PSYCHIATRIC DIAGNOSES IN INNER CITY OUTPATIENTS WITH MODERATE TO SEVERE ASTHMA*

Transcription

1 7INT L. J. PSYCHIATRY IN MEDICINE, Vol. 30(4) , 2000 PSYCHIATRIC DIAGNOSES IN INNER CITY OUTPATIENTS WITH MODERATE TO SEVERE ASTHMA* E. SHERWOOD BROWN, PH.D., M.D. DAVID A. KHAN, M.D. SUSAN MAHADI, M.ED. The University of Texas Southwestern Medical Center, Dallas ABSTRACT Objective: Psychiatric symptoms may be associated with increased asthma morbidity and mortality. However, no investigations have identified syndromal psychiatric diagnoses in asthma patients using current diagnostic criteria or examined treatment received for mental illness. Method: We conducted structured clinical interviews on 32 patients with moderate to severe asthma to identify current and past psychiatric illness. Results: Twenty-five percent of subjects had current major depressive disorder, but only 25 percent of these received antidepressants. Anxiety disorders, including panic disorder (6 percent), and social (3 percent) and specific phobias (28 percent) were also common. All subjects with panic disorder were receiving appropriate therapy. Conclusions: Asthma patients with moderate to severe asthma treated at community health facilities may have high rates *Presented in part at the American College of Neuropsychopharmacology Annual Meeting, Acapulco, Mexico, December 2-7, 999. Supported, in part, by the National Alliance for Research on Schizophrenia and Depression (NARSAD), the Sarah M. and Charles E. Seay Center for Basic and Applied Research in Psychiatric Illness, John Schemerhorn Psychiatric Fund, the Theodore and Vada Stanley Foundation (ESB). 2000, Baywood Publishing Co., Inc. 39

2 320 / BROWN ET AL. of often untreated mood and anxiety disorders. Interventions aimed at identifying and treating psychiatric disorders in this population are needed. (Int l. J. Psychiatry in Medicine 2000;30:39-327) Key Words: asthma, depression, anxiety, antidepressant INTRODUCTION Historically, asthma has been considered a psychosomatic illness in which psychological factors play an important role in initiating and exacerbating symptoms of airway obstruction []. Psychiatric symptoms may be common in persons with asthma. Badoux and Levy [2] reported increased depressive, obsessive compulsive, anxiety, phobic anxiety, paranoid ideation, and psychotism on the Brief Symptom Inventory (BSI), a self-report questionnaire of psychiatric symptoms, in asthma patients compared to a group of normal controls. Jones et al. [3] reported elevated levels of depression and somatization in asthma patients compared to normals on the Minnesota Multiphasic Personality Inventory (MMPI). Bosley et al. [4] observed elevated scores for depression, but not anxiety, on the Hospital Anxiety and Depression Scale (HADS) in asthma patients with a history of medication noncompliance. The presence of psychiatric illness may be associated with increased morbidity and mortality with asthma. Strunk et al. [5] reported symptoms of depression were a variable which distinguished children who died of asthma (n = 2) from survivors matched for age, sex, and severity of illness. Similarly, Picado et al. [6] reported four of six adults who died during asthma exacerbations had received treatment for symptoms of anxiety and depression. In all cases the subjects had self-discontinued the psychiatric medication prior to the fatal attack. However, Yellowlees et al. [7] found low rates of depression and anxiety disorders both in a group of asthma patients with a history of near fatal attacks and a control group with less severe symptoms. Thus, some evidence supports that psychiatric symptoms are common in persons with asthma and appear to be associated with an unfavorable asthma course. However, no studies have used structured clinical interviews (SCID) to assess psychiatric disorders using Diagnostic and Statistical Manual IV (DSM IV) criteria [8]. As syndromal diagnoses, not isolated symptoms, are the basis for treatment in psychiatry, the prevalence of mental illness based on current diagnostic criteria is necessary to identify patients who might need psychotropic medications. As part of an investigation examining mood changes during brief courses of corticosteroids, we conducted SCID interviews in a group of asthma patients at a large county-operated hospital to assess past and present psychiatric illnesses. Information about psychiatric treatment was also obtained. We hypothesized that psychiatric disorders, particularly depression, would be common, and frequently unrecognized and untreated.

3 METHODS MODERATE TO SEVERE ASTHMA / 32 Patients treated at the Parkland Health and Hospital System Asthma Clinic, and scheduled to receive a burst of prednisone (at least 40 mg initially and lasting for at least 7 days) for an asthma exacerbation, were recruited as part of another research study examining steroid effects on mood. All subjects signed an IRB approved informed consent form prior to participation in the study. Inclusion criteria included ) age between 8 65 years, 2) no severe or life-threatening medical illnesses which would make them unable to follow up for scheduled appointments, 3) stable medication regimen other than the addition of prednisone therapy, and 4) a reasonable expectation that they will follow up with appointments and comply with medical treatment. Excluded based on a brief screening interview were ) non-english speaking subjects, 2) subjects likely to meet criteria for current alcohol abuse or dependence or drug abuse or dependence within the past six months, and 3) persons with illnesses with prominent neuropsychiatric symptoms (e.g., multiple sclerosis, brain tumors, systemic lupus erythematosis). Information on current asthma medications and pulmonary function (FEV percent) was also obtained. The patients were scheduled for a follow-up appointment 3 7 days after the Asthma Clinic visit at which time a SCID (clinician version) [8] interview was performed to assess current and past psychiatric history. Information about current and past psychiatric treatment including medications was also obtained. We did not obtain information on psychotherapy. However, as psychotherapy is only available at Parkland Hospital on a limited basis through the Psychiatry Clinic, few patients were likely receiving this form of treatment. The SCID-IV interview was conducted by ESB or SM after they received extensive training in the use of this instrument provided by the UTSW Psychiatry Department. Following the SCID interview, the subjects were paid $25.00 to cover time, transportation costs, and inconvenience. RESULTS Thirty-two of 60 subjects returned for follow-up and received SCID interviews. These subjects consisted of 6 men and 26 women. Twenty-two of the subjects were African American, three White, five Hispanic, and two were from other ethnic groups. The mean age was 46.9 (SD ± 2.9). Mean FEV percent was 53.9 percent (SD ± 4.4) consistent with moderate to severe asthma. Results of the SCID interviews are presented in Table. Mood disorders were the most common illnesses, occurring in 63 percent of the subjects. Anxiety disorders were the second most common class of psychiatric disorders, with 59 percent of subjects having at least one anxiety disorder. Psychotic illnesses were less common, occurring in only 9 percent of the sample. Lifetime drug or alcohol related disorders were reported in 22 percent of the patients. Only 6 percent of the subjects had no current or past psychiatric diagnosis on the SCID.

4 322 / BROWN ET AL. Table. Psychiatric Diagnoses in Outpatient Asthmatics (n = 32) Scheduled to Receive a Prednisone Burst Disorder n (%) Major Depressive Disorder Current Lifetime Depressive Disorder NOS Bipolar I Disorder Bipolar II Disorder Substance-Induced Mood Disorder, past (secondary to corticosteroids) Any Lifetime Mood Disorder (25) (47) (6) (63) Schizophrenia Schizoaffective Disorder Bipolar Type Psychotic Disorder NOS Any Lifetime Psychotic Disorder 3 (9) Post Traumatic Stress Disorder Social Phobia Specific Phobia Panic Disorder without Agoraphobia Panic Disorder with Agoraphobia Agoraphobia without Panic Disorder Generalized Anxiety Disorder Any Lifetime Anxiety Disorder (9) (3) (28) (6) (9) (0) (59) PCP Dependence (past) Cocaine Abuse (past) Sedative Dependence (past) Abuse or Dependence on Other Drugs (e.g., amphetamines, cannabis) Alcohol Abuse (past) Alcohol Dependence (past) Any Lifetime Drug or Alcohol Related Disorder No Lifetime Psychiatric Diagnosis (0) (6) (6) (22) (6)

5 MODERATE TO SEVERE ASTHMA / 323 Twelve of the 32 subjects (38 percent) had two or more psychiatric diagnoses; seven of the subjects (22 percent) three or more diagnoses; and one subject had four diagnoses (3 percent). Of the eight subjects with current major depressive disorder, two (25 percent) were taking antidepressants. Two of the seven (29 percent) patients with a past history of major depressive disorder had received antidepressant therapy. Two of the three subjects (67 percent) with bipolar disorder were taking psychiatric medication but only one was receiving therapy with a mood stabilizer (valproic acid), aimed at treating the core symptoms of this illness. All five subjects with panic disorder were taking medications, such as benzodiazepines, selective serotonin reuptake inhibitors or tricyclic antidepressants which are considered standard treatments for this illness. The two subjects with schizophrenia or schizoaffective disorder both were taking antipsychotic medications. DISCUSSION Psychiatric illnesses were extremely common in this group of patients. The 63 percent lifetime prevalence of mood disorders is substantially greater than the 9 percent reported in the general population [9]. Anxiety disorders (59 percent) were also more prevalent than in the general population (25 percent) [9]. As the subjects primarily consisted of women this may, in part, explain the elevated rates of mood and anxiety disorders. However, the lifetime rates of mood (24 percent) and anxiety disorders (3 percent) reported for women in the general population are still substantially lower than those reported in our sample [9]. Although the high prevalence of women may seem somewhat surprising, a high female to male ratio has been reported in other studies at this clinic (Brown et al., unpublished data; D. Schull, personal communication) possibly reflecting greater utilization of clinic services by women and emergency room use by men. The rates of depression in our sample are also higher than those reported in primary care settings. Simon et al. [0] reported only a 7 percent current prevalence of major depressive disorder in a group of patients (n = 952) in HMO primary care clinics. As prior studies have not examined syndromal psychiatric diagnoses consistent with current diagnostic criteria in asthma patients, it is difficult to compare these data with earlier reports in this population. However, the results seem in contrast to the relatively low rates of mood and anxiety disorders reported by Yellowlees et al. [7]. The dichotomous results may be due to differences in diagnostic criteria, socioeconomic status of the subjects, or perhaps cultural factors as the Yellowlees et al. study was performed in Australia. Our sample consisted of mostly African- American persons. Minimal data are available on rates of psychiatric illness in African-American patients in medical settings. However, Brown et al. [] recently examined rates of mood and anxiety disorder in African-American (n = 225) and white (n = 220) patients treated at a primary care clinic and found similar rates of disorders between races.

6 324 / BROWN ET AL. The high rates of psychiatric disorder we found may be secondary to the psychosocial stressor of chronic medical illness. However, some data suggest a possible biological link between asthma and mood disorders. DSM-IV criteria and therefore SCID interview do not classify mood disorders as secondary to a general medical condition unless a direct physiologic link can be established (e.g, depression after onset of hypothyroidism). Nonetheless, some animal data possibly suggest a more direct association between asthma and depression. Flinders Line rats are sensitive to cholinergic agonists and exhibit depressive behaviors in several animal models of depression [2]. Recently, increased bronchoconstriction and inflammation of the airways in response to allergens has also been reported in these rats similar to persons with asthma [3]. In addition, glucocorticoid resistance (reduced receptor number or sensitivity) has been reported in both a subset of persons with asthma [4-5] and depression [6-7]. Although clearly speculative, these findings suggest a possible association between asthma and depression beyond the effect of having a chronic medical condition. Potentially consistent with this idea, some studies have found higher rates of depressive symptoms in asthma patients than in patients with other general medical conditions [8-9]. Our report is now the first to our knowledge to suggest high rates of depressive disorders in a group of asthma patients. Importantly, the mood and anxiety disorders were not due to the prednisone received for asthma symptoms. All of the psychiatric diagnoses reported were present before the current prednisone therapy. Mood symptoms which were present exclusively during past corticosteroid therapy would be diagnosed as a substance-induced mood disorder in DSM-IV. Only one subject met criteria for this diagnosis and this was during a period of chronic corticosteroid therapy in the past. The possible chronic effects of other medications (e.g., inhaled -agonists) may contribute some to mood and anxiety symptoms. However, none of the subjects had disorders which were clearly temporarily related to initiation or increase in dosage of these medications. The rates of drug and alcohol abuse or dependence were relatively low in this sample. However, as part of our general screening at the initial clinic visit, self-report of current drug or alcohol abuse was an exclusion criteria for the study. Therefore, these results probably underestimate the prevalence of drug and alcohol abuse in this clinic population. As a strong association generally exists between drug and alcohol related disorders and other psychiatric illnesses, including mood and anxiety disorders, this study may actually underestimate the prevalence of overall psychopathology in this population [20]. This investigation also attempted to determine if psychiatric illness, when present, was appropriately treated. These data suggest that depression may be frequently untreated in this population. The results are consistent with the report by Simon et al. [0] which found only 39 percent of patients with current major depressive disorder at primary care clinics were taking antidepressants. As

7 MODERATE TO SEVERE ASTHMA / 325 depression may be associated with non-compliance with medical care and even death in asthma patients, interventions in asthma clinics designed to identify and treat mood disorders are needed. Subjects with panic disorder, schizophrenia, and schizoaffective disorder were in all cases receiving treatment. As the pharmacotherapy of social phobia and posttraumatic stress disorder remains controversial and clearly effective treatments are not currently available, we did not attempt to examine if appropriate therapy was given for these illnesses. The strength of this study lies in being the first to use the SCID to obtain syndromal psychiatric diagnoses in a group of asthma patients in a community health system. However, this study also has some limitations. As these data were obtained as part of a larger study examining mood changes in patients scheduled to receive brief courses of prednisone, persons with mild asthma not requiring oral corticosteroid therapy were excluded, as were subjects with severe oral steroid dependent asthma. This sample consists of asthma patients with moderate to severe persistent asthma. Thus, the results may not be generalizable to all populations. One limitation to our study is the small sample size. Given the small sample size and limited range of asthma severity in our sample, we were unable to explore the relationship between asthma severity and the presence or absence of the various psychiatric illnesses found. Preliminary data from other investigations by our group suggest a complex relationship between asthma and depression, with less severe asthma in people with a lifetime mood disorder but a strong negative correlation between severity of depressive symptoms and physical functioning [2]. However, the data do suggest high rates of psychopathology in a relatively under-studied group of patients, which includes African Americans and persons of low income in a county-operated hospital. Data suggest increased asthma prevalence and mortality in recent years, particularly in African-American persons [22]. Therefore, further research in this population is needed. There may also be some selection bias in this study in that subjects with psychiatric symptoms may have been more likely to follow-up for the diagnostic interviews, perhaps hoping to receive an assessment or treatment from a psychiatrist. Alternately, subjects with severe depression or social phobia may refuse follow-up. However, this bias is inherent in any investigation of this type as SCID interviews by their timeconsuming nature cannot be conducted at a brief clinic appointment. Additional studies in asthma patients using brief diagnostic measures (e.g., the mood disorder module of the SCID) which do not require a follow-up appointment are needed to confirm the preliminary finding from this study. CONCLUSIONS This study suggests that psychiatric illnesses, particularly anxiety disorders and depression, may be common in patients with moderate to severe asthma in a public health system. The results also suggest that at least in the inner-city population

8 326 / BROWN ET AL. studied, these psychiatric illnesses are frequently not recognized or treated. This is of great concern, as psychopathology may contribute to a poor outcome in patients with asthma including sudden death. Therefore, interventions designed to identify and treat psychiatric disorders in asthma patients are needed. ACKNOWLEDGMENTS The authors thank Carol Nunley for manuscript preparation, Nancy Thomas, M.A., for proofreading, Vickie Nejtek, Ph.D. for helpful comments and suggestions and Kenneth Z. Altshuler, M.D., Stanton Sharp Distinguished Chair, Professor and Chairman, Department of Psychiatry, UT Southwestern Medical Center at Dallas for administrative assistance. REFERENCES. Vachon L. Respiratory disorders. Comprehensive textbook of psychiatry/iv 6th Edition. Baltimore: Williams & Wilkins, Badoux A, Levy DA. Psychologic symptoms in asthma and chronic urticaria. Annals of Allergy, Asthma, and Immunology 994;72: Jones NF, Kinsman RA, Schum R, Resnikoff P. Personality profiles in asthma. Journal of Clinical Psychology 976;32: Bosley CM, Fosbury JA, Cochrane GM. The psychological factors associated with poor compliance with treatment in asthma. European Respiratory Journal 995; 8: Strunk RC, Mrazek DA, Fuhrmann GSW, LaBrecque JF. Physiologic and Psychological characteristics associated with deaths due to asthma in childhood. Journal of the American Medical Association 985;254: Picado C, Montserrat JM, depablo J, Plaza V, Agusti-Vidal A. Predisposing factors to death after recovery from a life-threatening asthmatic attack. Journal of Asthma 989;26: Yellowlees PM, Haynes S, Potts N, Ruffin RE. Psychiatric morbidity in patients with life-threatening asthma: Initial report of a controlled study. Medical Journal of Australia 988;49: First MB, Spitzer RL, Gibbon M, Williams JBS. Structured clinical interview for DSM-IV Axis I Disorders clinician version. Biometrics Research Department, New York State Psychiatric Institute, Department of Psychiatry, Columbia University, Kessler RC, McGonagle KA, Zaho S, Nelson CB, Hughes M, Eshleman S, Wittchen HU, Kendler KS. Lifetime and 2-month prevalence of DSM III-R psychiatric disorders in the United States. Archives of General Psychiatry 994;5: Simon GE,VonKorff M. Recognition, management, and outcomes of depression in primary care. Archives of Family Medicine 995;4: Brown C, Shear MK, Schulberg HC, Madonia MJ. Anxiety disorders among African- American and white primary medical care patients. Psychiatry Services 999; 50:

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