Elsevier

General Hospital Psychiatry

Volume 23, Issue 2, March–April 2001, Pages 77-83
General Hospital Psychiatry

Law, ethics, and psychiatry
Depression, anxiety comorbidity, and disability in tuberculosis and chronic obstructive pulmonary disease patients: applicability of GHQ-12

https://doi.org/10.1016/S0163-8343(01)00116-5Get rights and content

Abstract

Our aim was to study anxiety and/or depression comorbidity and the influence of these comorbid conditions on disability for 3 clinical groups of pulmonary tuberculosis and chronic obstructive pulmonary disease (COPD). We also investigated the applicability of General Health Questionnaire 12 (GHQ12) for these clinical groups as a simple screening test for psychiatric comorbidity. A total of 157 male inpatients were included in the study: 42 with recently diagnosed (RDtb), 39 with defaulted (Dtb), 39 with multidrug resistant tuberculosis (MDRtb) and 38 with COPD. The presence of depression and anxiety was assessed by Composite International Diagnostic Interview (CIDI). Disability was evaluated by Brief Disability Questionnaire. The validity of GHQ12 for the study groups was examined in order to determine a functional cut-off point. Depression and/or anxiety comorbidity was 19% for RDtb, 21.6% for Dtb, 25.6% for MDRtb and 47.3% for COPD. Patients with psychiatric comorbidity had higher disability scores than the group without psychiatric comorbidity. For the tuberculosis group a 3/4 cut-off point of GHQ had 80.7% sensitivity and 87.1% specificity while a 5/6 cut-off point with 83.3% sensitivity and 80% specificity was applicable to the COPD group.

Introduction

With the growing interest in psychiatric comorbidity in medical and surgical patients, its consequences have been understood better. In early studies, it was reported that 25–35% of patients admitted to surgical or medical departments of general hospitals had psychiatric comorbidity, although only half of them could be recognized [1]. A recent two-phase epidemiological survey in a general hospital revealed that about one quarter had a formal ICD-10 mental disorder and an additional 11.7% had a subthreshold psychiatric disorder [2]. It is a well known fact that psychiatric comorbidity in general medical illness lengthens the patient’s hospital stay, increases his/her exposure to diagnostic procedures, increases the cost of the treatment and reduces the efficacy of medical and surgical treatment [3].

Lung disease is among the chronic medical conditions that are strongly associated with psychiatric disorders [4]. Despite the high prevalence and morbidity of respiratory disorders their psychological aspects have not received the same attention as other areas of general medicine such as heart diseases or cancer. Recently, the HIV epidemic has focused the attention on pulmonary tuberculosis, which had been a neglected area of research for many decades, although tuberculosis has always been a major health concern in certain parts of the world. In Turkey, according to the 1997 figures of the Ministry of Health 20.778 cases of pulmonary tuberculosis were diagnosed within one year and the incidence rate was 0.0331% [5].

Early psychiatric studies on tuberculosis were focused on the personality traits that may predispose one to tuberculosis, but were unable to specify a “tuberculosis prone” personality. The role of emotional stresses was also associated with immunological responsiveness and the reactivation of the bacillus [6]. Some studies examining psychiatric morbidity in tuberculosis patients showed high rates of depression and anxiety in tuberculosis [7], [8], [9], [10]. A retrospective cohort analysis of 440 tuberculosis patients revealed psychiatric disorders, alcoholism and drug addiction among the causes of poor compliance, which led to relapse [11]. The psychiatric effects of antituberculosis medications were also a matter of concern [12], [13] although no systematic research has been conducted on this subject.

Another common and disabling lung disease which may require hospital treatment, chronic obstructive pulmonary disease (COPD) was chosen for evaluation of the pulmonary tuberculosis with regard to psychiatric comorbidity and disability. Literature on the psychological aspects of COPD is scarce as well. It has been estimated that 42% of patients with COPD are complicated by depression [14]. The conclusion of a recent review on the prevalence of depression in COPD patients, however, was that the empirical evidence for a significant risk of depression in patients with COPD remained inconclusive, due to the poor methodological quality of the studies on the topic [15]. Collis [13] emphasized the difficulties of psychiatric assessment of patients with respiratory disease. They often minimize the psychological symptoms and concentrate on physical symptoms with the result that depressive disorders may be masked and left untreated.

Disability research, on the other hand, ranked respiratory and cardiac diseases as the two most disabling disorders in terms of disability-adjusted life years (DALY). The Global Burden of Disease study reported the rate of burden caused by both respiratory and cardiac diseases to be 11% and alcohol, drug and mental disorders to be 10.5% of the total burden [16].

Recognizing anxiety and depression in a person staying in a general hospital is of crucial importance. As a simple screening instrument the General Health Questionnaire was developed to meet this requirement [17]. However, it needs to be further studied in different clinical samples in order to determine valid cut-off points. In this respect, some studies have been performed in different patient populations, such as neurological patients and pain patients [2], [18], [19], [20], [21].

In this study our aims were as follows: (i) to compare depression and anxiety rates in different clinical groups of pulmonary tuberculosis and COPD, (ii) to assess the effect of psychiatric comorbidity on the disability caused by lung disease, (iii) to perform validity functions of GHQ12 to provide a simple screening test for psychiatric comorbidity in tuberculosis and COPD patients, which can be used by chest physicians.

Section snippets

Sampling

The study was performed between June and November 1999, in the Ankara Atatürk Chest Diseases and Thoracic Surgery Hospital, which is the largest chest hospital in the country. 600 inpatient beds for tuberculosis and nontuberculosis lung diseases are available in the hospital. As a reference center this hospital provides facilities for pulmonary tuberculosis patients who are referred from 270 Tuberculosis Control Dispensaries spread all around the country. It serves to nontuberculosis lung

Psychiatric comorbidity

DSM-IV generalized anxiety disorder (GAD) and major depression (MD) were present in all study groups. None of the patients fulfilled the DSM-IV panic disorder criteria. The rates of major depression and generalized anxiety disorder were respectively 16.7% (n=7) and 2.3% (n=1) in the RDtb group; 21.1% (n=8) and 2.6% (n=1) in the Dtb group; 25.6% (n=10) and 15.4% (n=6) in the MDRtb group; and 39.5% (n=15) and 15.8% (n=6) in the COPD group (Table 2). 10 patients fulfilled both the MD and GAD

Discussion

This is a cross-sectional study comparing two different pulmonary diseases with regard to psychiatric comorbidity and disability. According to our literature survey, the present study is the first which compared psychiatric morbidity in COPD and pulmonary tuberculosis patients. Doubtlessly, the chronic nature of COPD with no chance of complete recovery differs from tb which is a treatable illness in most cases. Keeping our reservations about the different clinical characteristics of tb and COPD

Conclusion

The findings reported in the present study broaden our knowledge about the rates of GAD and MD in two lung disorders, and the relationship between psychiatric comorbidity and disability. In addition to the high disablement caused by respiratory disorders, the presence of psychiatric comorbidity increases the disability. GHQ-12 is an easy and valid screening instrument for identification of psychiatric comorbidity in tuberculosis and COPD patients. Identifying and treating psychiatric disorders

Acknowledgements

We want to thank Drs. Şeref Özkara and Tuğrul Şipit from Atatürk Chest Diseases and Thoracic Surgery Hospital for their permission for us to evaluate their patients; to Drs. Murat Rezaki and Elif Kabakçı for their help in statistical analyses, Drs. Berna Uluğ and M.Orhan Öztürk for their excellent comments on the manuscript.

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