باورهای آسیب شناسی روانی و بیماری تحت تاثیر خودمدیریتی COPD

Objective To explore the influence of psychological characteristics in Chronic Obstructive Pulmonary Disease (COPD) self-management. Methods Patients admitted with an exacerbation of COPD were interviewed for psychiatric symptoms, illness beliefs and self-management behaviour using a new COPD Self-Management Interview (COPD-SMI). This comprised three scenarios to mimic a future evolving exacerbation. Responses were scored for knowledge and actions (adherence) for each scenario. Results Of 47 people approached, 39 participated; 41% had panic attacks, 33% general anxiety, 35% a depression history, 31% an anxiety history and 21% an alcohol dependence history. Twenty-six (67%) had a self-management plan. When hypothetically “well” lower (poorer) COPD-SMI Knowledge Scores were associated with an alcohol dependence history (P=.025), no panic (P=.021) and males (P=.028). Those perceiving less influence over COPD had lower Action Scores during this scenario (P=.01) and the “early exacerbation” scenario (P=.05). Lower Knowledge Scores for the “early exacerbation” were associated with no panic (P=.01) and no self-management plans (P=.03). For the “severe exacerbation”, lower Action Scores were associated with depression history (P=.004), panic (P=.002), higher FEV1% and no self-management plans (P=.005). Higher PaCO2 was associated with lower confidence in symptom recognition, self-management ability and medical care influencing COPD. Conclusion Anxiety, depression, alcohol use and illness beliefs may differentially influence self-management. Depression, previous alcohol dependence and perceived less influence over COPD inhibited self-management. Those with panic demonstrated more self-management knowledge when “well” but performed poorly on actions during the “severe exacerbation”. Those with self-management plans had better knowledge and actions.

Chronic Obstructive Pulmonary Disease (COPD) is a slowly progressive lung disorder characterised by airflow obstruction [1]. Typically, patients experience acute episodes of exacerbation, which may include increased breathlessness, cough or sputum production and require altered self cares and additional medication [1]. This condition is one of the most expensive chronic medical disorders. It is among the four major causes of avoidable hospitalisation for New Zealanders aged 45 and over [2]. The average length of stay in New Zealand hospitals is 6.2 days with a total cost of 16.4 million per annum [2]. Morbidity rates for COPD are expected to increase in the next 20 years placing a significant economic burden on health care services [2]. Written self-management plans, which have previously been successful in reducing hospital admissions in asthma [3], have been instigated in New Zealand to encourage COPD patients to respond quickly to impending exacerbation with the potential to reduce hospital admissions [4]. Such plans comprise written information with specific instructions regarding management when symptoms deteriorate. A small (n=56) randomised controlled study of a nationally adopted COPD Action Plan in primary care indicated that such plans can increase early intervention behaviours with regard to oral corticosteroids and antibiotics but did not show differences in lung function or quality of life [4]. Evaluation of patient's self-management knowledge and capacity to act on that knowledge is fundamental to any self-management plan that aims to improve independent performance of health-related behaviours [5], [6] and [7]. Methods of assessing patient knowledge vary. Self-report questionnaires have the advantage of easy nonexpert administration and limited responses [6]. Whilst more expedient, these approaches do not create the conditions in which disease knowledge must be applied. Another approach, which aims to overcome this problem, involves an interview using disease-specific hypothetical scenarios. Scenarios have been used to explore patients' self-management knowledge in asthma [6], [7] and [8]. Such scenarios can identify self-management behaviour, which includes delays in calling for emergency services and not initiating oral corticosteroids in a timely manner [8]. The impact of psychological characteristics such as anxiety, depression, alcohol use and illness beliefs on self-management behaviour during an exacerbation of COPD has not been evaluated. This is despite a growing number of studies indicating that anxiety and depression are common in people with moderate/severe COPD [9], [10] and [11]. Few studies have gone beyond examining the relative prevalence of these disorders. Theoretically, anxiety and depression may influence self-management in a number of ways. Anxiety is thought to enhance motivation to learn, however, it can also lead to misinterpretation of body symptoms and potentially incorrect self-management actions [12] and [13]. Conversely, depression is known to decrease motivation to perform activities [14]. This implies that the impact of these variables on self-management behaviour may be complex with potentially positive and negative consequences. There are two areas in which alcohol may impact on self-management behaviour in COPD, i.e., learning difficulties and adherence. Prolonged heavy alcohol intake has been associated with difficulty in learning new information [15]. In COPD, no studies have directly addressed this issue. Only one study appears to have examined the impact of alcohol use and adherence in mild lung impairment. This study found that high alcohol consumption was associated with failure in attempts to quit smoking [16]. Patient's negative perceptions of their illness and ability to self-manage have been associated with nonadherence in a number of conditions [17] and [18]. Very few studies have addressed illness beliefs in COPD. One study has indicated that those who have difficulty in accepting their diagnosis may have less confidence to self-manage [19]. In other chronic diseases, negative patient beliefs about the ability to influence symptoms have been associated with nonadherence to rehabilitation and self-management regimens [20]. Extrapolating this to COPD, it might be expected that patients who perceive greater influence over their symptoms would have better self-management adherence. The aim of this study was to explore the influence of patients' psychological characteristics (i.e., anxiety, depression, alcohol and illness beliefs) on self-management knowledge and behaviours by using structured scenarios to mimic an evolving exacerbation of COPD.

Patients with a current depression, with a previous alcohol dependence history and who perceive that their actions have a low influence over their COPD may have difficulty with learning and applying self-management plans. Patients prone to panic attacks may give the impression of adequate self-management knowledge when well but be unable to utilise this knowledge when distressed and unwell. Scenarios could be used as a monitoring and teaching tool to assist patients who panic to perform self-management actions in emotionally distressing situations.