Published online December 1, 2006
PEDIATRICS Vol. 118 No. 6 December 2006, pp. e1715-e1720 (doi:10.1542/peds.2006-1119)
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow P3Rs: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when P3Rs are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via CrossRef
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Brown, E. S.
Right arrow Articles by Rush, A. J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Brown, E. S.
Right arrow Articles by Rush, A. J.
Related Collections
Right arrow Asthma

ARTICLE

Psychiatric Symptomatology and Disorders in Caregivers of Children With Asthma

E. Sherwood Brown, MD, PhDa, Vanthaya Gan, MDb, Jala Jeffress, BAa, Kacy Mullen-Gingrich, BAa, David A. Khan, MDc, Beatrice L. Wood, PhDd, Bruce D. Miller, MDe, Rebecca Gruchalla, MD, PhDc and A. John Rush, MDa,f

a Departments of Psychiatry
b Pediatrics
c Internal Medicine
f Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
d Departments of Psychiatry and Pediatrics, State University of New York at Buffalo, Buffalo, New York
e Child and Adolescent Psychiatry, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York


   ABSTRACT
TOP
 ABSTRACT
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. The prevalence of asthma and asthma-related mortality has increased in recent years. Data suggest an association between psychiatric symptoms in the caregiver and asthma-related hospitalizations in the child. We examined the prevalence of psychiatric symptoms and disorders and their relationship to asthma-related service utilization in caregivers of children hospitalized for asthma.

PATIENTS AND METHODS. Caregivers (n = 175) were assessed during the child’s hospitalization. The number of asthma-related hospitalizations, emergency department visits, and unscheduled clinic visits in the past 12 months was obtained. The Brief Symptom Inventory, an assessment of psychiatric symptoms including somatic, anxiety, and depression subscales, and the Mini International Neuropsychiatric Interview, a structured clinical interview for psychiatric disorders, were administered.

RESULTS. Mean age of the caregivers was 34.2 ± 7.3 years; 96.0% were women; 15.4% were white, 57.7% were black, and 26.3% were Hispanic. A total of 47.9% had incomes less than $25000/year. Caregivers with clinically significant elevations in 2 or more Brief Symptom Inventory subscales reported more asthma-related child hospitalizations in the past 12 months than did caregivers with lower Brief Symptom Inventory scores. Asthma-related hospitalizations correlated with Brief Symptom Inventory total, somatic, anxiety, and depression subscale scores. Caregiver diagnosis of an anxiety disorder (n = 36) was associated with more asthma-related hospitalizations in the child. Children of caregivers with current depression (n = 44) had more unscheduled clinic visits than children of caregivers without depression.

CONCLUSION. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition–defined psychiatric disorders, particularly depressive disorders, were common in caregivers and associated with a greater frequency of asthma-related hospitalizations in the child.

Key Words: asthma • depression • caregiver • child hospitalization • service utilization

Abbreviations: BSI—Brief Symptom Inventory • ED—emergency department • CMCD—Children’s Medical Center of Dallas • IRB—institutional review board • MINI—Mini International Neuropsychiatric Interview • DSM-IV—Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

Asthma is a common and severe medical illness. The rate of asthma in the US population is >7%.1 In the past 2 decades, the prevalence of asthma has increased by 75%,2 asthma-related hospitalizations have increased by >70%, and the asthma mortality rate has doubled.3

Depression and anxiety are common in individuals with asthma.4,5 Adults and children with asthma have higher levels of depressive symptom severity than healthy controls and persons with other medical illnesses.4 When present, depression may be associated with a poor asthma prognosis, including increased asthma-related morbidity, mortality, and unscheduled service utilization.4

Psychiatric symptoms are also common in caregivers of children with asthma and are associated with poor outcomes in the child, including greater use of acute care resources. Wade et al6 found that 764 (50%) of 1528 caregivers of inner-city children with asthma had significant psychiatric symptom severity based on Brief Symptom Inventory (BSI) Global Severity scores. Weil et al7 found that asthmatic children of caregivers with BSI scores indicating significant psychopathology were almost twice as likely to be hospitalized for asthma compared with children whose caregivers had fewer psychiatric symptomatologies. Bartlett et al8 found that 47% of mothers of inner-city children with asthma had clinically significant levels of depressive symptoms. Mothers with high levels of depression were, even after controlling for asthma symptom severity, 40% more likely to report an emergency department (ES) visit by their child in the following 6 months than those with lower depressive symptom severity.8

Psychiatric symptoms seem to be common in caregivers of children with asthma and are associated with increased service utilization by the child. However, available data do not identify specific classes of psychiatric disorders in caregivers associated with high rates of unscheduled treatment. This information is potentially important, because psychiatric treatment is targeted at specific disorders rather than symptoms. Therefore, in this study, we set out to quantify psychiatric disorders in caregivers of children with asthma. We examine the prevalence of psychiatric symptoms and specific psychiatric disorders in caregivers of primarily minority, inner-city children hospitalized for asthma. In addition, we evaluate the relationships between these psychiatric symptoms and disorders in the caregiver and asthma-related service utilization for the child. We hypothesize that depression in the caregiver will be associated with increased rate of urgent care utilization by the child.


   PATIENTS AND METHODS
TOP
 ABSTRACT
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
This was a prospective study of caregivers of children hospitalized for an asthma exacerbation at Children’s Medical Center of Dallas (CMCD). Between March 2004 and February 2006, a total of 175 primary caregivers of children hospitalized for asthma were enrolled. The children were initially identified by hospital asthma educators who received a daily list of all admissions using procedures approved by our local institutional review board (IRB) and Health Insurance Portability and Accountability Act office. The study research associate then located the primary caregivers of the hospitalized children and invited them to participate in the study. All participants completed an IRB-approved informed consent process and gave written informed consent. The assessment consisted of a 45- to 75-minute caregiver interview in which basic demographic information on caregiver and child (eg, age, ethnicity, annual income) was obtained. In addition, the following were administered: (a) the Mini International Neuropsychiatric Interview (MINI),9 and (b) 18-item BSI.10 The MINI is a brief structured interview for major axis I disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), including major depressive disorder, dysthymia, bipolar disorders, psychotic disorders, anxiety disorders, eating disorders, and alcohol and substance abuse/dependence.9 The MINI shows high validation and reliability scores when compared with the Structured Clinical Interview for DSM-IV Patient Edition but can be administered in a much shorter period of time (<30 minutes). The BSI is a validated self-report measure of current psychiatric symptomatology and includes subscales for somatic, depressive, and anxiety symptoms. The 18-item version of the BSI can be completed in ~4 minutes. We defined elevated BSI scores by a cutoff score of t ≥63 on 2 subscales. This cutoff was used by the developer of the instrument and in previous reports to identify clinically significant psychiatric symptoms.6,7 We also examined individual subscale scores using the cutoff of ≥63 to define clinically significantly elevated symptoms. The number of asthma-related hospitalizations, ED visits, and unscheduled clinic appointments by the child within the preceding 12 months was assessed by caregiver report.

Caregivers were eligible for the study if they were adult men or women, English- or Spanish-speaking, and were the primary caregivers of a child between the ages of 5 to 16 who was hospitalized at CMCD for an asthma exacerbation. Potential participants were excluded, consistent with our IRB guidelines, if they were mentally retarded or had another severe cognitive impairment that could diminish their ability to provide informed consent or were a member of a vulnerable population defined as a jail or prison inmate or pregnant or nursing woman.

Statistical Analyses
Prevalence of each psychiatric illness on the MINI was calculated. Caregivers (n = 175) were grouped by psychiatric illness (current depressive disorder defined as either current major depressive disorder or bipolar disorder, depressed phase, anxiety disorder defined as panic disorder, generalized anxiety disorder, social phobia, specific phobia, agoraphobia, or obsessive-compulsive disorder) and BSI score. Frequency of emergent asthma service utilization (defined as an asthma-related hospitalization, ED visit, or unscheduled clinic appointment) by the child in the past 12 months was compared between those with the presence or absence of a depressive disorder or anxiety disorder and with and without clinically significant BSI scores using independent-sample t tests. Correlations between caregiver BSI scores and the child’s asthma-related hospitalizations, ED visits, and unscheduled clinic appointments were explored by using Pearson’s correlation coefficient. In some cases, totals do not equal 175 because of missing data. In other cases (eg, anxiety disorders), the sum of each disorder is greater than the total number of participants with an anxiety disorder, because some had >1 anxiety disorder.


   RESULTS
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Demographic characteristics of the caregivers are shown in Table 1. Consistent with the patient population at CMCD, the majority of caregivers were from minority ethnic and racial groups and from households with low annual income. Most caregivers (96%) were female. The children were 71.4% boys and 28.6% girls, with a mean age of 8.7 ± 2.9 years.


View this table:
[in this window]
[in a new window]

  		TABLE 1 Demographic Characteristics of Caregivers (n = 175)

 
Caregivers with ≥2 BSI subscale t scores of ≥63 (considered elevated BSI scores; n = 23 [14%]) reported significantly more asthma-related hospitalizations by their child in the past 12 months than caregivers with <2 BSI subscale scores of ≥63 (n = 144 [86.2%]; Table 2). Elevated BSI somatic, anxiety, and depression subscales were also associated with significantly more asthma-related hospitalizations by the child in the past 12 months.


View this table:
[in this window]
[in a new window]

  		TABLE 2 Asthma-related Service Utilization in Caregivers With Elevated BSI Scores With and Without Depressive or Anxiety Disorders

 
Psychiatric disorders, particularly mood and anxiety disorders, were common in the caregivers. A total of 47 caregivers (26.9%) were diagnosed with a current depressive episode (n = 42 with major depressive episode or n = 5 with bipolar depression) and 36 (20.6%) with an anxiety disorder (see Table 1). Twenty-one caregivers reported a lifetime history of treatment for a psychiatric disorder. The presence of a current depressive episode in the caregiver was associated with significantly more unscheduled clinic appointments than in those without a current depressive episode. Asthma-related hospitalization and ED visits were not significantly different for caregivers with and without a current depressive disorder. Diagnosis of an anxiety disorder was associated with significantly more hospitalizations than in those without an anxiety disorder but not for ED visits or unscheduled clinic visits for asthma (see Table 2). We also examined caregiver age, ethnicity, and income on BSI scores and asthma service utilization. Income of less than $25000/year, caregiver age below the sample mean, and race were not associated with significantly different asthma service utilization.

Asthma-related hospitalizations correlated significantly with BSI total (r = 0.20; P ≤ .01) and somatic (r = 0.21; P ≤ .01), anxiety (r = 0.21; P ≤ .01) and depression (r = 0.16; P ≤ .05) subscale scores (Table 3). No significant correlations were found between asthma-related ED visits or unscheduled clinic appointments and BSI scores.


View this table:
[in this window]
[in a new window]

  		TABLE 3 Correlations Between BSI Scores in the Caregiver and Asthma-Related Hospitalization, ED Visits, and Unscheduled Clinic Visits by the Child

 

   DISCUSSION
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Caregivers with ≥2 elevated BSI subscale scores reported 64% more asthma-related hospitalizations of their child than those with lower scores. Elevated scores on the BSI somatic, anxiety, and depression subscales were associated with 69%, 64%, and 43% increases in child asthma hospitalizations, respectively. Each of the BSI subscales showed modest but significant correlations with the number of asthma-related hospitalizations. Our findings replicate the findings of Weil et al,7 who found that elevated BSI scores in caregivers were associated with increased hospitalization rates but not an increase in unscheduled clinic visits. We also examined the BSI subscales and found that each was associated with increased rates of hospitalization. The somatic and anxiety subscales were somewhat more strongly associated with increased rates of hospitalization than the depression subscale.

In addition to the psychiatric symptoms assessed by the BSI, psychiatric disorders (particularly mood and anxiety disorders) were common in the caregivers. To our knowledge, this is the first study to quantify categorical psychiatric disorders in caregivers of children with asthma. Previous reports have assessed psychiatric symptom burden rather than using DSM-IV diagnostic criteria. A total of 44 caregivers (26.3%) were diagnosed with a current depressive disorder and 36 (20.6%) with an anxiety disorder. Other psychiatric disorders were relatively uncommon in this sample. These rates of mood disorders, and perhaps also anxiety disorders, were higher than in the general population. Recent epidemiologic studies have found a 12-month prevalence of 11% to 18% for anxiety disorders and 5% to 7% for major depressive disorder.11–13 Because our sample consisted primarily of women from minority groups with low household incomes, comparison of rates of mood and anxiety disorders to those in the general population may be misleading. Female gender and low income are associated with an increased risk of major depressive disorder, but Hispanic and black individuals have lower rates of major depressive disorder than white individuals.12 The 24% current prevalence of a major depressive episode found in our study is much higher than the 7% 12-month prevalence of major depressive disorder recently reported in women.12

A depressive disorder in the caregiver was associated with a statistically significant (58%) increase in unscheduled clinic visits by the child but not a significant increase in hospitalizations or ED visits. An anxiety disorder was associated with a statistically significant (31%) increase in asthma-related hospitalizations but not a significant increase in unscheduled clinic visits or ED visits. Caregiver age, race, and socioeconomic status were not associated with significant differences in asthma service utilization by the child.

In adult patients with asthma, depression seems to be more strongly related to asthma outcomes than anxiety.14,15 Our data suggest that anxiety in the caregiver may be more strongly associated with use of asthma services by the child than depression. The relationship between psychiatric symptoms and disorders in the caregiver and the child’s asthma is undoubtedly complex and may include life stress, parent-child interactions, and access to services.16 Our data extend previous research in this area by identifying specific classes of psychiatric diagnoses in the caregiver associated with asthma-related service utilization patterns for the child’s asthma. Our findings suggest that awareness by clinicians treating children with asthma of the caregiver’s mental health may be an important part of an asthma management program.

The reason for the association between caregiver psychiatric disorders and asthma-related hospitalization by their child is not entirely clear. One possibility is that the children of caregivers with psychiatric symptoms or disorders have more severe asthma. However, Bartlett et al8 found a relationship between asthma symptoms in the mother and ED visits by the child even after controlling for asthma symptom severity. We did not find that caregiver age or socioeconomic status was related to hospitalization frequency. Thus, the association between psychiatric disorder and hospitalizations is probably not related to these demographic characteristics. Anxiety in the caregiver could potentially result in greater use of unscheduled service utilization. Psychiatric symptoms could also result in poorer treatment adherence. Future research should focus on mediators and moderators of unscheduled service utilization by caregivers with mood or anxiety disorders and the impact of effective treatment of these disorders on service utilization patterns.

The study has several limitations. First, the study primarily focused on individuals of lower socioeconomic status from ethnic and racial minority groups. This is an important population that has had an increase in asthma and asthma-related morbidity and mortality. However, the findings may not be generalizable to other populations of caregivers of children with asthma. Second, we cannot rule out selection bias, in which caregivers with psychiatric symptoms and with children who have had multiple hospitalizations may have been more likely to participate. We could not obtain informed consent from caregivers who declined to participate in the study. Therefore, we do not have data to compare them to the caregivers who did participate in the study. Third, we relied on caregiver report of asthma service utilization, which may not be accurate. The alternative would have been to use information in the child’s medical charts. However, hospital charts can be inaccurate or incomplete, particularly if some care was provided at another facility, which is often the case at our institution.


   CONCLUSIONS
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
This study suggests a relationship between current psychiatric symptomatology, especially depression and anxiety, in the primary caregiver and exacerbation of asthma in the child. This relationship deserves additional investigation because successful treatment of depressive and anxiety symptoms in the caregiver may reduce the need for asthma-related services for the child.


   ACKNOWLEDGMENTS
 
This study was supported by the Texas Higher Education Coordinating Board Minority Health Research and Education Grant Program.


   FOOTNOTES
 
Accepted Aug 3, 2006.

Address correspondence to E. Sherwood Brown, MD, PhD, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8849. E-mail: sherwood.brown{at}utsouthwestern.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

  1. Centers for Disease Control and Prevention. Self-reported asthma prevalence among adults, United States, 2000. MMWR Morb Mortal Wkly Rep. 2001;50 :682 –686[Medline]
  2. Yawn BP, Wollan P, Kurland M, Scanlon P. A longitudinal study of the prevalence of asthma in a community population of school-age children. J Pediatr. 2002;140 :576 –581[CrossRef][ISI][Medline]
  3. Yunginger JW, Reed CE, O’Connell EJ, Melton LJ 3rd, O’Fallon WM, Silverstein MD. A community-based study of the epidemiology of asthma, incidence rates, 1964–1983. Am Rev Respir Dis. 1992;146 :888 –894[ISI][Medline]
  4. Zielinski T, Brown ES. Depression in patients with asthma. In: Brown ES, ed. Advances in Psychosomatic Medicine: Asthma-Social and Psychological Factors and Psychosomatic Syndromes. Basel, Switzerland: Karger Publishers; 2003:42–40
  5. Goodwin RD, Jacobi F, Thefeld W. Mental disorders and asthma in the community. Arch Gen Psychiatry. 2003;60 :1125 –1130[Abstract/Free Full Text]
  6. Wade S, Weil C, Holden G, et al. Psychological characteristics of inner-city children with asthma. Pediatr Pulmonol. 1997;24 :263 –276[CrossRef][ISI][Medline]
  7. Weil CM, Wade SL, Bauman LJ, Lynn H, Mitchell H, Lavigne J. The relationship between psychosocial factors and asthma morbidity in inner-city children with asthma. Pediatrics. 1999;104 :1274 –1280[Abstract/Free Full Text]
  8. Bartlett SJ, Kolodner K, Butz AM, Eggleston P, Malveaux FJ, Rand CS. Maternal depressive symptoms and emergency department use among inner-city children with asthma. Arch Pediatr Adolesc Med. 2001;155 :347 –353[Abstract/Free Full Text]
  9. Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59 (suppl 20):22–33
  10. Derogatis L, Melisaratos N. The brief symptom inventory: an introductory report. Psychol Med. 1983;13 :595 –605[ISI][Medline]
  11. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61 :807 –816[Abstract/Free Full Text]
  12. Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry. 2005;62 :1097 –1106[Abstract/Free Full Text]
  13. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62 :617 –627[Abstract/Free Full Text]
  14. Bosley CM, Fosbury JA, Cochrane GM. The psychological factors associated with poor compliance with treatment in asthma. Eur Respir J. 1995;8 :899 –904[Abstract]
  15. Krommydas GC, Gourgoulianis KI, Angelopoulos NV, Kotrotsiou E, Raftopoulos V, Molyvdas PA. Depression and pulmonary function in outpatients with asthma. Respir Med. 2004;98 :220 –224[CrossRef][ISI][Medline]
  16. Bleil ME, Ramesh S, Miller B, Wood B. The influence of parent-child relatedness on depressive symptoms in children with asthma: Tests of moderator and mediator models. J Pediatr Psychol. 2000;25 :481 –491[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow P3Rs: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when P3Rs are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via CrossRef
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Brown, E. S.
Right arrow Articles by Rush, A. J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Brown, E. S.
Right arrow Articles by Rush, A. J.
Related Collections
Right arrow Asthma