Jonathan M. Feldman

Psychiatric Disorders and Asthma Outcomes Among High-risk Inner-city Patients

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 β2-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. 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.

Depressive Symptoms, Low Adherence, and Poor Asthma Outcomes in the Elderly

Objective. To examine the impact of depressive symptoms on asthma outcomes and medication adherence in inner-city elderly patients with asthma. Methods. Cohort study of elderly asthmatics receiving primary care at three clinics in New York City and Chicago from 1 January 2010 to 1 January 2012. Depressive symptoms were ascertained with the Patient Health Questionnaire (PHQ-9). Outcomes included asthma control (Asthma Control Questionnaire, ACQ), asthma-related quality of life (Asthma Quality of Life Questionnaire, AQLQ), and acute resource utilization (inpatient and outpatient visits). Asthma medication adherence was evaluated using the Medication Adherence Reporting Scale (MARS). Results. Three hundred and seventeen participants ≥60 years were included in the study (83% women, 30% Hispanic, and 31% Black). In unadjusted analyses, participants with depressive symptoms were more likely to report poor asthma control (p < .001), worse AQLQ scores (p < .001), and higher rates of inpatient asthma-related visits (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.04–3.99). Those with depressive symptoms also reported lower medication adherence (OR: 0.23, 95%CI: 0.10–0.54). Similar results were obtained in analyses adjusting for age, sex, race/ethnicity, income, asthma medication prescription, years with asthma, intubation history, comorbidities, and health literacy. Conclusion. In this cohort of elderly inner-city participants, depressive symptoms were associated with poorer asthma control and quality of life, as well as with lower rates of adherence to controller medications. Future work exploring possible mediators, including adherence, might elucidate the relationship between depression and poorer asthma outcomes in this population.

Child and Family Psychiatric and Psychological Factors Associated With Child Physical Health Problems: Results From the Boricua Youth Study

To examine associations among Puerto Rican childrens physical health problems and childrens internalizing disorders, parental psychopathology and acculturative stress, and family factors. A population-based probability sample of 2491 Puerto Rican children, aged between 5 and 13 years, and caregivers from the South Bronx and the U.S. Commonwealth of Puerto Rico participated in this study. The parent version of the Diagnostic Interview Schedule for Children-IV was used to assess childrens internalizing disorders. Childrens anxiety disorders, parental psychopathology, and acculturative stress were associated with childhood asthma, abdominal pain, and headaches. Childrens depressive disorders, maternal acceptance, and family functioning were associated with abdominal pain and headaches. Parents of children living in Puerto Rico were more likely to report physical health problems in their children than in the Bronx. Childrens internalizing disorders, parental psychopathology, and acculturative stress may be important areas to target among Puerto Rican children with physical health problems.

Health Care Use and Quality of Life Among Patients with Asthma and Panic Disorder

The purpose of this study was to assess the associations between panic disorder (PD) and health services use, health-related quality of life, and use of short-acting beta2-agonists among individuals with asthma. We studied 21 adults with comorbid asthma and panic disorder (asthma-PD) and 27 asthma patients without PD (asthma-only). Participants attended a single session at a laboratory to complete the study. A retrospective chart review was conducted to assess use of health care resources for asthma treatment during the past 12 months. Patients completed the Asthma Quality of Life Questionnaire and lung function testing. Asthma-only and asthma-PD patients displayed no differences on asthma severity, as measured by spirometry and asthma medication class. Asthma-PD patients had more visits to their primary care physicians for asthma (p < 0.01) and reported a lower quality of life related to asthma (p < 0.01) and greater use of short-acting beta2-agonists (p < 0.05) than asthma-only patients. These findings were independent of pulmonary function, asthma medication class, and sociodemographic status. These data show that coexistence of PD in asthma is associated with increased use of primary care health resources and greater perceived impairment from asthma, independent of asthma severity. These findings indicate a need to develop interventions to improve quality of life and self-management of asthma among PD patients.

Symptom Perception in Children with Asthma: Cognitive and Psychological Factors

OBJECTIVE This study tested the differential effects of several cognitive and psychological variables on childrens perception of asthma symptoms by use of an Asthma Risk Grid. Childrens subjective and objective assessments of PEFR (peak expiratory flow rate) were characterized as representing perceptual accuracy, symptom magnification, and/or underestimation of asthma symptoms. DESIGN The study included 270 children with asthma (ages 7-17) and their primary caregivers who completed measures assessing cognitive and psychological factors and a 5 to 6 week symptom perception assessment. MAIN OUTCOME MEASURES Childrens symptom perception scores by use of the Asthma Risk Grid. RESULTS Childrens attentional abilities had more of a bearing on their symptom monitoring abilities than their IQ estimates and psychological symptoms. The more time children took on Trails and Cancellation Tasks and the fewer errors they made on these tasks, the more likely they were to perceive their asthma symptoms accurately. More time on these tasks was associated with more symptom magnification scores, and fewer errors were related to fewer symptom magnification scores. More errors and higher total scores on the Continuous Performance Task were associated with a greater proportion of scores in the danger zone. CONCLUSION Statistical support was provided for the utility of attentional-based instruments for identifying children who may have problems with perceptual accuracy, and who are at risk for asthma morbidity.

The relationship between perceived stress and morbidity among adult inner-city asthmatics.

Background. Psychological stress has been linked in some studies to asthma prevalence and outcomes in children. The authors sought to evaluate the relationship between perceived stress and morbidity among inner-city adults with asthma. Methods. The authors interviewed a prospective cohort of 326 moderate-to-severe asthmatics receiving care at two large, urban, hospital-based general medicine clinics in New York City and New Jersey. Psychological stress was assessed at baseline using the Perceived Stress Scale (PSS), a validated 4-item instrument. Outcomes included the Asthma Control Questionnaire (ACQ), the Asthma Quality of Life Questionnaire (AQLQ), and the Medication Adherence Reporting Scale (MARS) measured at baseline, 1, 3, and 12 months of enrollment. Results. Higher perceived stress was significantly correlated with worse asthma control (ACQ scores; r = .30 to .37, p < .0001), poor quality of life (AQLQ scores; r = −.49 to − .35, p < .0001), and decreased medication adherence (MARS scores; r = −.25 to −.15, p < .028) at baseline and across the follow-up interviews. In multivariate analyses, increased stress remained a significant predictor of worse ACQ (p < .0001), AQLQ scores (p < .0001), and MARS (p < .0001) after adjusting for age, sex, income, number of years with asthma, and comorbidities. Conclusions. Among inner-city asthmatics, higher perceived stress is strongly associated with increased asthma morbidity across a 1-year follow-up. Further research is needed to identify mechanisms mediating the association between stress and asthma morbidity in adults.

Asthma and mental health among youth: Etiology, current knowledge and future directions

Asthma and mental health problems, such as depression, anxiety and behavior disorders, are common among youth and are significant sources of morbidity. There is a consistent association between asthma and anxiety/depression and a less consistent association between asthma and behavior disorders. Possible biological and psychological mechanisms may include inflammatory processes as well as the stress of having to live with a life-threatening condition. Future studies are warranted with longitudinal designs to establish temporality as well as measures of potential confounds. Biological and psychological measures would complement the longitudinal design to further establish causality. In addition, more information on the degree to which asthma and mental health have reciprocal influences on each other over time – and the mechanisms of these relationships – are needed in order to develop more effective intervention strategies to improve asthma control and mental health among those with both.

Prediction of peak flow values followed by feedback improves perception of lung function and adherence to inhaled corticosteroids in children with asthma

Background Failure to detect respiratory compromise can lead to emergency healthcare use and fatal asthma attacks. The purpose of this study was to examine the effect of predicting peak expiratory flow (PEF) and receiving feedback on perception of pulmonary function and adherence to inhaled corticosteroids (ICS). Methods The sample consisted of 192 ethnic minority, inner-city children (100 Puerto Rican, 54 African-American, 38 Afro-Caribbean) with asthma and their primary caregivers recruited from outpatient clinics in Bronx, New York. Childrens PEF predictions were entered into an electronic spirometer and compared with actual PEF across 6 weeks. Children in one study were blinded to PEF (n=88; no feedback) and children in a separate study were able to see PEF (n=104; feedback) after predictions were locked in. Dosers were attached to asthma medications to monitor use. Results Children in the feedback condition displayed greater accuracy (p<0.001), less under-perception (p<0.001) and greater over-perception (p<0.001) of respiratory compromise than children in the no feedback condition. This between-group difference was evident soon after baseline training and maintained across 6 weeks. The feedback condition displayed greater adherence to ICS (p<0.01) and greater quick-relief medication use (p<0.01) than the no feedback condition. Conclusions Feedback on PEF predictions for ethnic minority, inner-city children may decrease under-perception of respiratory compromise and increase adherence to controller medications. Children and their families may shift their attention to asthma perception and management as a result of this intervention.

Optimism and health-related quality of life in adolescents with cancer

OBJECTIVE To delineate the relationship between optimism and health-related quality of life (HRQOL) and quality of life (QOL) in adolescents with cancer living in the Bronx, New York. METHODS Optimism was assessed using the Life Orientation Test, Revised (LOT-R). HRQOL and QOL were measured using the Pediatric Quality of Life Inventory, Cancer Module, Acute Version and The Pediatric Quality of Life Inventory, Generic Core Scale, respectively. Associations between optimism and HRQOL and QOL were assessed using Pearsons product-moment correlations. RESULTS Twenty-three adolescents participated in this study; the mean age was 16 and the majority was male. This sample was highly optimistic and reported high HRQOL and QOL. Optimism was correlated with less reported pain and hurt, better communication with doctors, higher reported psychological functioning and higher overall QOL. CONCLUSION Optimism is associated with higher QOL in inner city adolescents with cancer. Further research should assess whether interventions that increase optimism lead to greater QOL in this population.

Defensiveness and individual response stereotypy in asthma

Objective Previous literature has shown that the psychological trait of defensiveness is related to elevated sympathetic reactivity to stress and to several cardiac risk factors. The aim of this study was to examine whether these previous findings on defensiveness extend to an asthmatic population. Methods Defensiveness was measured by the Marlowe-Crowne Social Desirability Scale using a quartile split: high (upper 25%) and low (bottom 75%). Twenty-two defensive and 66 nondefensive participants with asthma were exposed to laboratory tasks (initial baseline rest period, reaction time task, and a shop accident film). Results During the tasks there was evidence of lower skin conductance levels and greater respiratory sinus arrhythmia amplitudes among defensive patients with asthma. After exposure to the tasks, defensive patients with asthma showed a decline on spirometry test measures compared with nondefensive asthmatic patients, who displayed an increase. Conclusions These data confirm individual response stereotypy and suggest that defensiveness may be characterized by sympathetic hypoarousal and parasympathetic hyperarousal among patients with asthma. Future studies are needed to determine whether defensiveness is a risk factor for stress-induced bronchoconstriction.