Psychological and social-economic characteristics of patients with severe asthma.

Psychological and social-

economic characteristics of

patients with severe asthma

Index

•Introduction

•Methods

•Database

•Results

•Discussion of the Results

•Limitations

•Gantt Chart

IntroductionDefinition

No consensual definition: 1

Different disease: lack of response to usual treatment2:

1) resistance to corticosteroids (CS) that prevents CS from having an effect on the pathology;

2) altered response to CS because of modified airways structure.

Different Phenotype: heterogeneity in the severe asthma group: some patients have more similarity with mild to moderate asthma group.

1) Wenzel S.E., A different disease, many diseases or mild asthma gone bad? Challenges of severe asthma, European Respiratory Journal, 2003; 22: 397-938

2) M. Gaga, N.Papageorgiou, G. Yougiotti, P. Karydi, A. Liapikou, H.Bitsakoy, E.Zervas, Risk factors and characteristics associated with severe and difficult to treat asthma phenotype: an analysis of the ENFUMOSA group of patients based on the ECRHS questionnaire, Clinical and Experimental Allergy, 2005; 35: 954-959

IntroductionCharacteristics of severe/ difficult to treat asthma

patients

• Predominance of female1

• High level of corticosteroids use3

• Increased in healthcare utilization1

• High level of neutrophils in sputum1

• High number of activated T lymphocytes4

1) Wenzel S.E., A different disease, many diseases or mild asthma gone bad? Challenges of severe asthma, European Respiratory Journal, 2003; 22: 397-3983) Brinke A., Ouwerkerk M., Zwinderman A., Spinhoven P., Bel E., Psychopathology in Patients with Severe Asthma Is Associated with Increased Health Care

Utilization, American Journal of Respiratory and Critical Care Medicine, 2001; Vol 163, page 1093-10964) Caramori G., Pandit A., Papi A., Is there a difference between chronic airway inflammation in chronic severe asthma and chronic obstructive pulmonary

disease?, Current Opinion in Allergy and Clinical Immunology, February 2005; 5(1):77-83

IntroductionCharacteristics of severe/ difficult to treat asthma

patients

• Chronic airway inflammationcentral and peripheral5

• High air-trapping and obstruction1

• Low diffusing capacity1

• Forced expiratory volume during the first second (FEV1) ≤60% of predicted6

• Peak expiratory flow (PEF) variability over 30%6

1) Wenzel S.E., A different disease, many diseases or mild asthma gone bad? Challenges of severe asthma, European Respiratory Journal, 2003; 22: 397-398

5) Smith J. R., Mildenhall S., Noble M. J., Shepstone L., Koutantji M. Mugford M.,Harrison B. D., The Coping with Asthma Study: a randomised controlled trial of a home based, nurse led psychoeducational intervention for adults at risk of adverse adthma outcomes, Thorax, December 2005;30/12):1003-11

6) Stirling R. G., Chung K. F., Severe asthma: definition and mechanisms, Allergy, September 2001; 56(9):825-40

IntroductionRationale

• Psychological aspects of severe/ difficult to treat asthma have

been insufficiently studied7;

• Psychosocial problems are a known risk factor for dying from

asthma8;

• High costs of the severe asthma due to hospitalizations,

emergency and domiciliary care7.

7) Osborne M., Deffebach M., The Epidemiology and Natural History of Asthma Outcomes and Treatment Regimens (TENOR)Study, Annals of Allergy, Asthma and Immunology, 2004

8) Barton C.A., McKenzie D.P., Walters E.H., Abramson M.J. , Interactions between psychosocial problems and management of asthma: who is at risk of dying?, The Journal of asthma, May 2005; 42(4):249-56

Introduction Aims of the study

To compare psychological and social characteristics in adult patients

with severe asthma and patients with mild to moderate asthma;

Relevant Questions that may be answered in this study

• Is depression related to severe asthma?

• Is there any relation between anxiety scores and the severity of asthma?

• Is there any association between severe asthma and the age of severe asthma patients?

• Is social status related to severe asthma?

• Is there any relation between schooling and the severity of asthma?

• May factors as age and gender cause overfitting?

Instruments

Self-Anxiety (Zung, 1975)

Depression Inventory (Beck, 1961)

Asthma Control Questionnaire (Juniper, 1999)

Mini-Asthma Quality of Life Questionnaire (Juniper, 1998)

SpirometryPeak Expiratory Flow (PEF)Forced Expiratory volume in 1st second (FEV1)

FlowchartPhase 2: Database analysis

Start

Database cleaning

Acquaintance/ primary analisys of the database: 119 variables;

189 individuals

Are the variables useful?N= 78

Excluded

no N= 35yes

Variables’ characteristics

analisys

Grouping individuals*

Do individuals have intermediate caharacteristics related to asthma?

N=115 N=74yes no

Separation of the resulting

group*

Severe asthma:

n=37

Mild to moderate asthma:

n=37

Eufumosa= 1 (severe) e GINA=4,00 (severe) ?

Statistics analisys: comparing variables

on both groups

Graphs/ tables elaboration

Article elaboration

Website plan elaboration

End

* Eufumosa: criteria for classification of asthma gravity – quality of life; oral corticosteroid use; GINA: scale for classification of asthma gravity

Logistic Regression

Separation of the resulting

group*

Severe asthma:

n=37

Mild to moderate asthma:

n=37

Enfumosa= 1 (severe) and GINA=4,00 (severe) ?

Statistics analisys: comparing variables

on both groups

Logistic Regression

Sample description Demographic Characteristics

FemaleMaleGender

severenon-severe severenon-severe

50

40

30

20

10

0

Per

cen

t (%

)

p<0,05 (0,003)

>6141-6031-40<31Age (years)

severenon-severe

severenon-severe

severenon-severe

severenon-severe

40

30

20

10

0

Per

cen

t (%

)

p<0,001

Sample description Social Characteristics

Class VClass IVClass I, II or IIIGraffar Social Classification

severenon-severe severenon-severe severenon-severe

30

25

20

15

10

5

0

Per

cen

t (%

)

p<0,05 (0,001)

Divorced orSeparatedWidowerSingleMarried

Marital Status

severenon-severe

severenon-severe

severenon-severe

severenon-severe

40

30

20

10

0

Per

cen

(%

)t

p>0,05 (0,051)

Sample description Social Characteristics

>1210-125-90-4Education (Years)

severenon-severe

severenon-severe

severenon-severe

severenon-severe

30

25

20

15

10

5,

0

Per

cen

t (%

)

p<0,05 (0,003)

53210Number of children

severenon-severe

severenon-severe

severenon-severe

severenon-severe

severenon-severe

25

20

15

10

5

0

Per

cen

t (%

)

p>0,05 (0,264)

Sample description Psychological Characteristics

Pathologic AnxietyNo Pathologic AnxietyAnxiety Level

severenon-severe severenon-severe

40

30

20

10

0

Per

cen

(%

)t

P>0,05 (1,0)

Middle or Severe DepressionNo Depression or Light DepressionDepression Level

severenon-severe severenon-severe

50

40

30

20

10

0

Per

cen

t (%

)

p<0,05 (0,013)

Multivariate Analysis Social Characteristics

Age ²- age recoded (<31/ >=31)

Multivariate Analysis Social Characteristics

Age ²- age recoded (<31/ >=31)

Multivariate Analysis Social Characteristics

Multivariate Analysis Psychological Characteristics

Age ¹ - age ( <31 / 31-40 / 41-60 / >=61)

Multivariate Analysis Psychological Characteristics

Age ¹ - age ( <31 / 31-40 / 41-60 / >=61)

Multivariate Analysis Psychological Characteristics

Age ¹ - age ( <31 / 31-40 / 41-60 / >=61)

Multivariate Analysis Psychological Characteristics

Age ¹ - age ( <31 / 31-40 / 41-60 / >=61)

Discussion

9) Baumeister, H., Korinthenberg, K., Bengel, J., Harter, M.Bronchial asthma and mental disorders - A systematic review of empiricalstudies. Psychotherapie Psychosomatik Medizinische Psychologie (2005), 55 (5),Pages 247-255

10) Eisner, M.D., Katz, P.P., Lactao, G., Iribarren, C. Impact of depressive symptoms on adult asthma outcomes. Annals of Allergy, Asthma and Immunology (2005), 94 (5), Pages 566-574.

Gender and Age always significative

Severe asthma is independent of these variables (9)

Quality of life: Non significative

Low social status may determine worse physical condition, wich explain frequent emergency care (10) , but not influence severity of asthma

Education: Non significative

Anxiety: Non Significative

Anxiety may complicate asthma management and quality of life (11) but not influence severity of asthma

Depression: Non Significative (though significative in univariate analyses)

Depressive symptoms associated with asthma severity (10)

Severe asthma individuals with low levels of depression after asthma treatment (12)

Grouping psychological variables:

Depression is significative – depression is a heavier factor in the severity of asthma than anxiety

(11) Lavoie, K.L., Cartier, A., Labrecque, M., Bacon, S.L., Lemiere, C., Malo, J.-L., Lacoste, G., (...), Ditto, B.Are psychiatric disorders associated with worse asthma control and quality of life in asthma patients? Respiratory Medicine (2005), 99 (10), Pages 1249-1257

(12) Heaney, L.G., Conway, E., Kelly, C., Gamble, J.Prevalence of psychiatric morbidity in a difficult asthma population: Relationship to asthma outcome. Respiratory

Medicine (2005), 99 (9), Pages 1152-1159

Limitations

• Small Sample

• Nature of study

• Subjective evaluation of psychological parameters

Gantt Chart First Phase

Gantt Chart Second Phase

Gantt Chart Third Phase

Mariana Cunha

Mariana Koehler

Mariana Taveira

Marta Rodrigues

Marta Tavares da Silva

Marta Santos Silva

Marta Alves

Marta Lopes

Miguel Almeida

Authors

Web Site

Project ManagersProf. Dr. Altamiro PereiraDr. João Fonseca