The association between common mental disorders and quality of life in adolescents with asthma

Abstracts

INTRODUÇÃO: A asma é a doença crônica mais prevalente no adolescente, traz limitações à sua qualidade de vida e preocupações quanto a sua saúde. Possuir uma doença crônica nessa faixa etária, além dos limites causados pela própria doença, aumenta a vulnerabilidade a danos emocionais, tais como transtornos mentais comuns (TMC). OBJETIVO: Avaliar a associação entre TMC e qualidade de vida em adolescentes asmáticos. MÉTODO: Estudo seccional de base ambulatorial, realizado com 210 adolescentes asmáticos de 12 a 21 anos, atendidos em um ambulatório especializado de um serviço universitário voltado à atenção ao adolescente, no Rio de Janeiro. A qualidade de vida (QV) foi avaliada através do Paediatric Asthma Quality of Life Questionnaire - PAQLQ, e a presença de TMC pelo General Health Questionnaire (GHQ-12). A qualidade de vida total e suas diferentes dimensões foram tratadas como variáveis dicotômicas e utilizou-se o modelo log-binomial para o cálculo das razões de prevalência brutas e ajustadas. RESULTADOS: A prevalência total de asmáticos com TMC foi de 32,4%. A prevalência de QV ruim entre adolescentes com TMC foi de 36,6%. O modelo final ajustado mostrou uma associação entre TMC e QV total ruim (RP = 1,84 IC 95% 1,19 - 2,86), assim como para os domínios referentes à emoção (RP = 1,77 IC 95% 1,16 - 2,62) e sintomas (RP = 1,75 IC 95% 1,14 - 2,70). Para o domínio atividade física, a associação com TMC foi apenas borderline (RP = 1,43 IC 95% 0,97 - 2,72). CONCLUSÃO: Os resultados do estudo sugerem a necessidades de maior atenção aos aspectos emocionais dos adolescentes portadores de doenças crônicas, de forma a subsidiar ações mais efetivas na área de saúde mental, visando a melhor qualidade de vida e o tratamento global do paciente asmático.

Qualidade de vida; Asma; Adolescentes; Transtornos mentais comuns

SPECIAL ARTICLE

^INúcleo de estudos da saúde do adolescente da Universidade do Estado do Rio de Janeiro - UERJ

^IIDepartamento de Saúde Coletiva do Instituto de Medicina Social da Universidade do Estado do Rio de Janeiro - UERJ

Correspondência

ABSTRACT

INTRODUCTION: Asthma is the most prevalent chronic disease among adolescents, not only affecting their quality of life but also bringing deep concern about their health. Having a chronic disease in this age group, in addition to the limits caused by the disease itself, increases vulnerability to emotional damage including common mental disorders (CMD).

OBJECTIVE: to evaluate the association between CMD and quality of life in adolescents with asthma.

METHODS: This cross-sectional study investigated 210 asthmatic adolescents from 12 to 21 years old treated in an outpatient adolescent healthcare facility in Rio de Janeiro, Brazil. The Pediatrics Asthma Quality of Life Questionnaire (PAQLQ) and the General Health Questionnaire (GHQ-12) were used to assess QoL and common mental disorders (CMD) respectively. Total quality of life and its various dimensions were treated as dichotomous variables. A binomial log-rhythmic model was used to calculate raw and adjusted prevalence ratios.

RESULTS: The prevalence of asthmatics with CMD was 32.4% while the prevalence of poor QoL among adolescents with CMD was 36.6%. The final adjusted models showed an association between CMD and poor total quality of life (PR = 1. 84 95% CI 1.19 - 2.86) as well as for areas related to emotions (PR = 1.77 95% CI 1.16 - 2.62) and symptoms (RP = 1.75 95% CI 1.14 - 2.70). For the physical activity domain, the association with CMD was only borderline (RP = 1.43 95% CI 0.97 - 2.72).

CONCLUSION: The results of this study suggest that greater attention should be paid to the emotional needs of adolescents with chronic diseases, including more effective actions in the field of mental health in order to improve quality of life and overall treatment of young asthmatic patients.

Palavras-chave: Quality of life, Asthma, Adolescents, Common mental disorders

Introduction

To define adolescence is a difficult task. The concepts found in the literature and in common sense are usually not sufficient to describe these individuals who are neither children nor adults. For adolescents themselves, this category has no meaning either: they see it as something external, spoken of by others¹. For health professionals, this is an opportune moment for preventive actions, aimed at adolescent health care, to be developed, promoting a healthy life and boosting self-esteem.

A disease with a prolonged course prevents an individual from innumerable sources of personal pleasure, in the sense that it interferes with self-esteem, control of one's own body, and interpersonal relationships.² These limitations, in a stage of life as delicate as adolescence, become even greater. Sawyer et al.³, in a cohort study, observed a loss of quality of life in adolescents with chronic diseases such as asthma, cystic fibrosis and diabetes.

Asthma is the main chronic disease during adolescence and it is in this stage when maturation and growth, including that of the respiratory system, greatly speed up⁴. A reduction in the respiratory function in such stage may lead to irreversible changes in pulmonary structure and also a decrease in the final height. In addition to problems inherent in adolescence, the association with a chronic disease such as asthma can cause feelings of failure, hopelessness, anger, self-criticism, loss of self-esteem and fear, becoming an extra burden on adolescents.

In children and adolescents, there are repercussions not only for the patient, but also the entire familial and educational universe, which may create complex problems and have implications in the long term, translating into a reduction in quality of life of the whole group⁵.

Quality of life in patients with chronic diseases, particularly asthma, has been a recurrent theme in the literature. The World Health Organization-Quality of Life Group (WHOQOL) defined quality of life as "an individual's perception of their position in life, in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns". This is a far-reaching concept, influenced in a complex way by an individual's physical health, psychological status, level of independence, social relations and environmental characteristics⁶.

Thus, to define quality of life has been a highly controversial task among researchers in health areas. Bowling⁷ points out that quality of life is a broad concept, which has been used by innumerable disciplines and fields of activity, such as geography, literature, philosophy, health economics, marketing and advertising, health promotion and social and medical sciences (sociology and psychology).

Recent studies in the literature try to correlate severe asthma with a higher risk of damage to adolescents' mental health⁸. In Brazil, in a study with 4,030 workers from a university of the state of Rio de Janeiro, Nogueira⁹ observed that individuals with a history of medical diagnosis of asthma were more likely to have common mental disorders (PR = 1.37; 95% CI 1.22-1.55) than those without this diagnosis.

In children and adolescents, the incidence of emotional disorders has been considered high. In the United States, approximately 7% of the child population suffers from asthma and a review of epidemiological studies concluded that 12% of these children show a certain type of emotional disorder¹⁰. Studies on adolescents performed in Brazil showed a strong positive association between common mental disorders and chronic disease^1,11. Neves et al.¹⁰ showed that approximately 30% of children with a diagnosis of severe asthma and hospitalized in a tertiary hospital, had depression as an important marker of fatal asthmatic crises.

Adequate control of asthma is associated with the patient's ability to detect changes in the intensity of the obstruction and quickly follow therapeutic guidance, according to the individualized action plan¹². Mood disorders may interfere with the identification of bronchial obstruction in asthmatics¹³. Thus, the presence of mental disorders in asthmatic patients should be carefully evaluated, because it could mean an even greater impact on these patients' quality of life.

Considering the epidemiological and social relevance of the theme and the scarce national production on it, the analysis of the association between common mental disorders (CMD) and quality of life and their different domains in a population of adolescents becomes relevant in the Brazilian urban context.

Materials and Methods

Study design and reference population

A cross-sectional, outpatient-based study was performed. The study population was comprised of 240 asthmatic adolescents, 35% of the 688 patients cared for in the Ambulatório de Alergia-Imunologia do Núcleo de Estudos da Saúde do Adolescente (NESA - Rio de Janeiro State University, Center for Adolescent Health Studies, Allergy-Immunology Outpatient Clinic). Data were collected between March and November 2006. Criteria for eligibility were as follows: to have asthma, diagnosed according to the III Consenso Brasileiro de Asma (3^rd Brazilian Congress of Asthma); to be aged between 12 and 21 years (not yet completed); and to live in the city of Rio de Janeiro or its metropolitan area. Individuals with a neurological or cognitive disease that prevented them from completing the questionnaire were excluded. Only one family refused to participate in the survey and 29 questionnaires were not fully completed or did not include the criteria to be categorized as asthma.

Data collection and instruments

Data were collected between March and November 2006. Adolescents were recruited through the Allergy-Immunology Outpatient Clinic (Programa de Qualidade de Vida nas Doenças Respiratórias - Program of Quality of Life in Respiratory Diseases) once a week.

The questionnaire used was designed from the joining of three aspects of investigations. Initially, socio-demographic and economic data were collected, including age, sex, parents' level of education, adolescent's level of education, ethnic group, per capita household income, smoking habit, physical activity, adolescent's occupation, use of medication and presence of other allergic diseases. The Pediatric Asthma Quality of Life Questionnaire - PAQLQ¹⁴, which includes the following 23 items and three domains, was used to assess quality of life: symptoms (10 questions), physical activity (5 questions) and emotional aspects (8 questions). This questionnaire can quantify changes of quality of life in an individual throughout time. La Scala¹⁵ validated it to Brazilian Portuguese. This instrument was designed to be applied to children aged between seven and 17 years, through face-to-face interviews or self-completion questionnaires. It lasts ten minutes on average. Questions are always related to the previous week and, according to the question, are divided into a blue card, to assess the severity of discomfort, and a green card, to quantify the frequency of symptoms. The response options for each item were classified according to a scale of seven points, where one indicates maximum harm and seven, no harm. Results are shown as means of scores per item and for each domain, in addition to a total score¹⁴.

Finally, the assessment of common mental disorders (CMD) was performed through the short version of the General Health Questionnaire (GHQ-12), an instrument which is well established and widely used in both national and international studies^{16, 17}. This self-completion questionnaire was assessed in its original¹⁸ and Brazilian versions¹⁶, using the Clinical Interview Schedule¹⁹ as the gold standard in both cases. The cut-off point used for the questionnaire considers each item as present or absent (0 or 1), according to the GHQ method. Cases that were positive for three items of the GHQ-12²⁰ were considered as CMD cases. The GHQ reference period were the two weeks prior to questionnaire completion.

Study variables

Quality of life was treated as a dichotomous outcome (good-poor) and is based on the mean of response scores, the one most frequently used in the literature²¹. As regards the three domains (physical activity, emotions and symptoms), the same criteria were used. Responses varied from 1 (poorest quality of life) to 7 (best quality of life). The explanatory variable was the presence of common mental disorders (CMD), treated as a dichotomous variable, and the cut-off point was three or more positives for the CMD "case" codification. The following socio-demographic and economic variables were assessed as covariables: sex, ethnic group (black, white, and mixed), age (less than 15 years and 15 years or more), adolescent's level of education (incomplete primary education, complete primary education, incomplete secondary education, complete secondary education, and higher education), per capita household income (up to one minimum wage, between one and two minimum wages, between two and four minimum wages, and more than five minimum wages), time of diagnosis of disease (less than five years, between five and ten years, more than ten years), whether the adolescent worked, parents' marital status (married, not married), whether adolescents lived with their parents or not, severity of asthma and use of medication.

Data analysis

Data were input with the Epi Info 2000 software. All statistical analyses were performed with the R statistical software, version 2.3.4²². In the first stage, the distributions of frequency and graphs of each variable in the study were produced and analyzed. In the bivariate analysis, chi-square test (independence) was employed to observe whether the associations found showed significant differences (p < 0.10), using this criterion to select possible confounding factors.

In the multivariate analysis, although the traditional logistic regression model is frequently used in prevalence studies, this new study chose the log-binomial regression model^23,24, once this model is capable of directly estimating the adjusted prevalence ratio (PR). The log-binomial model was adjusted to include the covariables that were statistically associated in the bivariate analyses, with the variables associated with the outcome remaining in the model and sex and age being forced into it.

Ethical aspects

Prior to data collection, the protocols for this study were approved by the Comitê de Ética do Hospital Universitário Pedro Ernesto (Pedro Ernesto University Hospital Ethics Committee), to which NESA is subject. A written informed consent form was shown to and signed by the adults responsible for adolescents aged less than 18 years and by those aged more than 18 years who were interviewed. Through this document, patients and their responsible adults were informed about the relevance of the study and the importance of their participation. Permanence in the outpatient clinic was guaranteed, when families stopped participating in the study and after the end of such study.

Results

In the population studied, 64.29% of adolescents were older than 15 years of age and 61% were females. There was a predominance of patients with incomplete secondary education, 31.4%. The majority of adolescents did not work. A total of 32.4% had CMDs and 55.3% showed good total quality of health, as did the different domains of physical activity, emotions and symptoms. In all domains, a similar portion of adolescents were classified as showing poor quality of life (Table 1).

With regard to the association among socio-demographic characteristics in the different quality of life domains (Table 2), there was little variation among responses for the domains of symptoms, physical activity and emotions.

Table 3 shows that the prevalence of poor total quality of life (QoL) in patients with common mental disorders (CMD) was 61.8%, the same occurring with the domains of symptoms and emotions, with a small difference in the physical activity domain (55.9%), which showed poor quality of life.

After adjustment for sex and age (Table 4), a prevalence ratio of 1.94 was found (95% CI 1.28- 2.92) in the total score of quality of life in this population. As regards the domains, the crude prevalence ratio of physical activity was 1.44 (95% CI 0.97-2.14); while that of emotions was 1.83 (95% CI 1.22 -2.72), similar to the domain of symptoms.

Discussion

This study found a strong association between the presence of common mental disorders and loss of quality of life (1.94 (95% CI 1.28- 2.92)) and this association repeats itself in the different domains. Although the Brazilian literature includes few studies on quality of life and asthmatic adolescents, there is a world trend towards greater use of instruments that assess different implications of asthma^25,26. A state of depression associated with a chronic disease such as asthma may interfere with one's adherence to treatment and result in loss of quality of life to control asthma²⁷.

Findings from this study are in accordance with previous studies performed in other countries. Lavoie²⁸ conducted a study using the Asthma Quality of Life Questionnaire (AQLQ) and observed an association between depression and poorer quality of life. Goldbeck et al.⁸ showed that the presence of an emotional disorder affects the severity of symptoms and quality of life of asthmatic adolescents more greatly.

The predominance of adolescents aged more than 15 years in this sample can be explained by the fact that the majority of pediatric services in the public health network do not care for this population and that the NESA is a referral service. Socio-demographic data from this study show a predominance of diagnosis of asthma in females (61%), whereas this diagnosis totaled 39% in males. In the general population, there is a predominance of asthma in boys during childhood, although this relationship greatly changes in adolescence, once boys have more remission and more new cases occur in girls²⁹. After the age of 30 years, the difference between sexes disappears^30,31.

In the literature, there are certain studies that assess the association between chronic disease and common mental disorders. Newacheck³², in a study with Brazilian adults, observed that chronically ill patients show a 35% higher risk of developing behavioral disorders such as anxiety and depression.

In a study performed by Machado³³ with a Brazilian population, depression was found in 25% of asthmatic adults, a frequency that was two times higher than that observed in patients followed in a general outpatient clinic³⁴ and five times higher than that of the general population³⁵. In a randomized study, Gillaspy et al.³⁶ assessed the history of self-reported asthma of 221 asthmatic adolescents and 192 adolescents without a history of asthma and observed that individuals with a diagnosis of self-reported asthma had a higher risk of suffering from common mental disorders than those without a diagnosis of asthma (p<0.01).

The General Health Questionnaire (GHQ-12) provides an approximation between common mental disorders and psychological suffering (proxy for emotional stress) and, through its use, asthmatic adolescents can be followed and assessed. Although the use of the GHQ is not recommended for children, this instrument has been used by other authors in adolescents, including in Brazil^1,11,37. Data from the present study showed a result of 32.4% for the presence of CMD in asthmatic patients. This finding is consistent with the international literature, which estimates that a chronic disease increases psychological suffering during adolescence³⁸.

The sample of this study showed a relevant prevalence of poor QoL and asthma, both in the total score and in the three domains. Recent studies showed that asthmatic patients have poor quality of life^39,40. Regardless of the severity of asthma, there is a reduction in QoL in the physical, psychological and social domains of the HRQOL, with the majority of asthmatics showing restrictions in their lives and a poorer health status than individuals without asthma^41,42. In 2003, Ford et al.³⁹ performed a major population-based study and observed that asthmatics have a significantly poorer quality of life than those who had never had asthma. In Brazil, there is a lack of studies that associate quality of life, asthma and adolescents.

In addition, it should be emphasized that the present study was performed with a sample of asthmatic adolescents cared for in a referral outpatient clinic with unique characteristics. This population lives in a metropolitan area of the city of Rio de Janeiro, subject to social and economic urban adversities, thus limiting the possibility of findings being generalized to the general population. However, these findings are consistent with those of the international literature, emphasizing the relevance of longitudinal studies that assess the long-term effects of asthma.

The experience of working with quality of life in asthma revealed a wealth of information that usually passes unnoticed by the health team and which is highly relevant for patients. Patients were satisfied with the questions and often reported that nobody had ever made such questions before.

However, the cross-sectional nature of the study did not enable the temporal precedence between exposure and outcome to be safely established.

Thus, the possibility of reverse causality between common mental disorders and quality of life should not be ruled out, bringing about the reflection on the extent to which poor quality of life could lead to depression and anxiety in adolescents, and vice-versa.

Knowledge about the association between poor quality of life and CMD should sensitize health professionals to questions of an emotional nature of their patients and also subsidize actions aimed at preventing such disorders in asthmatic patients. These findings emphasize the multidisciplinary teams' need to pay attention to the emotional aspects of asthmatic patients, especially those with less experience with this disease. It is believed that the search for good quality of life in programs for asthmatic adolescents is of key importance for these patients to have a better relationship with their friends, family, society and themselves.

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The association between common mental disorders and quality of life in adolescents with asthma

Katia T. Nogueira^I; Claudia S. Lopes^II

Publication Dates

• Publication in this collection
  13 Sept 2010
• Date of issue
  Sept 2010

History

• Received
  21 Sept 2009
• Reviewed
  26 Feb 2010
• Accepted
  07 Apr 2010