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1、 Lou2021,12:53 :/ biomedcentral /1471-2466/12/53RESEARCH ARTICLEOpenAccessPrevalenceandcorrelationswithdepression,anxiety,andotherfeaturesinoutpatientswithchronicobstructivepulmonarydiseaseinChina:across-sectionalcasecontrolstudyPeianLou1*,YananZhu2,PeipeiChen1,PanZhang1,JiaxiYu1,NingZhang1,NaChen1,
2、LeiZhang1,HongminWu2andJingZhao2AbstractBackground:Patientswithchronicobstructivepulmonarydisease(COPD)oftenexperiencedepressionandanxiety,depressionandanxietyinChinesepatientswithCOPD.Methods:Acasecontrolledstudywasdesignedwith1100patientswithCOPDenrolledinthecasegroupinbothgroupswereevaluatedusing
3、theHospitalAnxietyandDepressionScale(HADS).Thebodymassindex,degreeofairflowobstruction,dyspnea,andexercisecapacity(BODE)indexwasusedtoassessCOPDseverity.Binarylogisticregressionmodelswereusedtotesttheassociationbetweenanxietyanddepression.Results:ThepatientswithCOPDweremorelikelythancontrolstoexperi
4、encedepression(cases,HADS10.53.6,prevalence35.7%;controls,HADS8.72.7,prevalence7.2%)andanxiety(cases,HADS10.43.1,prevalence18.3%;controls,HADS8.62.1,prevalence5.3%).SubjectswithanxiousanddepressivesymptomshadpoorerhealthoutcomesincludingahigherBODEindex,ashorter6-minute-walkdistance(6MWD),moredyspne
5、a,andahigherStGeorgewithincreasingBODEscores.Onthebasisofbinarylogisticregression,theBODEindexwassignificantlycorrelatedwithanxiety(OR=1.47,p0.001)anddepression(OR=1.51,p0.001).Anxiousanddepressivesymptomswerealsoassociatedwithseveralfactorsincludingyoungerage,femalesex,highereducationlevel,lowerhou
6、seholdincomeandhistoryofsmoking.Conclusions:ThisstudyconfirmedthehighprevalenceofanxietyanddepressioninChineseoutpatientswithTrialregistration:ChineseClinicalTrialsRegistration(ChiCTR-TRC-12001958)Keywords:Chronicobstructivepulmonarydisease,Anxiety,Depression,HospitalAnxietyandDepressionScale*Corres
7、pondence:loupeian2004yahoo 1XuzhouCenterforDiseaseControlandPrevention,142WestErhuanRoad,Xuzhou221006,ChinaFulllistofauthorinformationisavailableattheendofthearticleCommonsAttributionLicense( :/creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproductioninanymedium,p
8、rovidedtheoriginalworkisproperlycited. Lou2021,12:53Page2of9 :/ biomedcentral /1471-2466/12/53Backgroundworseningofrespiratorysymptoms,noX-rayormedica-Chronic obstructive pulmonary disease (COPD) is a tion changes within four weeks before recruitment; (3)leading cause of disability and death worldwi
9、de, with noprimarydiagnosisofasthma;and(4)nopreviouslungpopulation prevalence rates of 513% 1-3. Prevalence volumereductionsurgery,lungtransplantation,orpneu-ratesaredirectlyrelatedtotobaccosmokingandindoor monectomy. According to the sampling criteria, 1100air pollution, and are expected to rise as
10、 smoking rates healthyparticipantswereselectedascontrolsubjects.continue to increase, notably among women and indeveloping countries 1,3. By 2030, COPD is expectedDemographic datato represent the third leading cause of death in middle- Generalcharacterssuchasage,sex,educationlevel,aver-income countr
11、ies 4. COPD is characterized by poorly age number of family members, marital status, smokingreversiblelimitationsofairflowanddyspnea5,butitis status(current-,ex-ornever-smoker)andhouseholdnetnot limited to the lung. Some patients develop system- income were recorded based on patientreports. Subjecta
12、tic manifestations, including exercise limitations 6,7, weight and height were measured before carrying outperipheral muscle dysfunction 6,8, and malnutrition pulmonaryfunctiontestsandthebodymassindex(BMI)9. Two of the most common and least-treated co- was calculated by dividing the weight in kilogr
13、ams bymorbidities of COPD are anxiety and depression 10. height in meters squared. Education level was categor-Increasingevidencesuggeststhatanxietyanddepression ized as below high school, high school, or beyond highand exacerbation of COPD 11,12, rather than being ingsmokedatleast100cigarettesinone
14、 slifetime.consequences or markers of disease severity. Thus,detecting depression or anxiety in patients with COPDAssessment ofanxiety anddepressionis of great importance. Although the close correlation Anxiety and depression were measured using the Hos-betweenanxietyanddepressioniswellknown,fewstud
15、- pitalAnxietyandDepressionScale(HADS)13,14.Theies have examined their simultaneous occurrence in HADS has been specifically developed for detection ofpatients with COPD. Moreover, there are few studies anxiety and depression in patients with somatic condi-amongpatientswithCOPDinChina.ity in cases o
16、f anxiety and depression in patients withTheaimofthepresentcross-sectionalstudywastoin- chronic diseases (including COPD) 11,12,14. It isvestigatethelevelsandfrequencyofanxietyanddepres- divided into an anxiety subscale (HADS-A) and a de-sion among community-based patients with COPD. In pression sub
17、scale (HADS-D) both containing sevenaddition, we evaluated the correlation between anxiety, items, rated 03, giving a possible maximum score fordepression, and other features on patient status with anxietyanddepressionof21.Scores8indicatenoclin-COPDinChina.ical distress; scores from 8 to 10 indicate
18、 possible psy-chiatric morbidity; and scores 11 indicate probablepathologiclevelsofdistress13.TheMandarin-ChineseHADS was also translated and validated in our popula-MethodsSampling strategyThis is a cross-sectional survey conducted between tion(unpublisheddata).MarchandMay2021intheruralareasofXuzho
19、uarea.A cluster randomized sampling strategy was used.Assessment ofpulmonary functionAccording to Chinese alphabetical sorting, one out of Spirometry and bronchodilator response tests were car-everynineteencommunitieswasselectedasastudycom- ried out by trained professionals according to the stan-mun
20、ity. Twelve communities were selected out of 238 dardized guidelines of the American Thoracic Societycommunities.Allpatientsintheprimarycarestationsof (ATS) 15. Patients carried out the pulmonary functionthe12selectedcommunitieswereincluded.Basedonage test at least 12 hours after the withdrawal of i
21、nhaled(1 year),sex,educationlevel,averagenumberoffamily bronchodilators. Patients performed spirometry at 15members and marital status, healthy participants who and 60 minutes after inhaling salbutamol (200 g).livedinthesamevillagesasthepatientswithCOPDwere GOLD stages were defined as described in t
22、he updatedselected as control subjects. All sampled subjects were GOLD(2006edition)16.invitedtoparticipateinthestudyduringhomevisits.Assessment ofquality oflifeStudy populationHealth-related quality of 1ife (HRQL) was measuredPatientsmet thefollowingcriteria:(1)COPD diagnosed with Saint Georges Resp
23、iratory Questionnaire (SGRQ).by the standards of the Global Initiative for Chronic ThequestionnaireisawidelyusedquestionnairespecificObstructive Lung Disease (GOLD); (2) no fever, no to respiratory disease. It consists of 50 items and is Lou2021,12:53Page3of9 :/ biomedcentral /1471-2466/12/53separat
24、ed into three parts: symptoms (distress due to Pearsons correlation was used to assess the associationrespiratory symptoms), activities (effects due to im- between anxiety and depression. To evaluate the riskpairment of mobility or physical activity), and effects factors for depression, multivariate
25、 logistic regression(psychosocial effects of the disease) 17. Scores were analysis was performed, incorporating all factors thatweighted using empirically derived weights. The scores obtainedvaluesofp0.05inthebivariateanalyses.range from 0to l00 for thethree subscales with a sum-Ethical approval for
26、 the study wasgiven by the Ethicsmary total score. Higher scores indicate worse health Committee of the Xuzhou Center for Disease Controlstatus; 0 indicates no impairment and 100 indicates andPrevention,andtheRegionalEthical Vetting Board,maximalimpairment18.participants.Assessment ofdyspneaDyspnea
27、was measured using the Medical ResearchCouncil (MRC) dyspnea scale. The MRC dyspnea scaleResultsGeneral characteristics ofparticipantsclassifiesbreathlessnessintosixgrades(0to5)according There were 1683 patients with COPD receiving care intoself-perceivedbreathlessnessduringdailyactivities19. the 12
28、 selected communities. According to the patientscreeningcriteria,1145patients(68.0%)metthescreen-Assessment ofexercise capacitying criteria and 538 patients (32.0%) did not meet theThe six-minute walking distance test (6MWD) was car- screening criteria. Out of 1145 matching participants,ried out acc
29、ording to ATS guidelines. Each patient was 1100matchingparticipantshadcompletedthequestion-orderedtowalkasrapidlyaspossibleina solidandflat naires,while45pairedsubjects(12patients,33controls)corridor for six minutes. The test was repeated twice did not complete the questionnaires. There was no sig-w
30、ith an interval of at least 30 minutes 20. The better nificant difference in age between responders and non-walkingdistancesforeachpatientwererecorded.responders mean age 62.0 (SD 11.6) and 61.8(SD 12.0)years,respectively;p=0.76.Assessment ofanxiety anddepression impact onthehealth outcomes ofpatien
31、ts withCOPDThe demographic characteristics of the 1100 healthycontrols and the 1100 patients with COPD who com-modal measure of disease severity, to assess COPD se- age of all 2200 subjects was 62 years (range, 39 y to 76depression 21. The BODE index is based on the BMI, lar for both the control and
32、 COPD groups. Disease se-thedegreeofairflowobstructionmeasuredbyforcedex- verityaccordingtotheGOLDstageisshowninTable2.piratoryvolumeinonesecond(FEV1),gradeofdyspnea The presence of dyspnea had the following distribution:assessed by the modified MRC dyspnea scale 22, and 160 patients (14.5%), MRC 0;
33、 465 (42.3%), MRC l; 355exercise capacity measured by the 6MWD test. Each (32.3%), MRC 2; 91(8.3%) MRC 3; and 29 (2.6%), MRCcomponent is assigned a specific index and the total 4, with a median of 1 (P5-P95, 03). These patientsscorerangesfrom0to10points(higherscoresindicate showed a mean FEVl of 1.2
34、7 L (SD, 0.36 L), a mean2otherpooroutcomeswithCOPD21,23,24.TheBODE (SD, 2.8 k/m2), a mean SGRQ total score of 43.4 (SD,index can be divided into four quartiles:quartile I is a 17.6), and a median BODE index of 2 (P5-P95, l6).scoreof02;quartileIIisascoreof34;quartileIIIisa Females manifested a signif
35、icantly higher frequency ofscoreof56;andquartileIVisascoreof71021,25.depressive symptoms (44.3% vs. 34.0%, p 0.001) andlower frequency of anxious symptoms (16.2% vs. 19.3%,p0.001)thanmales(Table3).Statistical analysisThe computer-based analysis program Statistical Pack-age for Social Science (SPSS)
36、version 13.0 was used forPrevalence ofanxious symptoms inpatients withCOPDallcalculations.Theminimalstatisticalsignificancelevel Table 1 shows the mean scores on the HADS-A forforallanalyseswasp0.05.Groupcomparisonsforcat- patients with COPD. The mean anxiety scores ofegorical variables were perform
37、ed using Pearsons chi- patients with COPD were higher than those of healthysquare test or Fishers exact test. To compare groups of controls(p0.05).NotonlydidthepatientswithCOPDpatients,weusedANOVAsfornormallydistributeddata show a higher median anxiety score, but the patientsand the KruskalWallis te
38、st for non-normally distribu- with COPD were also significantly more likely thanteddata.Forcomparisonsbetweentwogroups,Students healthy controls to report anxious symptoms (patients:t-testandtheMannWhitneyUtestwereusedfornor- 18.3% vs. controls: 5.3%, p 0.01). Compared to themally and non-normally d
39、istributed data, respectively. patientswithCOPDwhohadnoanxioussymptoms,the Lou2021,12:53Page4of9 :/ biomedcentral /1471-2466/12/53Table1Baselinecharacteristicsofthestudypopulationaccordingtodiseasestatuspatients with COPD who had anxious symptoms hadsmallermeansofBMIand6MWDandhadhighermed-ians of MR
40、C, BODE index, and SGRQ score (Table 3).InasubgroupanalysisofpatientswithCOPD,increasedfrequency of anxious symptoms was correlated withincreaseddiseaseseverityaccordingtotheGOLDstages(2 =27.47, p0.001)(Table 2). The prevalence of anx-ious symptoms also increased with increasing BODEquartiles(2=78.6
41、9,p0.0001)(Table2).VariablesGroupspValueCOPDControls(n=1100)(n=1100)Number(Percentage,%)273(24.8)Femalesex273(24.8)21(1.9)Educatedleveltohighschoolorbeyond21(1.9)SmokinghistoryPastsmoker264(24.0)226(20.5)610(55.5)201(18.3)393(35.7)12(1.1)235(21.4)853(77.5)58(5.3)Prevalence ofdepressive symptoms inpa
42、tients withCOPDCurrentsmokerNeversmokerHADS-A8From Table 1, we knew that the HADSD scores andfrequency of depressive symptoms for the healthy con-trols and the patients with COPD differed significantly.The patients with COPD had higher HADSD scoresand greater frequency of depressive symptoms in com-
43、parisontothehealthycontrols(p0.05).IncomparisontothepatientswithCOPDwhohadnodepressivesymp-toms, the patients with COPD who had depressivesymptoms had smaller means of BMI, FEV1, and6MWD,andhadhighermediansofMRC,BODEindex,and SGRQ score (Table 3). In a subgroup analysis ofpatients with COPD, increas
44、ed frequency of depressivesymptomswascorrelatedwithincreaseddiseaseseverityaccording to the GOLD stages (2 = 133.03, p 0.001)(Table 2). The prevalence of depressive symptoms inpatientswithCOPDincreasedasBODEindexincreased(2=102.34,p0.0001)(Table2).HADS-D879(7.2)Mean(SD)ormedian(quartile)Age63.2(4075
45、)2.86(14)62.1(3976) Averagenumberoffamilymembers2.86(14)Annualnetincomeperfamily(yuan)17002(440)17477(469)BMI(kg/m2)23.3(2.8)1.27(0.36)45.2(10.8)47.9(11.5)445.0(91.0)4.8(2.3)23.4(3.0)2.55(0.68)88.6(9.2)83.6(9.3)580.1(99.8)3.1(1.6)FEV1(L)FEV1,%ofpredictedvalueFEV1/FVC6MWD(m)HADS-AscoreHADS-Dscore5.4(
46、2.6)3.5(2.4)HADS:HospitalAnxietyandDepressionScale:HADS-A:HADSanxiety;HADS-D:HADSdepression;FEV1,forcedexpiratoryvolumeinonesecond;FVC,forcedvitalcapacity;BMI:bodymassindex;6MWD:six-minutewalkingdistance;MRC:MedicalResearchCouncil;SGRQ:SaintGeorge sRespiratoryQuestionnaire:BODE:bodymassindex,degreeofairwayobstruction,dyspneaandexercisecapacity;Possibleanxiety(8HADS-Al0)andprobableanxiety(HADS-A11)werecombinedandreferredtoasanxiety(HADS-A8).Possibledepression(8HADS-Dl0)andprobabledepression(HADS-D11)werecombinedandreferredtoandasdepression(HADS