Law, ethics, and psychiatryDepression, anxiety comorbidity, and disability in tuberculosis and chronic obstructive pulmonary disease patients: applicability of GHQ-12
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.
References (49)
- et al.
Demographic/socioeconomic factors in mental disorders associated with tuberculosis in Southwest Nigeria
J Psychosom Res
(1998) - et al.
Depression, and self-esteemrapid screening for depression in black, low literacy, hospitalized tuberculosis patients
Soc Sci Med
(1992) - et al.
The validity of the General Health Questionnaire for first stage screening for mental illness in pain clinic patients
Pain
(1991) The prevalence of emotional, and cognitive dysfunction in a general medical populationusing the MMSE, GHQ, and BDI
Gen Hosp Psychiatry
(1983)- et al.
Cognitive, and affective reactions of black urban South Africans towards tuberculosis
Tubercle and Lung Disease
(1994) - et al.
Depression in ambulatory medical patientsprevalence by self-report questionnaire, and recognition by nonpsychiatric physicians
Arch Gen Psychiatry
(1980) - et al.
Evaluating psychiatric morbidity in a general hospitala two-phase epidemiological survey
Psychol Med
(1999) - et al.
Economic issues in consultation-liaison psychiatry
- et al.
Psychiatric disorder in a sample of the general population with, and without chronic medical conditions
Am J Psychiatry
(1988) - Republic of Turkey Ministry of Health. Guide for the Control of Tuberculosis in Turkey....
Psychiatric aspects of tuberculosis
Adv Psychosom Med
Assessing anxiety and depression in tuberculosis patients
Tuberculosis and Thorax
Anxiety symptoms, and depression in tuberculosis patients
Tuberculosis and Thorax
Lung disease
Depression in patients with COPD
Heart Lung
Prevalence of depression in patients with chronic obstructive pulmonary diseasea systematic review
Thorax
A User’s Guide to the General Health Questionnaire
Psychiatric morbidity among medical in-patientsa standardized assessment (GHQ-12, and CIS-R) using “lay” interviewers in a Brazilian hospital
Soc Psychiatry & Psychiatr Epidemiol
The validation of the GHQ-28, and the use of the MMSE in neurological in-patients
Br J Psychiatry
The Composite International Diagnostic Interview
Arch Gen Psychiatry
Cited by (130)
Depression among Tuberculosis patients and its association with treatment outcomes in district Srinagar
2021, Journal of Clinical Tuberculosis and Other Mycobacterial DiseasesCitation Excerpt :In community-based studies in Tuberculosis patients, the prevalence is about 49% [10] which can increase to 54% in hospitalized Tuberculosis patients [11]. There is no doubt about the fact that people with chronic diseases and comorbid depression are benefited from treatments for depression, including treatment with antidepressants. [12–16]. As intervention for depression among patients with TB, in the form of pill burden and potential stress is likely to incur additional costs, now we need to know to what extent TB treatment alone is effective against depressive symptoms.
The solubility profile and apparent thermodynamic analysis of doxofylline in pure and mixed solvents
2020, Journal of Chemical ThermodynamicsQuality of life with tuberculosis
2019, Journal of Clinical Tuberculosis and Other Mycobacterial DiseasesCo-morbidity research progress of tuberculosis and depression
2024, Chinese Journal of AntituberculosisThe Functional and Psychosocial Consequences of COPD
2023, Respiratory CareRelationship between Prospective Memory Functioning and Self-Assessment of Mood among Patients with Chronic Respiratory Conditions
2022, Journal of Drug and Alcohol Research