depression and pulmonary function in outpatients with asthma

5
Depression and pulmonary function in outpatients with asthma Georgios C. Krommydas a, *, Konstantinos I. Gourgoulianis b , Nikiforos V. Angelopoulos c , Evangelia Kotrotsiou d , Vasilios Raftopoulos d , Paschalis-Adam Molyvdas a a Lung function lab, Physiology Department, Medical School, University of Thessaly, Larissa, Greece b 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 Received 22 April 2003; accepted 12 September 2003 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 ques- tionnaire, 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 FEV 1 and FEV 1 /FVC values was observed in asthmatic patients with symptoms of depression. The mean value of FEV 1 was 81.84(720.83) in patients without symptoms and 63.73(717.99) in patients with symptoms of depression. The mean values of FEV 1 /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 condi- tions. 4 Exposure to stress and strong emotions can make asthma worse, while having asthma can give patient an increased vulnerability towards the 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 be- tween asthma and anxiety, asthma and depression and particularly the possible impact of these psy- chiatric disorders on the pulmonary function tests. ARTICLE IN PRESS KEYWORDS Asthma; Depression; Anxiety *Corresponding author. Tel.: þ 30-2410-623057. E-mail address: [email protected] (G.C. Krommydas). 0954-6111/$ - see front matter & 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmed.2003.09.018 Respiratory Medicine (2004) 98, 220224

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Page 1: Depression and pulmonary function in outpatients with asthma

Depression and pulmonary function in outpatientswith asthma

Georgios C. Krommydasa,*, Konstantinos I. Gourgoulianisb, NikiforosV. Angelopoulosc, Evangelia Kotrotsioud, Vasilios Raftopoulosd,Paschalis-Adam Molyvdasa

aLung function lab, Physiology Department, Medical School, University of Thessaly, Larissa, GreecebPulmonary Department, Medical School, University of Thessaly, Larissa, GreececDepartment of Psychiatry, Medical School, University of Thessaly, Larissa, GreecedTechnological Educational Institute of Larissa, Larissa, Greece

Received 22 April 2003; accepted 12 September 2003

Summary The purpose of this study was to examine the relation betweendepression, anxiety and pulmonary function in asthmatics. Thirty-eight adultasthmatic patients underwent psychometric evaluation with the DSSI/sAD ques-tionnaire, filled in an asthma questionnaire and underwent spirometry. The majorityof patients suffered from mild-persistent asthma. Twenty-six reported symptoms ofanxiety and 25 reported symptoms of depression. A statistically significant reductionin FEV1 and FEV1/FVC values was observed in asthmatic patients with symptoms ofdepression. The mean value of FEV1 was 81.84(720.83) in patients withoutsymptoms and 63.73(717.99) in patients with symptoms of depression. The meanvalues of FEV1/FVC were 0.85(70.11) and 0.75(70.10), respectively. These findingsindicate a high frequency of depression and anxiety in adult asthmatic patients. Abiological linkage between depression and impaired pulmonary function is proposed.& 2003 Elsevier Ltd. All rights reserved.

Introduction

Anxiety and depression are closely related toasthma.1 Estimates of psychopathology in severeasthmatics range from 30% to 63%.2,3 Children withasthma have higher rates of depression thanchildren with certain other chronic medical condi-tions.4 Exposure to stress and strong emotions canmake asthma worse, while having asthma can givepatient an increased vulnerability towards the

development of anxiety disorders.5,6 Whetherthese high rates of depression and anxiety observedin asthmatics are due to the consequence of thedisease only or there is also a genetic link betweenasthma and psychiatric disorders is controversial.3

On the other hand, psychiatric symptoms inasthmatic patients have been shown to be arisk factor for increased asthma morbidity andmortality.7

The present study investigated the relation be-tween asthma and anxiety, asthma and depressionand particularly the possible impact of these psy-chiatric disorders on the pulmonary function tests.

ARTICLE IN PRESS

KEYWORDS

Asthma;

Depression;

Anxiety

*Corresponding author. Tel.: þ 30-2410-623057.E-mail address: [email protected] (G.C. Krommydas).

0954-6111/$ - see front matter & 2003 Elsevier Ltd. All rights reserved.doi:10.1016/j.rmed.2003.09.018

Respiratory Medicine (2004) 98, 220–224

Page 2: Depression and pulmonary function in outpatients with asthma

Samples and methods

Subjects

We selected 40 asthmatic patients (14 women; agerange: 17–65 year old.). Patients were consecu-tively recruited during a 3-month period amongpatients that visited the University outpatientpulmonology clinic and asthma diagnosis was madeaccording to Global Initiative for Asthma (GINA)guidelines. Asthma was diagnosed by the LungFunction Laboratory of the Physiology Departmentof the University of Thessaly. Most patients hadalready a clinical asthma diagnosis made by a G.P.or a Pulmologist and they visited UniversityLaboratory for the confirmation of the diagnosisand further investigation. Others attented theUniversity outpatient pulmonology clinic. Thediagnosis of asthma was based on clinical findings,spirometry, and provocation tests, as necessary(reversibility in FEV1 and/or airway hyperrespon-siveness to histamine). We only included lifetimenon-smoking patients, with no previous history ofnear fatal asthma attack or hospitalization forasthma. Subjects did not experience respiratoryinfections or spontaneous asthmatic relapses duringthe 4 weeks preceding study. Two patients refusedto undergo the psychological evaluation. The finally38 enrolled patients were receiving anti-asthmatictherapy on a regular basis or as needed. All thesepatients were on inhaled medication only. Degreeof asthma severity was assessed according GINAguidelines.8 A brief asthma questionnaire basedupon a scale proposed by Woolcock and Jenkins9

was used. Assessment of asthma severity was basedon symptoms and use of anti-asthmatic drugs. Forlength of asthmatic history, we divided asthmaticsinto three groups: subjects with newly diagnosedasthma (duration of the disease p1 year), subjectswith long asthmatic history and with prolongedhistory of asthma (duration of the disease 41 andp10 and 410 years; respectively).

Before entering the study, each patient attendeda screening interview by a psychiatrist (N.A) to ruleout any form of present or past mental disorderaccording to the Greek version of ICD- 10.10 Nosubjects reported history of cognitive impairment,low instructional level, recent negative life events,and past or present endocrine or metabolicdisorder, obesity or recent weight loss, drug oralcohol addiction. Presence of atopy was not aprerequisite for selection. Atopy was assessed byskin prick tests to a standard battery of eightcommon inhalant allergens.

Pulmonary function assessment

Pulmonary function was measured by a flow-sensingspirometer connected to a computer for dataanalysis. Forced expiratory volume in the 1stsecond (FEV1), forced vital capacity (FVC) and theratio FEV1/FVC were calculated. FEV1/FVC is anindex of airway obstruction.

Psychometric evaluation

Each patient underwent psychometric evaluationwith the Bedford and Fould’s (DSSI/sAD) inven-tory.11,12 It consists of 14 questions, seven measur-ing anxiety and seven depression. The sAD scale isstatistically a highly acceptable measure of generalpsychological disturbance.13 It is an indicator of theintensity of anxiety and depression. The total scorefor each subscale is the sum of its item scores (0–21). The cut-off score for each subscale is 3. A scorebelow 3 (p3) means no psychiatric symptomatol-ogy, a score between 3 and 6 indicates some sort ofborderline symptomatology, while people thatscore above 6 should be regarded as psychiatricpatients. Approximately 95% of healthy individualsgive scores below the cut-off score, and should beregarded as free from psychiatric symptoms; 2.2%give score between 3 and 6 and they are regardedas having some sort of borderline symptomatology,while 1.4% score above six ð46Þ and could beregarded as having significant psychopathology.Thus a cumulative 5.1% of healthy persons scoreabove the 4þ threshold. On the contrary, percen-tages exceeding the 4þ threshold on state ofanxiety and depression among psychiatric patientsare 71.3% and 69%, respectively.11 High compliancehas been reported in both non-psychiatric patientand non-patient groups. British adult norms areused as a reference in this study, as the existingstudies of validity and psychometric structures ofsAD are based upon British patients.11,13 However,results from other countries, including Greece,highlighted the need for local norms in transcultur-al research.13

Variables and data analysis

FEV1 values were expressed as percent of predictedvalues. In order to include persons with even minormanifestations of depression and anxiety, separatecategorical variables for anxiety and depressionthat included the patients scoring below the cut-offscore (p3) and above 3 were defined. Independentsamples T-test was used to assess differences in

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Depression and pulmonary function in outpatients with asthma 221

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pulmonary parameters between these groups.Comparisons of proportions were evaluated bymeans of w2:14 A P value less than 0.05 wasconsidered significant. Statistics was processed bySPSS 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. Femalewere 14 individuals. Twenty-five out of 38 patientswere atopic. The mean duration of asthmaticdisease was 6.5 years with a range of 0.5–40 years.The mean values of FEV1 and FEV1/FVC were 71.8and 0.81, respectively. According to asthma symp-toms and also taking into account the use of drugs,28 out of 38 patients were presented with eitherintermittent or mild-persistent asthma (less than500 mg of BDP or equivalent). Seven patients wereclassified as having moderate-persistent asthmaand two as severe-persistent (8). Twenty-six pa-tients (68.5%) reported symptoms of anxiety and25(65.8%) patients reported symptoms of depres-sion (score43 in DSSI/sAD inventory) (Tables 2 and3). Mean value for anxiety scale was 7.9(SD:5.1)and for depression 5.6(SD:4.5). Twelve (31.5%) and18(47.3%) patients could be regarded as havingsignificant psychopathology since their score wasabove 6 in the scales of depression and anxiety,respectively, compared with the 1.4% reported inhealthy individuals. Asthmatic patients had astatistically significant higher score in psychometricevaluation in comparison with normals (Table 2).

Symptoms of depression were found to beassociated with a statistically significant reductionin the values of FEV1 and FEV1/FVC, when patients

with no symptoms (score p3) were compared withpatients 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 meanvalues of FEV1/FVC were 0.85(70:11) and0.75(70.10), respectively. On the contrary, pa-tients with symptoms of anxiety had no statisticaldifferences in the pulmonary measures comparedwith patients without any symptoms (mean value ofFEV1 was 84:7570:91 in patients without symptomsand 71:6379:94 in patients with symptoms ofanxiety, P:NS).

Discussion

Psychological disturbances are positively related tothe severity of asthma.1 The same happens in otherchronic conditions. Frequent admissions to hospi-tal, inability to work and limitations in otheractivities often lead to behavioral problems in-dicative of psychiatric morbidity.15 Although thereis not a unique pattern attributable solely toasthma, sometimes the scores in psychometricevaluation are proven to be higher than in othersevere chronic conditions, such as diabetes melli-tus.4 Rates of anxiety and depression in this studywere compatible with prior clinical studies, report-ing increased rates of anxiety and depressivedisorders in persons with asthma. Yellowleeset al.,2 studied adult patients with asthma andfound psychiatric morbidity in 58% of the samplewith anxiety disorders being the most commondiagnosis. High levels of anxiety and markedemotional imbalance characterize asthmatic pa-tients.16 Certain personality profiles are detectedin adult asthmatics.8 Affective and anxiety dis-orders are more common in children with asthma.17

Lower rates, however, have been demonstrated inepidemiological samples. These differences couldbe attributed to selection bias in clinical studies,where sicker patients are more likely to volunteerto participate in research.18 Greek populationsexhibit higher scores in sAD scales by contrast withthe initial British norms.13 Lyketsos et al.,19 trans-lated the sAD into Greek and collected data on 220healthy women with means of anxiety of 3.2 anddepression of 2.2, significantly higher than Greekmen. However, the scores in the present study stillremain considerably high. Indeed, percentagesabove the threshold were quite close to thoseobtained from British psychiatric patients andcomparable to data from psychosomatic groups in

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Table 1 Subjects’ characteristics (n¼ 38).

Patients withintermmitent/mild-persistent asthma (n)

28

Sex, F/M 14/24Ltopy yes/no 25/13Age (yr)Mean 47Range (17–65)

Duration of disease (yr)Mean 6.5Range (0.5–40)

FEV1 (% pred)Mean 71.8Range (44–119)

222 G.C. Krommydas et al.

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Greece, including patients with hypertension,irritable bowel syndrome, psoriasis and inpatientswith bronchial asthma.13 In the latter, the inpati-ents’ sAD mean of 13.4 on admission grosslyexceeded control and norms scores.20

Depression and anxiety have been shown to berisk factors for increased asthma morbidity andmortality. Moderate to severe asthma, pessimisticattitude towards prognosis, high levels of denialand non-compliance lead to steroid dependencyand deaths from asthma.1,7 Most studies refer tosevere asthma.2–6 In this study, patients werepresented with mild asthma. Nevertheless, theyscored significantly high in the scales of anxiety anddepression reminding of more severely ill somaticpatients. If few crises during the year cause far lessembarrassment compared to severe and difficult-to-control asthma, the scores observed in thepsychiatric tests could hardly be attributed to thechronic disease alone. Moreover, there is someevidence that even mild asthma is associated withanxiety and depression.18 This may be consistentwith common underlying mechanisms. Defects inthe function of the autonomic nervous system suchas a-adrenergic and cholinergic hyperresponsive-ness and b-adrenergic hyporesponsiveness evendistal from the airways has been demonstrated inasthmatic patients, as well as in depression. More-over, in depression, studies of central mediators inthe brain also demonstrate parasympathetic hyper-

responsiveness and b-adrenergic responsiveness.21

Although a similar imbalance to the autonomicnervous in the central nervous system is yet to befound in asthmatics, these data raise the questionof common biological pathways. It is supported thatdepression and asthma may each have similarrelative transmitter imbalance that additevelyworsen the severity of either or both in a givenpatient.22 Wamboldt et al.,3 suggested a possiblegenetic risk for both depression and asthma.However, this also may represent the contributionof medication and resultant side effects.23 In thisstudy, patients were on inhaled medication and noconstitutional effects were expected. The environ-mental link between psychopathology and asthmaseems to be less strong in these cases in favor of abiological-genetic one, which could make asth-matics more liable to psychiatric disorders.

In this study, a statistically significant differencewas observed in FEV1 and FEV1/FVC values betweenasthmatic individuals with symptoms of depressionand asthmatics with no depressive symptoms. Nosuch difference was observed in persons withsymptoms of anxiety. This could be attributed toa common biological pathway between asthma anddepression, but not anxiety, or simply to the smallsize of the samples. Emotional disturbances havebeen associated with low scores in objectivepulmonary measures. Asthmatic attacks and reduc-tion in FEV1 have been intentionally induced in

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Table 2 Distribution of anxiety and depression scores in asthmatic patientsFDSSI/sAD (n¼ 38).

Scale of anxiety Scale of depression Expectedn

(n¼ 38) mean: 7.9, SD (5.1) (n¼ 38) mean: 5.6, SD (4.5) mean: (sA:0.9,SD:0.6.), SD: (sA: 1.3, SD 1.5)

n % n % n %

p3 12 31.5 13 34.2 31 94.943 26 68.5 25 65.8 2 5.1Total 38 100 38 100 38 100

In healthy individuals.nPo0.05.

Table 3 Differences in pulmonary measures between asthmatic patients with symptoms of depression (score43in DSSI/sAD) and patients with no symptoms of depression (scorep3 in DSSI/sAD).

Patients with no symptoms (n¼ 13) Patients with symptoms of depression (n¼ 25) Pn

Mean 7 SD Mean 7 SD

FEV1 81.84 7 20.83 63.73 7 17.99 o0.05FVC 96.30 7 25.02 84.72 7 23.40 NSFEV1/FVC 0.85 7 0.11 0.75 7 0.10 o0.05

nT-test.

Depression and pulmonary function in outpatients with asthma 223

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asthmatic patients through exposure to emotionalstimuli.24 Gustaffson et al.,25 found a negativecorrelation between peak expiratory flow (PEF) inchildren and disturbed family cohesion in non-steroid dependent cases. In another study of ours,asthmatic attacks were more frequent in childrenwith mild asthma, whose parents had high scores ofanxiety and depression in sAD scales. This findingwas attributed rather to a biological link than thedisease of the children.26 There is also somesuggestion in the literature that treating theanxiety or depression of the asthmatic may actuallyimprove the control of asthma.6,27 Subjects givenbiofeedback training for facial relaxation exhibitedhigher pulmonary scores and more positive atti-tudes towards asthma.28

This study focuses on the issue that the presenceof depressive symptoms in adult asthmatics mayindicate worse objective pulmonary measures. Ifso, this could also mean that a most aggressivetherapy and psychological support are necessary inthese patients. The findings of this study lendsupport to the hypothesis that there are furtherimplications between depression and asthma andthat common biological pathways may exist. How-ever, this was a preliminary study. Further studiesconfirming our findings are necessary. These couldprobably include the use of psychiatric drugs andtheir possible impact on the course of asthma. Theresults of this study emphasized the relationsbetween psychiatric parameters and pulmonarymeasures and support the provision of interventionservices 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. Psychiatricmorbidity in patients with life threating asthma: initialreport 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 ofDSM-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 ofanxiety as a contributing factor of asthma; indigent vs.non-indigent. J Asthma 1993;30:165–9.

6. Yellowlees PM, Kalucy RS. Psychological aspects of asthmaand the consequent research implications. Chest 1990;97:628–34.

7. Mrazek DA. Psychiatric complications of pediatric asthma.Ann Allergy 1992;69:285–90.

8. Global Initiative for Asthma.National Heart, Lung and BloodInstitute. Revised 2002. NIH Publications.

9. Woolcock AJ, Jenkins CR. Management of asthma: adecreasing role for bronchodilatorts. Mod Med S A 1991;16:73–99.

10. The ICD-10. Classification of mental and behavioral dis-orders: clinical descriptions and diagnostic guidelines. WorldHealth Organization 1992.

11. Bedford A, Foulds GA, Sheffield BF. A new personaldisturbance scale: DSSI/sAD. Br J Soc Clin Psychol1976;15:387–94.

12. Gillespie N, Kirk KM, Heath AC, Martin NG, Hickie I. Somaticdistress as a distinct psychological dimension. Soc PsychiatryPsychiatr Epidemiol 1999;34:451–8.

13. Bedford A, Deary IJ. The personal disturbance scale (DSSI/sAD): development, use and structure. Person Individ Diff1997;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 andallergies: a survey of a non-clinical population. PsychotherPsychosom 1991;55:24–31.

17. Bussing R, Burket RC, Kelleher ET. Prevalence of anxietydisorders in a clinic based sample of pediatric asthmapatients. Psychosomatics 1996;37:108–15.

18. Bussing R, Halfon N, Benjamin B, Wells K. Prevalence ofbehavior problems in US children with asthma. Arch PediatrAdolesc Med 1995;149:565–72.

19. Lyketsos GC, Blackburn IM, Mouzaki D. Personality variablesand dysthymic symptoms: a comparison between a greekand a british sample. Psychol Med 1979;9:753–8.

20. Lyketsos GC, Karabetsos A, Jordanoglou J, et al. Personalitycharacteristics and dysthymic states in bronchial asthma.Psychother Psychosom 1984;44:177–85.

21. Wright JR, Rodriguez M, Cohen S. Review of psychosocialstress and asthma: an intergrated biopsychosocial approach.Thorax 1998;53:1066–74.

22. Fritz GK, Rubinstein S, Lewiston NJ. Psychological factors infatal childhood asthma. Am J Orthopsychiatry 1987;57:253–7.

23. Rappaport L, Coffman H, Guare R, et al. Effects oftheoffylline on behavior and learning in children withasthma. A J D C 1989;143:368–72.

24. Miller B, Wood B. Psychobiologic reactivity in asthmaticchildren: a cholinergically mediated confluence of path-ways. 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, AndreouG, Molyvdas PA. Left-handedness and parental psychopathol-ogy in the course of bronchial asthma in childhood. PediatrAsthma Allergy Immunol 2002;15:145–52.

27. Ago Y, Teshima H, Nagata S, Inoue S, Ikemi Y. Psychosomaticstudies 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 relaxationon measures of asthma severity in children. Biofeedback SelfRegul 1991;16:1–21.

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