© 2004 American Thoracic Society
Psychosocial Factors and AsthmaTo the Editor:There is accumulating evidence that an increase in asthma morbidity and mortality is associated not only with lower socioeconomic status and ethnicity, but also with a number of psychosocial and emotional factors such as denial of disease, anxiety, and inappropriate coping skills. These psychosocial and emotional factors are possible underlying reasons for noncompliance with asthma medications, irregular follow-up, and suboptimal asthma management in high-risk patients (1–3). The article by Castro and colleagues (4) describes a multifaceted intervention focusing on high healthcare users with asthma. One of the components of the intervention included providing psychosocial support and screening of patients for professional counseling. An earlier study by Brinke and colleagues (3) investigated the relationship between psychological dysfunction in patients with severe asthma and healthcare utilization, and showed that healthcare utilization in psychiatric patients was greater than for nonpsychiatric patients with severe asthma. Castro and colleagues (4) reported similar findings and concluded that patients in the intervention group who had access to nursing and psychosocial support may have benefited in terms of reduced hospitalizations for problems other than those intended by the intervention as compared with the "usual care" group. Given the impact of psychosocial factors on asthma morbidity and mortality, it would be interesting to know how many patients in the intervention group utilized psychosocial support from the nurse, social worker, or psychiatric nurse specialist. If some patients did utilize psychosocial support, was there any difference in the health outcomes between the two groups of patients within the intervention group? It is difficult to tease out the effective components of a multifaceted intervention like this one. However, given the data, an attempt can be made to identify the relationship of some components to asthma morbidity and mortality, which could contribute to the development of innovative interventions.
School of Pharmacy, West Virginia University Morgantown, West Virginia FOOTNOTES Conflict of Interest Statement: K.M.K. and L-A.M. have no declared conflict of interest. REFERENCES
From the Authors: Kamal and Miller raise important points regarding the potential role psychosocial and emotional factors may play in driving healthcare utilization due to asthma. Previous literature has well documented that psychological problems can contribute to asthma morbidity and mortality. Issues such as stress, depression, hopelessness, despair, family disturbances, and abnormal reactions to separation and loss (1–5) may be playing a role in addition to those raised by Kamal and Miller (i.e., denial, anxiety, and inappropriate coping skills). Tracking these issues prospectively in a randomized controlled trial poses significant challenges including patient confidentiality, patient acceptability of the medical profession, racial/ethnic differences, and indifference or lack of knowledge among the medical profession of the significant role psychosocial issues may be playing. Unfortunately, we did not prospectively track psychosocial issues in our multifaceted intervention (6). We did note that only 10% of a subset enrolled in our study were diagnosed with a psychiatric disturbance and referred for psychiatric counseling. These numbers are too low to examine whether there was a significant impact on health outcomes. Furthermore, we believe our nurse-directed intervention was successful in that it provided more than just education and medical management. Our nurses provided social support and helped the intervention group access resources that they needed beyond their asthma care. For example, they visited the participants' homes or shelters, provided coats, or helped them make sure they had access to electricity and heat. This aspect of the nursing–patient relationship often is difficult to measure, yet is likely crucial to the success of any intervention working with minority populations with frequent healthcare utilization. Lastly, in our hospital setting, we often encounter resistance among the providers in obtaining psychological or social worker input in patients with asthma, despite a history of high healthcare utilization. We advocate that any healthcare provider, including asthma educators, who cares for those patients with asthma with a history of frequent healthcare utilization should actively screen for underlying psychosocial issues, obtain psychiatric or social worker input when appropriate, and provide ongoing social support when possible.
Washington University School of Medicine St. Louis, Missouri FOOTNOTES Conflict of Interest Statement: M.C., N.Z., and S.C. have no declared conflict of interest. REFERENCES
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