INTERACTION BETWEEN CLINICAL AND PSYCHOLOGICAL CHANGES AMONG PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND PULMONARY TUBERCULOSIS CO-MORBIDITY
Natalia V. Zhovanyk, Mariana I. Tovt-Korshynska
Uzhgorod National University, Uzhhorod, Ukraine
Introduction: The association of chronic obstructive pulmonary disease and pulmonary tuberculosis is an important medical and social problem with a significant burden in terms of morbidity and mortality. The course and prognosis of chronic diseases such as chronic obstructive pulmonary disease and pulmonary tuberculosis is greatly influenced not only by the clinical features but also by the psychological characteristics of the patient.
The aim: To study the interaction between clinical changes and psychological characteristics considering gender differences among patients with chronic obstructive pulmonary disease in association with pulmonary tuberculosis.
Materials and methods: We studied 41patients with chronic obstructive pulmonary disease (grade 2, 3, groups А, B, С, D) and infiltrative pulmonary tuberculosis co-morbidity (11 women and 30 men). All patients underwent general clinical examination, Acid-Fast Bacillus Testing, spirometry, Spielberg anxiety scale, Beck depression scale.
Results: Patients with chronic obstructive pulmonary disease and pulmonary tuberculosis co-morbidity with more severe symptoms (according to Assesment Test scores) were older and, regardless of it, showed elevated depression and personal anxiety scores while situational anxiety scores were significantly lower compared to those with less severe symptoms. The correlation between symptoms severity and airflow limitation or smoking history was very mild. The elevated depression and personal anxiety could cause more severe symptoms. The revealed discrepancy between the symptoms severity and low levels of situational anxiety may be due to adaptation with displacement mechanisms to illness related chronic life stressors. We also observed elevated personal anxiety and depression scores together with less severe symptoms among female versus male chronic obstructive pulmonary disease/pulmonary tuberculosis patients, possibly reflecting physically ill women’s higher risk for depressive and anxiety related symptomatology relative to ill men.
Conclusions: We revealed that among patients with chronic obstructive pulmonary disease and pulmonary tuberculosis co-morbidity symptoms severity was largely influenced by the patients’ age, gender and psychological factors (depression and personal anxiety), but, unexpectedly, much less – by airflow limitation and smoking history. We also found higher emotional distress, namely elevated personal anxiety and depression scores, in combination with less severe symptoms among female versus male patients with chronic obstructive pulmonary disease and pulmonary tuberculosis co-morbidity.
KEY WORDS: chronic obstructive pulmonary disease, pulmonary tuberculosis, depression, anxiety
Wiad Lek 2019, 72, 4, 635-638
According to the World Health Organization, chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide inducing an economic and social burden that is both substantial and increasing , the same time, pulmonary tuberculosis (TB) is one of the top 10 causes of death and the leading cause from a single infectious agent, millions of people continue to fall sick with TB each year . COPD is a common comorbidity in patients with TB, and COPD patients are also at high risk of developing pulmonary TB. The history of TB negatively impacts the long-term course of COPD with increased frequency of exacerbations and early mortality [3, 4]
Somatopsychic and psychosomatic disorders have a mutually burdensome effect on the course of both somatic and psychoemotional pathology. According to the literature, there is a significant prevalence of somatopsychic disorders with negative impact on the course and prognosis of both COPD and TB [5, 6, 7, 8]. Information about the frequency of their discovery and severity, as well as the relationship between their presence and the clinical and functional manifestations of COPD or TB, are rather contradictory [1, 7, 9, 10, 11, 12]. However, in available literature we did not find research where the psychological state, its gender characteristics and the effect on the underlying disease in patients with combined pathology of COPD and TB were studied. Thus, the issue of the psychological disturbances’ influence on the course of COPD and TB co-morbidity remains unclear and needs further study.
To study the interaction between clinical changes and psychological characteristics considering gender differences among patients with chronic obstructive pulmonary disease in association with pulmonary TB.
MATERIALS AND METHODS
A total of 41 patients with a combination of chronic obstructive pulmonary disease and pulmonary tuberculosis were examined, including 11 women (39.5±3.8) years old and 30 men (43.9±2.3) years old. chronic obstructive pulmonary disease diagnosis was assigned according to the Global Initiative for Chronic Obstructive Lung Disease 2018 report . Clinical data on disease history and current status were collected by direct interviews, and by evaluation of medical case histories, utilizing the chronic obstructive pulmonary disease Assesment Test and the Modified British Medical Research Council Questionnaire ; all the patients underwent complete blood count test and biochemical blood analysis, Acid-Fast Bacillus Testing; spirometry; Beck Depression Inventory and Spielberger State-Trait Anxiety Index . The control group included 23 healthy persons (12 women, mean age (36.1±2.1) years, and 11 men, mean age (39.5±3.2) years).
Statistical analysis was performed using StatSoft “STATISTICA” (version 10.0.1011.0) and Microsoft Excel (version 2010). Data were presented as mean ± standard deviation. P-values <0.05 were considered statistically significant.
RESULTS AND DISCUSSION
In all 41 COPD/TB co-morbidity patients we revealed spirometric grade 2 and 3 airflow limitation (GOLD grade 2, 3). Almost in all these patients COPD was diagnosed for the first time. Only in two of them (from the first study group) COPD was diagnosed few years before, they have received a combination of short acting beta-agonists and anticholinergics on per needed basis, had two or more exacerbations per year. Others have not reported history of earlier exacerbations (development or acute worsening of respiratory symptoms that resulted in therapy with short acting bronchodilators and/or oral corticosteroids), but the received information could be insufficiently reliable due to the patients’ low range of socioeconomic status.
Looking for factors which could influence the elevated symptomatology of the COPD/TB patients, we revealed moderate positive correlation of symptoms severity (according to СAT scores) with patients’ age (r = 0.45), depression (r = 0.46) and trait anxiety (T-anxiety) scores (r = 0.44), while the correlations with FEV1 (r = 0.10) and pack-years of smoking (r = 0.07) where unexpectedly very mild. Correlation between symptoms severity and state anxiety (S-anxiety) scores was mild and negative (r = -0.10). Similar relationships we found regarding mMRC questionnaire.
To confirm the revealed correlates, patients with COPD/TB regarding the symptoms severity were stratified into two groups: the first group involved 24 patients with CAT scores ≥ 10; the second – 17 patients with CAT scores < 10. COPD/TB patients from the first group were older than in the second ((50.1±2.5) and (37.9±2.8) years respectively, р<0.05). In both groups there were more men than women, though the percentage of women in the first group was smaller than in the second (female 16.7 % and 41.2 %, р<0.05; male 83.3 % and 68.8 % respectively, р<0.05). No significant differences were found between the study groups with respect to smoking duration or smoking history ((15.7±2.6) and (10.8±2.1) pack-years respectively), and FEV1 ((44.1±2.7) % and (43.9±1.7) % respectively).
As the patients’ age could influence further study results, to clarify the interaction between clinical changes and psychological characteristics we excluded patients who were 60 years or older from the study groups (all these patients were men) and as a result we received no significant differences between these two groups (n=18 and n=17 respectively) regarding age ((44.1±3.5) and (37.9±2.8) years respectively) or gender (female 36.7 % and 41.2 % respectively). In these groups COPD/TB patients with more severe symptoms (first group) showed elevated depression and T-anxiety scores compared to those with less severe symptoms (second group), while S-anxiety rates were significantly lower (table I). Elevated depression scores were revealed among 88% of more severe COPD/TB patients (50% – mild, 33.3% – moderate and 4% – severe level), while among less severe patients – in 29.4%, p<0.01 (11.8% – mild, 11.8% – moderate and 6.3% – severe level). Elevated T- anxiety scores were revealed among 39 % of more severe COPD/TB patients, among less severe patients – 18%. It is also noteworthy, that depression and T-anxiety scores in the first group were higher than among healthy persons, in the second – were within expected normative levels, while S-anxiety scores in both groups were unexpectedly low in comparison with the healthy persons.
As the level of airflow limitation (FEV1) was approximately the same in the two study groups ((42.1±3.7) % and (43.9±1.7) % respectively), the elevated depression and T-anxiety scores (anxiety level as a personal characteristic) in the first group could cause more severe symptoms. The revealed discrepancy between the severity of the clinical symptoms and low levels of S-anxiety rates (is considered as a response to a particular stressful situation) may be due to adaptation with displacement mechanisms to illness related chronic life stressors. Such reaction can also reveal a failure of adaptive abilities, reflecting distress in areas of anxiety and health concern. These findings are consistent with our previous studies results where we observed alike reactions among asthmatic patients [15, 16, 17]. As the S-anxiety scores were decreased in both study groups (with more and less severe symptoms), it could be also explained by the patients’ low range of socioeconomic status and unwillingness or inability to objectively evaluate their psychological state.
We also revealed gender-related differences in symptoms severity and their correlation with psychological features. Women with COPD/TB showed lower symptoms severity scores (СAT (10.1±1.2) and mMRC (0.7±0.1)) than men (СAT (12.8±2.4), p<0.05 and mMRC (1.1±0.1), p>0.05) though no differences were found with respect to airflow limitation – FEV1 ((42.1±2.9) % and (39.9±1.6) % respectively). The same time, T-anxiety scores were significantly higher among women than men ((49.2±4.1) and (39.8±1.3) respectively, p<0.05), such correlation was revealed also regarding depression ((16.1±4.8) and (13.2±1.4) scores respectively) and S-anxiety ((11.9±2.9) and (7.9±1.2) scores respectively) but the differences were not significant. The revealed higher emotional distress to less severe symptoms among female versus male COPD/TB patients is consistent with other studies of physically ill persons reporting women to be at higher risk for depressive and anxiety related symptomatology, relative to ill men [15, 16, 17].
We revealed that among patients with chronic obstructive pulmonary disease and pulmonary tuberculosis co-morbidity symptoms severity was largely influenced by the patients’ age, gender and psychological factors, but, unexpectedly, much less – by airflow limitation and smoking history. More severe symptoms were correlating with older age, increased level of depression and personal anxiety level, but – with lower rates of situational anxiety. The revealed discrepancy between severe symptoms and low Situational anxiety rates may reflect adaptation with displacement mechanisms to illness related chronic life stressors and/or distress with failure of adaptive abilities. We also observed higher emotional distress, namely elevated personal anxiety and depression scores, to less severe symptoms among female versus male chronic obstructive pulmonary disease/pulmonary tuberculosis patients, possibly reflecting women’s higher risk for depressive and anxiety related symptomatology.
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According to the order of the Authorship.
Conflict of interest:
The Authors declare no conflict of interest.
Department of Internal Diseases,
Medical Faculty №2, Uzhhorod National University
Psychological tests, scores
Patients with COPD/TB
(healthy persons) (n=23)
more severe symptoms (n=18)
less severe symptoms (n=17)
11.8±1.8 ºº *
* – p<0.05, ** – p<0.01 vs. patients with more severe symptoms;
º – p<0.05, ºº – p<0.01 vs. healthy persons.