional disturbances have been associated with low scores in objective pulmonary measures. Asthmatic attacks and reduction in FEV1 have been intentionally induced in
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asthmatic patients through exposure to emotional stimuli.24 Gustaffson et al.,25 found a negative correlation between peak expiratory flow (PEF) in children and disturbed family cohesion in nonsteroid dependent cases. In another study of ours, asthmatic attacks were more frequent in children with mild asthma, whose parents had high scores of anxiety and depression in sAD scales. This finding was attributed rather to a biological link than the disease of the children.26 There is also some suggestion in the literature that treating the anxiety or depression of the asthmatic may actually improve the control of asthma.6,27 Subjects given biofeedback training for facial relaxation exhibited higher pulmonary scores and more positive attitudes towards asthma.28 This study focuses on the issue that the presence of depressive symptoms in adult asthmatics may indicate worse objective pulmonary measures. If so, this could also mean that a most aggressive therapy and psychological support are necessary in these patients. The findings of this study lend support to the hypothesis that there are further implications between depression and asthma and that common biological pathways may exist. However, this was a preliminary study. Further studies confirming our findings are necessary. These could probably include the use of psychiatric drugs and their possible impact on the course of asthma. The results of this study emphasized the relations between psychiatric parameters and pulmonary measures and support the provision of intervention services to asthmatics.
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