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Psychosomatic Medicine 67:989-996 (2005)
© 2005 American Psychosomatic Society

ORIGINAL ARTICLES

Psychiatric Disorders and Asthma Outcomes Among High-Risk Inner-City Patients

Jonathan M. Feldman, PhD, Mahmood I. Siddique, DO, Enid Morales, PharmD, Beverly Kaminski, RN, Shou-En Lu, PhD and Paul M. Lehrer, PhD

From the Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York (J.M.F.); Department of Medicine, Division of Pulmonary and Critical Care Medicine (M.I.S.), Eric B. Chandler Health Center (B.K.), Department of Biostatistics, School of Public Health (S.-E.L.), Department of Psychiatry (P.M.L.), University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Piscataway, New Jersey; Robert Wood Johnson University Hospital at Hamilton, Hamilton, New Jersey (M.I.S.); Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, New Brunswick, New Jersey (E.M.).

Address correspondence and reprint requests to Jonathan M. Feldman, PhD, Ferkauf Graduate School of Psychology, Yeshiva University, Rousso Building, 1300 Morris Park Avenue, Bronx, NY 10461. E-mail: JFeldman{at}aecom.yu.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
Objective: The purpose of this study was to examine the rate of psychiatric disorders among patients attending an ethnically diverse, inner-city asthma clinic for an initial visit and assess the association between psychiatric disorders and asthma morbidity.

Methods: A semistructured psychological interview was conducted to assess for psychiatric diagnoses. A pulmonary physician, who was blind to psychiatric disorder, established diagnosis of asthma based on national guidelines.

Results: Sixty-four percent of 85 participants received at least 1 psychiatric diagnosis. The pulmonary physician rated patients with a psychiatric disorder as achieving fewer goals (M = 2.3 ± 1.3) for asthma control than patients without a psychiatric disorder (M = 3.6 ± 1.5, p = .0002). Patients with a psychiatric diagnosis more frequently reported an emergency room visit for asthma during the past 6 months (OR = 4.89; 95% CI, 1.76–13.39) and greater use of short-acting ß2-agonist medication (M = 1.5 ± 0.9 canisters per month) than patients without a psychiatric diagnosis (M = 0.9 ± 0.8, p = .003). These findings were independent of demographics, health insurance, and asthma severity. No differences emerged between patients with and without a mental disorder on percent predicted FEV1. Patients with a psychiatric disorder reported a higher severity level for asthma symptoms than the severity level indicated by their pulmonary function in comparison to patients without a psychiatric diagnosis (OR = 3.52; 95% CI, 1.23–10.10). Health insurance appeared to be a confounding factor in this relationship.

Conclusion: A high rate of psychiatric disorders was found among inner-city asthma patients. Psychiatric diagnoses were associated with greater perceived impairment from asthma but not objective measurement of pulmonary function.

Key Words: asthma • mental disorders • quality of life • health-care-seeking behavior

Abbreviations: ER = emergency room; MDI = metered-dose inhaler; NHLBI = National Heart Lung and Blood Institute; PHQ = Patient Health Questionnaire; SCID-IV = Structured Clinical Interview for DSM-IV; SES = socioeconomic status.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
Individuals with low socioeconomic status (SES) are disproportionately affected by both mental illness (1,2) and asthma (3,4). A recent, large-scale longitudinal study (2) showed that this inverse relationship between SES and psychiatric disorders was nonlinear and primarily applied to low and middle SES groups. SES contributed directly and also indirectly to psychiatric illness via economic stressors specific to low SES groups, including poverty, unemployment, and housing unaffordability. This relationship between SES and mental illness was consistent across indicators of SES (e.g., education, income, occupational status) and types of psychiatric disorders.

The link between low SES and asthma among urban populations may be attributed to greater allergen exposure and sensitivity to cockroaches, mice, rats, and airborne fungi (5,6). Additionally, tobacco smoke exposure, traffic, and air pollution may also contribute to these asthma disparities (7). Low SES is also a risk factor for greater asthma morbidity (8), more frequent use of short-acting ß2-agonist medication (ie, quick-relief medication) (9), and poor medication adherence with inhaled steroids (ie, preventive medication) (10). Health insurance may be an important mediator in the relationship between low SES and asthma morbidity by limiting access to medications, health care providers, and asthma education. A recent study did not find an association between SES and rehospitalizations for asthma in Canada, a country with a universal health care system (11).

Patients with asthma are at increased risk for psychiatric disorders. Population-based studies have shown that adults with asthma are more likely than adults without asthma to have depressive and anxiety disorders (12–14). Clinic-based studies of outpatients with asthma have also consistently shown elevated rates of depressive and anxiety disorders, although there has been great variability in the rates that have been reported (15–17). Psychiatric disorders are often undetected and untreated among patients with asthma (15,17). Inner-city patients of low SES with asthma may be at particularly high risk for mental disorders.

Psychiatric symptoms are associated with adverse asthma self-management strategies and asthma outcomes. Adults with asthma who report high levels of psychological distress have poorer asthma medication adherence (18), higher doses of inhaled corticosteroids prescribed (19), greater utilization of health care resources (20), and poorer health-related quality of life (21). Although psychiatric symptoms are associated with greater perceived impairment from asthma, this relationship appears to be independent of more objective markers of asthma severity (17,22). These data are consistent with the earlier body of research showing that generalized panic-fear is a risk factor for hospitalizations and readmissions (23), overuse of short-acting ß2-agonist medication (24), and higher doses of corticosteroids being prescribed (25), independent of pulmonary function. Therefore, psychiatric symptoms may be associated with patients’ perception of asthma symptoms, which in turn may affect physicians’ decision making concerning asthma treatment.

Psychiatric symptoms may be a key factor in the accuracy of asthma symptom report. Asthma patients with psychiatric disorders have been to shown to display both under- and overestimation of airflow obstruction, which can have important clinical implications (26,27). Overestimation of asthma symptoms may lead to overuse of medications, frequent emergency health care utilization, and excessive functional limitations due to asthma. In contrast, underestimation of symptoms may lead to delays in seeking medical attention and using medication, which could have fatal consequences (28). A study (29) showed that negative affect and asthma symptom reports were associated with the use of more short-acting ß2-agonist medication, independent of objective measures of lung function. Anxiety and depression may lead individuals to mislabel general somatic symptoms and psychological distress as symptoms of asthma, which can lead to excessive use of quick-relief medication (29).

Taken together, these studies suggest that the combined maladaptive effects of low SES and clinically diagnosed mental illness may place asthma patients at high risk for poor health outcomes. Unfortunately, there is little published research that has examined these factors in the same study. The purpose of the present study was to examine the rate of mental disorders in a predominantly low SES, inner-city sample of asthma patients. Additionally, we sought to examine the association between clinically diagnosed psychiatric disorders and both subjective and objective measures of asthma control. It was hypothesized that patients with a psychiatric disorder would report poorer asthma control than patients without a mental disorder on subjective markers but would display no difference on an objective measurement of pulmonary function. An exploratory aim was to examine the relationship between classes of psychiatric diagnoses and asthma outcomes.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
Subjects
Eighty-six adult outpatients attending a university-affiliated, inner-city asthma clinic for an initial visit were recruited to participate in this study from 1999 to 2001. The asthma clinic was held 1 afternoon per week during this time period. English- and Spanish-speaking patients who were between 18 and 69 years old were approached for the study. Medical and psychiatric interviews with Spanish-speaking patients were conducted by using an interpreter who was a bilingual and bicultural researcher and board-certified pharmacotherapy specialist (E.M.).

Diagnosis of asthma was established by a board-certified pulmonary physician (M.I.S.) using the National Heart Lung and Blood Institute’s (NHLBI) guidelines (30). Inclusion criteria for the study were (i) a bronchodilator response of ≥12% with an absolute increase in FEV1 of ≥200 ml1 or (ii) clinical improvement in asthma symptoms and pulmonary function after initiation of anti-inflammatory medication at the asthma clinic. Clinical improvement was defined as an improvement in the NHLBI severity class by at least 1 category (eg, moderate persistent to mild persistent). Patients with a history of emphysema or nonasthma respiratory disease were excluded from the study. Therefore, fewer than 15% of the participants were cigarette smokers.

Measures
The Patient Health Questionnaire (PHQ; 31) is a brief, self-administered screening instrument used to identify psychiatric disorders in primary care. The PHQ assesses symptoms of major depressive disorder, other depressive disorder, panic disorder, other anxiety disorder, probable alcohol abuse/dependence, bulimia nervosa, binge eating disorder, and somatoform disorders. Both the English version (31) and the Spanish version (32) of the PHQ have demonstrated good sensitivity and specificity in detecting mental disorders when compared with diagnoses established by mental health professionals.

Markers of asthma morbidity were assessed by a pulmonary physician, who was blind to PHQ responses and psychiatric diagnoses. The physician rated the number of goals for asthma control that were achieved, according to NHLBI guidelines (see Table 1). Participants reported if they had experienced an emergency room (ER) visit or hospitalization related to asthma during the 6 months before this initial clinic visit. The physician also asked participants how many canisters of short-acting ß2-agonist medication they used during the last month. This class of medications is prescribed for as-needed (prn) use in response to symptoms and before trigger exposure.


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  		TABLE 1. Goals for Asthma Control

 

Each patient’s technique for using metered-dose inhalers (MDI) was assessed by a board-certified pharmacotherapy specialist (E.M.) or pulmonary physician. The scoring system (1–9) was based on NHLBI guidelines (30) and it consisted of the number of correct steps carried out by the patient in using a MDI.

Current asthma severity levels for symptom, pulmonary function, and medication class were categorized using NHLBI guidelines (30). Patients were not withdrawn from controller medications, and, therefore, these ratings reflect asthma control with the ongoing medication regimen, rather than underlying disease severity. The pulmonary physician rated asthma symptom severity based on an interview with the patient (30). Pulmonary function severity was based on percent predicted (%) FEV1 (33). Participants were asked to bring their asthma medications to the clinic and assessment of severity was based on participants’ report of current medication use. Medication data were lost for 5 patients with psychiatric disorders and 2 patients without psychiatric disorders. Mild intermittent and mild persistent were merged into a single category for symptom, medication, and pulmonary function classes due to the small number of subjects in the mild persistent category.

Comparisons on the NHLBI severity categories were made between symptoms and pulmonary function to classify patients as overreporters, congruent reporters, or underreporters. Participants with a higher symptom than pulmonary function severity class were classified as overreporters. Congruent reporters included individuals who had the same level of severity for symptoms and pulmonary function. Patients with a lower symptom than pulmonary function class were considered underreporters.

Procedure
A bilingual, registered nurse (B.K.) assessed participants’ bronchodilator responsiveness on their arrival to the clinic. Spirometry testing was conducted in accordance with the American Thoracic Society’s guidelines (34). The pulmonary physician, who was blind to psychiatric diagnoses and responses on the PHQ, obtained a clinical history and performed a physical examination. During this interview (30), demographic information was obtained and subjective assessments were made concerning asthma symptom severity and control.

Patients completed the PHQ (31), and individuals with positive indicators of psychiatric symptoms were interviewed by a licensed clinical psychologist (P.M.L.) or an advanced graduate student (J.M.F.) under supervision. The psychological interview consisted of the Structured Clinical Interview for DSM-IV (SCID-IV; 35), a semistructured interview. All modules from the SCID-IV assessing current psychiatric diagnoses were administered unless the patient specifically denied symptoms for a particular psychiatric disorder on the PHQ. Because the PHQ does not screen for psychotic symptoms, this module of the SCID-IV was administered in each psychological interview. Immediately after each interview, the assessment was discussed and psychiatric diagnoses were determined by consensus between the 2 clinicians. The psychological interview also consisted of clinical assessment of the following 3 domains: (1) if emotional factors triggered asthma symptoms (eg, "During these times when you are depressed, do you tend to experience more asthma symptoms?"), (2) if asthma symptoms triggered psychological symptoms (eg, "During asthma episodes, do you tend to experience more feelings of depression?"), and (3) if psychological factors interfered with a component of asthma self-management (eg, "When you are feeling stressed, is it more difficult for you to remember to take your asthma medication?"). This section of the interview was unstructured, and the clinician continued to assess further whether these changes in psychological and asthma symptoms represented a change from baseline. Data for these 3 domains were coded as yes/no based on participants’ responses and clinician judgment. Patients who did not endorse any psychiatric symptoms on the PHQ were not administered the psychological interview.

This study was approved by an institutional review board.

Statistical Analysis
Differences between patients with at least 1 psychiatric diagnosis and patients without a psychiatric diagnosis were tested by the use of {chi}2 for categorical variables, Fisher’s exact test (for small samples), or independent-samples t tests, as appropriate. Data were controlled for age, health insurance type, and race/ethnicity by using linear and logistic regression models. These variables were selected as covariates due to either significant between-group differences in the present study or associations reported in the literature between these variables and the dependent measures. The {chi}2 likelihood ratio test is also reported for continuous variables when controlling for covariates in the generalized linear regression model. Four percent of the participants belonged to a race/ethnicity category other than black/non-Hispanic, white/non-Hispanic, or Hispanic. These participants were combined with the black/non-Hispanic group for the purposes of controlling for race/ethnicity due to the small n for this "other" category. Combining these participants with the Hispanic group did not alter any of the results. Polytomous logistic regression (36) was used for analyses on asthma severity levels and concordance between symptom report and pulmonary function because these variables were classified as 3 distinct categories. A nonparametric test (Wilcoxon test) was used to assess between-group differences on MDI technique due to a bimodal distribution. A square-root transformation was performed to normalize the distribution on the number of goals for asthma control that were achieved. An {alpha} level of 0.05 was applied for all analyses.

Exploratory analyses were conducted to examine the relationship between specific classes of mental disorders, including psychiatric comorbidity, and the dependent measures. A maximum of 2 comorbid diagnoses was considered because descriptive statistics showed that only 8 patients had 3 or more psychiatric diagnoses. Associations between each dependent measure and each class of disorder or 2 specific comorbid disorders (with and without interactions) were examined by linear or logistic regression separately.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 NOTES
 REFERENCES
 
Patient Characteristics
Eighty-nine patients were eligible for the study and attended the clinic for an initial visit during the period of data collection. Eighty-five patients (60 female and 25 male) participated in this study. The mean age was 40.7 ± 12.9 years (range = 18–69) and the mean educational level completed was 11.9 ± 3.5. There was an equal number of black/non-Hispanic (37%) and Hispanic (37%) participants, and 22% were white/non-Hispanic. Twenty-seven percent of the participants were Spanish speaking. The majority of participants were not married (80%) and had either Medicaid (36%) or no health insurance (43%). Only 35% of the participants were currently employed, and 13% were students.

Table 2 shows the comparisons between patients with a psychiatric disorder and patients not meeting psychiatric diagnostic criteria. Patients with a mental disorder were older and more likely to have Medicaid than patients without a psychiatric diagnosis. Pairwise comparisons showed that patients with a psychiatric disorder were more likely than patients without a psychiatric disorder to have Medicaid versus private insurance (OR = 16.3; 95% CI, 2.3–114.1) and no insurance (OR = 4.6; 95% CI, 1.3–16.1).


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  		TABLE 2. Participants’ Characteristics

 

Psychiatric Disorders
Fifty-five patients (65.0%) were diagnosed with at least 1 psychiatric disorder, and 30 participants (35.0%) did not meet criteria for a psychiatric disorder. Table 3 shows that mood and anxiety disorders were the most common psychiatric diagnoses in this patient sample. {chi}2 analyses and Fisher exact test showed that there was significant comorbidity between mood disorders and anxiety disorders (OR = 24.42; 95% CI, 7.57–78.81) and between mood disorders and somatoform disorders (OR = 5.29; 95% CI, 1.07–26.19). Additionally, there was significant somatoform-psychotic disorder comorbidity (OR = 13.50; 95% CI, 1.95–93.25) and somatoform–substance use disorder comorbidity (OR = 6.56; 95% CI, 1.24–34.73). Approximately half of the patients received more than 1 psychiatric diagnosis.


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  		TABLE 3. Percentage of Current Psychiatric Diagnoses for the Entire Patient Sample (n = 85)

 

Asthma Morbidity
The pulmonary physician rated patients with a psychiatric diagnosis as achieving fewer goals for asthma control (M = 2.3 ± 1.3) than patients without a psychiatric disorder (M = 3.6 ± 1.5) (t (82) = 3.9, p = .0002). This relationship was not changed after statistically controlling for age, race/ethnicity, and health insurance ({chi}2 (1) = 13.10, p = .0003).

Figure 1 shows that patients with a psychiatric diagnosis were more likely than patients without a diagnosis to report an ER visit (62%; OR = 4.89; 95% CI, 1.76–13.39) and hospitalization (31%; OR = 3.83; 95% CI, 1.01–14.45) for asthma during the past 6 months. After statistically controlling for age, race/ethnicity, and health insurance, patients with a mental disorder were 4.5 times more likely (95% CI, 1.33–14.93) to have experienced an ER visit than patients without a psychiatric diagnosis. Although the adjusted odds ratio for hospitalizations increased to 4.7, only a trend was present (95% CI, 0.86–25.55). It is likely the confidence limit changed because of low power to determine the multivariate association, which was indicated by the wide confidence interval.



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  		Figure 1. Emergency health care utilization for asthma during the past 6 months.

 

Patients with a mental disorder also reported using more short-acting ß2-agonist canisters per month (M = 1.5 ± 0.9) than patients without a mental disorder (M = 0.9 ± 0.8) (t (81) = 3.02, p = .003). This effect remained significant after statistically controlling for age, race/ethnicity, and health insurance ({chi}2 (1) = 4.40, p = .04). Finally, a nonsignificant trend (Z = 1.85, p = .06) was present showing that patients with a psychiatric diagnosis tended to display fewer correct steps (M = 5.1 ± 2.5) in using their MDI than patients without a psychiatric diagnosis (M = 6.1 ± 2.3).

Asthma Severity
No differences were found between patients with and without a psychiatric disorder on asthma severity (see Figure 2), as defined by asthma symptoms ({chi}2 (2) = 4.6, p = .10), pulmonary function class ({chi}2 (2) = 0.44, p = .80), and asthma medication regimen ({chi}2 (2) = 4.6, p = .10). Patients with a psychiatric disorder displayed similar levels on %FEV1 (M = 76.9 ± 21.3) compared with patients without a psychiatric disorder (M = 77.3 ± 26.9). Adjusted analyses showed no between-group differences on asthma symptom or pulmonary function severity level. However, there was a trend toward differences on medication level between patients with and without a mental disorder after controlling for age, race/ethnicity, and health insurance ({chi}2 (2) = 5.85, p = .054). Patients with a psychiatric disorder were more likely to be using medications indicated for severe persistent versus moderate persistent asthma (OR = 6.10; 95% CI, 1.34–27.78) in comparison to patients without a psychiatric disorder. The association between health insurance and medication level was not significant ({chi}2 (6) = 2.62, p = .85).



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  		Figure 2. Asthma severity measured by symptoms, pulmonary function, and medications.

 

Concordance Between Symptom Report and Pulmonary Function
A comparison between NHLBI symptom class and pulmonary function class (Figure 3) showed that between-group differences emerged on classification of underreporters, concordant reporters, and overreporters ({chi}2 (2) = 6.25, p < .05). Patients with a psychiatric disorder were more likely than patients without a psychiatric disorder to be overreporters than concordant reporters (OR = 3.52; 95% CI, 1.23–10.10). Fifty-one percent (n = 26) of patients with a psychiatric diagnosis were classified as overreporters in comparison to 23% (n = 7) of patients without a psychiatric disorder. In contrast, only 37% (n = 19) of patients with a psychiatric disorder were concordant reporters, as compared with 60% (n = 18) of patients without a psychiatric diagnosis. The between-group comparisons were not significant for underreporters versus overreporters (OR = 3.10; 95% CI, 0.73–13.16) and underreporters versus concordant reporters (OR = 0.88; 95% CI, 0.23–3.39).



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  		Figure 3. Concordance between symptom class and pulmonary function class.

 

Health insurance may have been a confounding factor in the relationship between accuracy of symptom report and psychiatric diagnosis. The association between accuracy of symptom report and psychiatric diagnosis was not significant after controlling for age, race/ethnicity, and health insurance ({chi}2 (2) = 3.34, p = .19). The association between accuracy of symptom report and psychiatric diagnosis was significant when controlling for age and race/ethnicity but excluding health insurance from the model ({chi}2 (2) = 6.76, p = .03). A trend was present in the association between health insurance and accuracy of symptom report ({chi}2 (6) = 11.26, p = .08).

Between-group contrasts showed that patients with Medicaid were more likely (OR = 5.29; 95% CI, 1.69–16.39) to be classified as overreporters (61%; n = 19) than concordant reporters (26%; n = 8) in comparison to patients without health insurance (26% [n = 9] overreporters, 57% [n = 20] concordant reporters). Patients with Medicaid were also more likely (OR = 11.9; 95% CI, 1.19–125.0) to be overreporters versus concordant reporters than patients with private insurance (14% [n = 1] overreporters, 71% [n = 5] concordant reporters). These data on health insurance should be interpreted with caution due to the small cell size that violated the assumptions of the {chi}2 test. Nevertheless, health insurance may play an important role in the report of asthma symptoms.

Relationship Among Classes of Psychiatric Diagnostic Categories and Health Outcomes
Linear regression analyses showed that individuals with mood disorders (p = .0002) and anxiety disorders (p = .005) achieved fewer goals for asthma control. When 2 comorbid disorders were considered simultaneously, the association between mood and goals for asthma control remained significant when each of the other psychiatric disorders (including anxiety) was entered in the model. Anxiety remained a significant predictor of goals for asthma control when somatoform, psychotic, and substance use disorders were included in the model.

Report of ER use for asthma treatment was higher among patients with mood disorders (OR = 1.28; 95% CI, 1.04–1.6), anxiety disorders (OR = 1.31; 95% CI, 1.07–1.6) and substance use disorders (OR = 1.50; 95% CI, 1.03–2.19) versus patients without these diagnoses. Mood disorder remained a significant predictor of ER use when each of the other mental disorders was included in the model, except for anxiety disorders. The association between ER use and anxiety disorders remained significant when separately controlling for somatoform, psychotic, and substance use disorders. Substance use disorders remained significant only when including somatoform disorders in the model. No individual psychiatric diagnostic category was associated with hospitalizations for asthma.

Individuals with mood disorders (p = .001), anxiety disorders (p = .03), and somatoform disorders (p = .008) reported greater use of short-acting ß2-agonists than patients without these mental disorders. The association between mood disorders and ß2-agonist use remained significant after including each of the other psychiatric disorders in the model. The association with anxiety was significant after separately controlling for somatoform, psychotic, and substance use disorders. Somatoform disorder was a significant predictor of ß2-agonist use after including both psychotic and substance use disorders in separate models. Finally, accuracy of asthma symptom report was not associated with any single class of mental disorders.

In summary, these findings show that mood and anxiety disorders are consistently associated with greater asthma morbidity. Additionally, mood disorder appears to be a stronger predictor of asthma morbidity when including anxiety disorder in regression models.

Relationship Between Emotions and Asthma Symptoms
A relationship between emotions and asthma symptoms was assessed in more than two-thirds (68%) of the participants with a psychiatric diagnosis. Among patients with a psychiatric disorder, 45% reported that emotional factors trigger their asthma symptoms and 44% reported that asthma exacerbates their psychological symptoms. Furthermore, 47% of patients with a psychiatric disorder reported that their psychological symptoms interfere with a component of asthma self-management.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
NOTES
 REFERENCES
 
Subjective indicators of asthma control showed that patients with a psychiatric diagnosis had poorer control than patients without a psychiatric disorder. Patients diagnosed with a psychiatric disorder were rated by a physician as achieving fewer goals for asthma control than patients without a mental disorder. Furthermore, patients with psychiatric disorders reported greater emergency health care utilization for asthma than patients without a psychiatric disorder. These findings were independent of sociodemographic measures and health insurance. The presence of a mood disorder was the strongest predictor of greater asthma morbidity, followed by the diagnosis of an anxiety disorder.

An objective, physiological indicator of asthma control (% FEV1) showed that there was no difference between patients with and without a mental disorder. This discrepancy between subjective and objective markers of asthma control is consistent with the literature on psychiatric symptoms (17,20–25) and extends this finding to clinically diagnosed psychiatric disorders among high-risk, low SES patients with asthma. Patients with psychiatric disorders tend to feel more impaired than others. These data demonstrate the importance of comparing subjective assessment of asthma with more objective markers among patients with mental disorders.

Patients with psychiatric disorders also reported greater use of short-acting ß2-agonist medication than patients without a psychiatric diagnosis. This finding may reflect inadequate treatment with preventive medication or inappropriate use of quick-relief medication. Anti-inflammatory medication is typically underprescribed and underutilized among inner-city asthma patients (37). However, a nonsignificant trend showed that patients with psychiatric diagnoses tended to use medications indicated for severe asthma, which is consistent with previous research (19,25). Poor adherence with preventive medication is associated with psychological symptoms (18), which might also contribute to greater use of quick-relief medication. Approximately 45% of patients with mental disorders in the present study reported that their psychological symptoms interfered with asthma self-management. Additionally, there was evidence showing poor MDI technique among patients with psychiatric diagnoses, although there was no significant difference between the 2 groups. Confusion between asthma and psychiatric symptoms (eg, dyspnea) may lead to excessive use of short-acting ß2-agonists and side effects, which include sympathetic activation (38). This may trigger a maladaptive cycle of short-acting ß2-agonists being used to treat respiratory anxiety symptoms that are mistaken as asthma, thus leading to further increases in anxiety (39,40).

The relationship between asthma symptoms and emotions may be bidirectional. Almost half of individuals with a psychiatric disorder reported a reciprocal relationship between psychological and asthma symptoms. Stress may trigger asthma symptoms via inflammatory, autonomic, and behavioral pathways. During final examination periods, students with asthma have been shown to demonstrate a shift toward a Th2 cytokine response profile, which reflects a heightened inflammatory response that may exacerbate asthma (41). Furthermore, chronic stress may increase vulnerability toward developing upper respiratory infections (42) and, in turn, asthma exacerbation (43). The autonomic nervous system may also be involved in stress-induced asthma via parasympathetic rebound following sympathetic activation (44) or passive behavioral responses to stress and accompanying vagal activation, which may occur with depression (45). Emotions may also lead to asthma exacerbation by poor self-management behavior (18). Conversely, asthma may contribute to greater psychological symptoms via fatigue, disability, self-perception as being sick, and the frightening nature of dyspnea.

A very high rate (65%) of psychiatric disorders, particularly mood (51%) and anxiety disorders (45%), was found in this sample of high risk inner-city asthma patients. It is difficult to compare rates across studies due to variations in samples and assessment techniques. Nevertheless, the rate of having at least 1 psychiatric diagnosis has been estimated to be between 28% to 30% in the general population (46). The rate of a current mood disorder in the present study was also higher than the rate (16%) found among a small sample of inner-city asthma patients, although both studies used the SCID-IV to assess psychiatric diagnoses (17). This discrepancy may be related to differences in the racial/ethnic composition of the samples as more African-American patients (61%) and substantially fewer Hispanic patients (5%) participated in this study (17) than the present one. These data collectively demonstrate the high rate of psychiatric comorbidity in the present study.

Common environmental stressors and biological pathways may play a role in this link between asthma and mental disorders among inner-city populations. It has been hypothesized that stress early in a child’s life may alter the development of the immune system toward a Th2 immune response and thus predispose the child toward developing asthma (47,48). Exposure to traumatic events is associated with asthma morbidity (49) and internalizing disorders among children (50). A population study showed that adults who reported experiencing physical abuse as a child were more likely to develop comorbidity between lung disease, depression, and panic attacks (51). There is evidence showing that the link between low SES and heightened inflammatory responses among patients with asthma may be mediated by greater stress and less perceived control over health (52). Patients with asthma have been shown to be more susceptible to learned helplessness (53), which may maintain the comorbidity between asthma and psychiatric disorders.

Health insurance appeared to be a confounding factor in the association between mental disorders and concordance between symptom report and pulmonary function. The finding that patients with psychiatric disorders were overreporters of asthma symptoms may have been attributed to Medicaid insurance. A greater percentage of patients with Medicaid had a mental disorder and were overreporters of symptoms. High comorbidity between psychiatric illness and pulmonary disease has been previously reported among patients with Medicaid (54). A separate study showed that half of patients with Medicaid reported medically unexplained symptoms that occurred on a regular basis, and 75% of this group reported seeking medical treatment for these symptoms (55). Perhaps greater availability of health care services prompts more attention to symptoms among patients with Medicaid. Additionally, these patients may have been confusing psychiatric and asthma symptoms. This serendipitous finding should be explored in future research by matching patients with and without psychiatric disorders on health insurance to tease apart these 2 effects.

There are certain limitations that should be considered when interpreting the findings of this study. Emergency health care utilization for asthma and use of short-acting ß2-agonist medication were based on retrospective self-report. Also, psychological and medical interviews were conducted via an interpreter, although this individual was a bilingual and bicultural researcher and board-certified pharmacotherapy specialist. Additionally, rates of comorbidities may not be representative due to sampling bias and relatively small sample size, compared with epidemiological studies. Finally, the objective measurement of pulmonary function was based on testing performed on the day of the study, rather than daily measures. It is possible that this snapshot of pulmonary function may be an underestimate of pulmonary impairment on a more typical day. However, this assessment was performed at an initial clinic visit for asthma treatment and, thus, patients may have been more symptomatic on this particular day. Future research should collect daily measures of pulmonary function and subjective assessments at the same time points to obtain more accurate measures of symptom perception. Daily measures of pulmonary function would provide data as to whether patients with mental disorders actually have poor control over their asthma or simply perceive greater impairment. Negative, passive mood states have been shown to be associated with reductions in daily measures of pulmonary function (56,57).

The results of the present study suggest that psychiatric disorders should be taken into account when treating asthma. Our findings suggest that multidisciplinary treatment approaches are recommended for inner-city asthma patients to target the following areas: (1) asthma symptom perception, (2) education on asthma symptoms and medications, (3) stress management and treatment of psychiatric conditions, and (4) culturally sensitive, written asthma management plans consistent with the national guidelines (30). Training patients to use objective markers of airflow obstruction (eg, peak flow meters) may be an important area of intervention for patients with comorbid asthma and psychiatric illness. These data also highlight the importance of incorporating spirometry into assessments of asthma to guide medical decision making. Additionally, health care providers should consider the presence of anxiety and/or depression among asthma patients who report poor control over their asthma but consistently display normal lung function. Future studies are necessary to establish whether treatment of the psychiatric condition leads to concomitant improvements in asthma control.


   NOTES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
REFERENCES
 
1FEV1 is the volume of air expired during the first second of a forced vital capacity maneuver, which involves maximal inspiration followed by a forceful and rapid expiration into a spirometer. Back

This study was supported by the Rutgers Community Health Foundation.

DOI:10.1097/01.psy.0000188556.97979.13


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 

  1. Weich S, Lewis G. Poverty, unemployment, and common mental disorders: population based cohort study. BMJ 1998;317:115–9.[Abstract/Free Full Text]
  2. Hudson CG. Socioeconomic status and mental illness: tests of the social causation and selection hypotheses. Am J Orthopsychiatry 2005;75:3–18.[CrossRef][Medline]
  3. Basagana X, Sunyer J, Kogevinas M, Zock JP, Duran-Tauleria E, Jarvis D, Burney P, Anto JM; European Community Respiratory Health Survey. Socioeconomic status and asthma prevalence in young adults: the European Community Respiratory Health Survey. Am J Epidemiol 2004;160:178–88.[Abstract/Free Full Text]
  4. Gwynn RC. Risk factors for asthma in US adults: results from the 2000 Behavioral Risk Factor Surveillance System. J Asthma 2004;41:91–8.[CrossRef][Medline]
  5. Lewis SA, Weiss ST, Platts-Mills TA, Syring M, Gold DR. Association of specific allergen sensitization with socioeconomic factors and allergic disease in a population of Boston women. J Allergy Clin Immunol 2001;107:615–22.[CrossRef][Medline]
  6. O’Connor GT, Walter M, Mitchell H, Kattan M, Morgan WJ, Gruchalla RS, Pongracic JA, Smartt E, Stout JW, Evans R, Crain EF, Burge HA. Airborne fungi in the homes of children with asthma in low-income urban communities: the Inner-City Asthma Study. J Allergy Clin Immunol 2004;114:599–606.[CrossRef][Medline]
  7. Gold DR, Wright R. Population disparities in asthma. Annu Rev Public Health 2005;26:89–113.[CrossRef][Medline]
  8. Boudreaux ED, Emond SD, Clark S, Camargo CA Jr. Acute asthma among adults presenting to the emergency department: the role of race/ethnicity and socioeconomic status. Chest 2003;124:803–12.[Abstract/Free Full Text]
  9. Lynd LD, Sandford AJ, Kelly EM, Pare PD, Bai TR, Fitzgerald JM, Anis AH. Reconcilable differences: a cross-sectional study of the relationship between socioeconomic status and the magnitude of short-acting beta-agonist use in asthma. Chest 2004;126:1161–8.[Abstract/Free Full Text]
  10. Apter AJ, Boston RC, George M, Norfleet AL, Tenhave T, Coyne JC, Birck K, Reisine ST, Cucchiara AJ, Feldman HI. Modifiable barriers to adherence to inhaled steroids among adults with asthma: it’s not just black and white. J Allergy Clin Immunol 2003;111:1219–26.[CrossRef][Medline]
  11. Chen Y, Stewart P, Dales R, Johansen H, Scott G, Taylor G. Ecological measures of socioeconomic status and hospital readmissions for asthma among Canadian adults. Respir Med 2004;98:446–53.[CrossRef][Medline]
  12. Goodwin RD, Jacobi F, Thefeld W. Mental disorders and asthma in the community. Arch Gen Psychiatry 2003;60:1125–30.[Abstract/Free Full Text]
  13. Goodwin RD, Fergusson DM, Horwood LJ. Asthma and depressive and anxiety disorders among young persons in the community. Psychol Med 2004;34:1465–74.[CrossRef][Medline]
  14. Hasler G, Gergen PJ, Kleinbaum DG, Ajdacic V, Gamma A, Eich D, Rossler W, Angst J. Asthma and panic in young adults: a twenty year prospective community study. Am J Respir Crit Care Med 2005;171:1224–30.[Abstract/Free Full Text]
  15. Brown ES, Khan DA, Mahadi S. Psychiatric diagnoses in inner city outpatients with moderate to severe asthma. Int J Psychiatry Med 2000;30:319–27.[CrossRef][Medline]
  16. Nascimento I, Nardi AE, Valenca AM, Lopes FL, Mezzasalma MA, Nascentes R, Zin WA. Psychiatric disorders in asthmatic outpatients. Psychiatry Res 2002;110:73–80.[CrossRef][Medline]
  17. Nejtek VA, Brown ES, Khan DA, Moore JJ, Van Wagner J, Perantic DC. Prevalence of mood disorders and relationship to asthma severity in patients at an inner-city asthma clinic. Ann Allergy Asthma Immunol 2001;87:129–33.[Medline]
  18. Cluley S, Cochrane GM. Psychological disorder in asthma is associated with poor control and poor adherence to inhaled steroids. Respir Med 2001;95:37–9.[CrossRef][Medline]
  19. Bonala SB, Pina D, Silverman BA, Amara S, Bassett CW, Schneider AT. Asthma severity, psychiatric morbidity, and quality of life: correlation with inhaled corticosteroid dose. J Asthma 2003;40:691–9.[CrossRef][Medline]
  20. ten Brinke A, Ouwerkerk ME, Zwinderman AH, Spinhoven P, Bel EH. Psychopathology in patients with severe asthma is associated with increased health care utilization. Am J Respir Crit Care Med 2001;163:1093–6.[Abstract/Free Full Text]
  21. Strine TW, Ford ES, Balluz L, Chapman DP, Mokdad AH. Risk behaviors and health-related quality of life among adults with asthma: the role of mental health status. Chest 2004;126:1849–54.[Abstract/Free Full Text]
  22. ten Brinke A, Ouwerkerk ME, Bel EH, Spinhoven P. Similar psychological characteristics in mild and severe asthma. J Psychosom Res 2001;50:7–10.[CrossRef][Medline]
  23. Dirks JF, Schraa JC, Brown EL, Kinsman RA. Psycho-maintenance in asthma: hospitalization rates and financial impact. Br J Med Psychol 1980;53:349–54.[Medline]
  24. Dahlem NW, Kinsman RA, Horton DJ. Panic-fear in asthma: requests for as-needed medications in relation to pulmonary function measurements. J Allergy Clin Immunol 1977;60:295–300.[CrossRef][Medline]
  25. Dirks JF, Horton DJ, Kinsman RA, Fross KH, Jones NF. Patient and physician characteristics influencing medical decisions in asthma. J Asthma Res 1978;15:171–8.[Medline]
  26. Rushford N, Tiller JW, Pain MC. Perception of natural fluctuations in peak flow in asthma: clinical severity and psychological correlates. J Asthma 1998;35:251–9.[Medline]
  27. van Peski-Oosterbaan AS, Spinhoven P, van der Does AJ, Willems LN, Sterk PJ. Is there a specific relationship between asthma and panic disorder? Behav Res Ther 1996;34:333–40.[CrossRef][Medline]
  28. Magadle R, Berar-Yanay N, Weiner P. The risk of hospitalization and near-fatal and fatal asthma in relation to the perception of dyspnea. Chest 2002;121:329–33.[Abstract/Free Full Text]
  29. Main J, Moss-Morris R, Booth R, Kaptein AA, Kolbe J. The use of reliever medication in asthma: the role of negative mood and symptom reports. J Asthma 2003;40:357–65.[CrossRef][Medline]
  30. National Heart Lung and Blood Institute. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma: Update on Selected Topics 2002: National Asthma Education and Prevention Program. Washington, DC: US Department of Health and Human Services; 2003. NIH Publication No. 02-5074.
  31. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study: Primary Care Evaluation of Mental Disorders: Patient Health Questionnaire. JAMA 1999;282:1737–44.
  32. Diez-Quevedo C, Rangil T, Sanchez-Planell L, Kroenke K, Spitzer RL. Validation and utility of the patient health questionnaire in diagnosing mental disorders in 1003 general hospital Spanish inpatients. Psychosom Med 2001;63:679–86.[Abstract/Free Full Text]
  33. Crapo RO, Morris AH, Gardner RM. Reference spirometric values using techniques and equipment that meet ATS recommendations. Am Rev Respir Dis 1981;123:659–64.[Medline]
  34. American Thoracic Society. Standardization of spirometry: 1994 update. Am J Respir Crit Care Med 1995;152:1107–36.[Medline]
  35. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV Axis I Disorders, Research Version, Non-patient Edition (SCID-I/NP). New York: Biometrics Research, New York State Psychiatric Institute; 1996.
  36. Hosmer DW, Lemeshow S. Applied Logistic Regression. 2nd ed. New York: Wiley; 2000.
  37. Riekert KA, Butz AM, Eggleston PA, Huss K, Winkelstein M, Rand CS. Caregiver-physician medication concordance and undertreatment of asthma among inner-city children. Pediatrics 2003;111:214–20.
  38. Scalabrin DMF, Sole D, Naspitz CK. Efficacy and side effects of beta2-agonists by inhaled route in acute asthma in children: comparison of salbutamol, terbutaline, and fenoterol. J Asthma 1996;33:407–15.[Medline]
  39. Rihmer Z. Successful treatment of salbutamol-induced panic disorder with citalopram. Eur Neuropsychopharmacol 1997;7:241–2.[CrossRef][Medline]
  40. Feldman JM, Lehrer PM, Borson S, Hallstrand TS, Siddique MI. Health care use and quality of life among patients with asthma and panic disorder. J Asthma 2005;42:179–84.[Medline]
  41. Liu LY, Coe CL, Swenson CA, Kelly EA, Kita H, Busse WW. School examinations enhance airway inflammation to antigen challenge. Am J Respir Crit Care Med 2002;165:1062–7.[Abstract/Free Full Text]
  42. Cohen S, Tyrell DA, Smith AP. Psychological stress in humans and susceptibility to the common cold. N Engl J Med 1991;325:606–12.[Abstract]
  43. Smith A, Nicholson K. Psychosocial factors, respiratory viruses and exacerbation of asthma. Psychoneuroendocrinology 2001;26:411–20.[CrossRef][Medline]
  44. Lehrer PM, Hochron SM, Mayne TM, Isenberg S, Lasoski AM, Carlson V, Gilchrist J, Porges S. Relationship between changes in EMG and respiratory sinus arrhythmia in a study of relaxation therapy for asthma. Appl Psychophysiol Biofeedback 1997;22:183–91.[CrossRef][Medline]
  45. Miller BD, Wood BL. Influence of specific emotional states on autonomic reactivity and pulmonary function in asthmatic children. J Am Acad Child Adolesc Psychiatry 1997;36:669–77.[CrossRef][Medline]
  46. Narrow WE, Rae DS, Robins LN, Regier DA. Revised prevalence estimates of mental disorders in the United States: using a clinical significance criterion to reconcile 2 surveys’ estimates. Arch Gen Psychiatry 2002;59:115–23.[Abstract/Free Full Text]
  47. Klinnert MD, Nelson HS, Price MR, Adinoff AD, Leung DY, Mrazek DA. Onset and persistence of childhood asthma: predictors from infancy. Pediatrics 2001;108:E69.
  48. Wright RJ, Cohen S, Carey V, Weiss ST, Gold DR. Parental stress as a predictor of wheezing in infancy: a prospective birth-cohort study. Am J Respir Crit Care Med 2002;165:358–65.[Abstract/Free Full Text]
  49. Wright RJ, Mitchell H, Visness CM, Cohen S, Stout J, Evans R, Gold DR. Community violence and asthma morbidity: the Inner-City Asthma Study. Am J Public Health 2004;94:625–32.[Abstract/Free Full Text]
  50. Thabet AA, Abed Y, Vostanis P. Comorbidity of PTSD and depression among refugee children during war conflict. J Child Psychol Psychiatry 2004;45:533–42.
  51. Goodwin RD, Wamboldt MZ, Pine DS. Lung disease and internalizing disorders: is childhood abuse a shared etiologic factor? J Psychosom Res 2003;55:215–9.[CrossRef][Medline]
  52. Chen E, Fisher EB, Bacharier LB, Strunk RC. Socioeconomic status, stress, and immune markers in adolescents with asthma. Psychosom Med 2003;65:984–92.[Abstract/Free Full Text]
  53. Chaney JM, Mullins LL, Uretsky DL, Pace TM, Werden D, Hartman VL. An experimental examination of learned helplessness in older adolescents and young adults with long-standing asthma. J Pediatr Psychol 1999;24:259–70.[Abstract/Free Full Text]
  54. Jones DR, Macias C, Barreira PJ, Fisher WH, Hargreaves WA, Harding CM. Prevalence, severity, and co-occurrence of chronic physical health problems of persons with serious mental illness. Psychiatry Serv 2004;55:1250–7.
  55. Hartz AJ, Noyes R, Bentler SE, Damiano PC, Willard JC, Momany ET. Unexplained symptoms in primary care: perspectives of doctors and patients. Gen Hosp Psychiatry 2000;22:144–52.[CrossRef][Medline]
  56. Ritz T, Steptoe A. Emotion and pulmonary function in asthma: reactivity in the field and relationship with laboratory induction of emotion. Psychosom Med 2000;62:808–15.[Abstract/Free Full Text]
  57. Affleck G, Apter A, Tennen H, Reisine S, Barrows E, Willard A, Unger J, ZuWallack R. Mood states associated with transitory changes in asthma symptoms and peak expiratory flow. Psychosom Med 2000;62:61–8.[Abstract/Free Full Text]



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