Chronic obstructive lung disease and posttraumatic stress disorder: current perspectives

Figures & data

Figure 1 Flow diagram displaying the study selection process.

Table 1 Selected studies included in the systematic review examining for an association between PTSD and COPD and the impact of PTSD on COPD related outcomes

Study	Population and sample size	Design/data source	PTSD definition or method of identification	COPD definition or method of identification	Reported associations of interest between COPD and PTSD	Summary of findings on the primary measured outcomes
Abrams et al^Citation18	Sample of Veteran patients admitted for a COPD exacerbation (n=26,591)	Retrospective cohort design Veterans Affairs (VA) administrative data	Physician diagnosis recorded in outpatient visits prior to COPD admission	Physician diagnosis of COPD coded on inpatient encounter	Hospital readmission, 30 days mortality	No difference in readmission rates for patients with PTSD (HR, 1.17; 95% CI: 0.96–1.17) or mortality (OR, 1.19; 95% CI: 0.92–1.55). Rates of PTSD among Veterans admitted for COPD exacerbation were lower than general Veteran population (5.9%)
Felker et al^Citation19	Sample of Veteran patients with COPD attending a VA medical center (n=251)	Prospective cohort design with clinical data collection	PTSD checklist (PCL); probable PTSD with a score of ≥50	Physician diagnosis of PTSD	Association between moderate, severe, or very severe COPD and PTSD	No significant association between moderate, severe, and very severe COPD and PTSD. Rates of PTSD among mild or no COPD were 10% vs 12%, 11%, and 12% for moderate, severe, and very severe respectively (P=0.9)
Glaesmer et al^Citation21	Representative sample of German population (n=1,456)	Cross-sectional self-report survey	Posttraumatic diagnostic scale (PTDS) and impact of events scale	Self-report of either COPD or bronchitis	Association between self-reported diagnoses of COPD or bronchitis and either trauma exposure or PTSD diagnosis	Trauma was associated with a higher OR for either COPD or bronchitis (3.25; 95% CI: 1.84–5.76; P<0.001); however, self-report of PTSD diagnosis according to PTDS instrument did not reach significance for association with COPD (OR, 2.25; 95% CI: 0.99–4.64)
Jones et al^Citation22	Representative sample of patients with COPD attending pulmonary rehabilitation clinic (n=100)	Prospective cohort design with clinical data collection	PTDS, impact of events scale	Physician confirmed diagnosis of COPD; chronic respiratory questionnaire – self report (CRQ-SR)	Association between improvements in exercise capacity, quality of life scores, and PTSD severity symptoms	PTSD reported in 8% of sample, PTSD symptoms did not improve following the receipt of pulmonary rehabilitation; however, symptoms of anxiety and pulmonary disease burden (CRQ-SR) scores were higher for subjects with PTSD (3.78 vs 2.99; P=0.03)
Kronish et al^Citation17	Veteran sample of two VA medical centers (n=724)	Prospective cohort design with clinical data collection	Clinician administered PTSD scale	Self-report questionnaire for COPD	Association between PTSD and COPD self-report, impact of PTSD on medication adherence	COPD was reported more often in veterans with PTSD than without PTSD (22.7 vs 16.3; P=0.03). PTSD was associated with the decision to skip medications (OR, 1.95; 95% CI: 1.31–2.91; P=0.001)
Trivedi et al^Citation23	Single medical center sample of COPD clinic patients (n=77)	Observational cohort design with medical records data collection	Clinician recorded PTSD diagnosis	Clinician recorded COPD diagnosis	Associations between having preexisting psychiatric illness and FEV1 levels receiving home oxygen therapy	Preexisting psychiatric illness (including PTSD) was associated with lower FEV1 levels receiving oxygen 1 (P=0.049)
Sareen et al^Citation24	Large population survey, the Canadian Community Health Survey, (n=36,984)	Cross-sectional survey of community representative sample	Report of a physician diagnosis of PTSD	Report of a physician diagnosed condition of chronic bronchitis, emphysema, or COPD	Association between PTSD and obstructive pulmonary disease adjusting for demographics, other mental health comorbidity	3.8% of the sample without PTSD reported obstructive pulmonary disease vs 17.3% with PTSD; adjusted OR was 3.08 95% CI: 2.01–4.72; P<0.001. Samples reporting PTSD had lower scores on psychological well-being (OR, 2.11), past 1 year suicide attempt (OR, 2.35), and worse distress (OR, 2.66) and more days of mental health disability (OR, 2.72)
Seng et al^Citation12	Public health insurance database of adult females in Michigan, (n=17,081)	Case-control design of Medicaid program identifying 2,133 cases of PTSD matched to 14,948 without PTSD diagnosis	Administrative data code for PTSD (309.81)	Administrative data code for respiratory system illness	Associations between PTSD diagnosis, PTSD diagnosis with depression, or complex PTSD (PTSD + personality disorder) and respiratory system condition; regression models adjusting for comorbid mental health conditions	OR for respiratory system condition with any one of the PTSD conditions ranged from 3.0 to 5.1; P<0.002 after Bonferroni multiple comparison correction
Spitzer et al^Citation14	Population based health examination of German community sample, (n=3,171)	Cross-sectional survey design	PTSD determined by Structured Clinical Interview for DSM-IV. (SCID)	Computer assisted personal interview, survey questions asked about illnesses of chronic bronchitis or bronchial asthma	Logistic regression analyses examining the relationship between medical illness and PTSD controlling for clinical and demographics. Determined relationship between trauma exposure and medical illness as well	Among individuals experiencing trauma, 5.7% and 3.5% reported bronchitis or asthma respectively vs 3.8% and 1.9% without trauma Adjusted OR, 1.3 and 1.2 respectively each significant at P<0.001. For patients with PTSD, rates of bronchitis were 21.0 and for asthma 11.3; OR, 3.0 and 2.9; P<0.05 for both
Spitzer et al^Citation26	Same as 2009 study restricting sample to n=1,772 with spirometry	Cross-sectional survey design	PTSD determined by Structured Clinical Interview for DSM-IV. (SCID)	Computer assisted personal interview, physician exams and pulmonary function tests, FVC, FEV1, and % predicted	Logistic regression analyses examining the relationship between pulmonary function and trauma exposure and PTSD controlling for clinical and demographic characteristics	Many significant associations between PTSD and a number of respiratory symptoms (OR ranging from 2.6 for chronic bronchitis to 8.8 for asthma attack). FVC, FEV1, and % predicted were each lower for PTSD group, P<0.01
Boscarino^Citation20	Registry of Vietnam era Veterans, Veterans experience study (n=1,399)	Cross-sectional design analyses performed on a cohort of Vietnam Era Veterans 20 years postservice	PTSD determined using the Diagnostic Interview Schedule (DIS)	Physician diagnosis of respiratory illnesses included asthma and obstructive lung diseases confirmed by medical records review (ICD-9CM codes 480–486, 490–496)	Associations between PTSD and respiratory illnesses per medical records	Unadjusted OR, 2.00, 95% CI: 1.38–2.90. Adjusted OR, 1.54, P=0.042
Schnurr et al^Citation11	Registry of Veterans, Normative Aging Study, (n=2,280)	Observational cohort design	Mississippi combat rating scale, score of >89 indicating PTSD	Physician diagnosis of either asthma or emphysema on exam completed every 3–5 years (ICD-8 codes 490–493)	Hazard ratio (HR) for associations between PTSD and either asthma or emphysema. Impact of medical comorbidity and PTSD on HR for cumulative survival	Unadjusted HR, 1.05; 95% CI: 0.89–1.22; adjusted HR, 0.95; 95% CI: 0.80–1.13. HR for pulmonary condition on cumulative survival in models including PTSD =1.22; P<0.05
Spiro et al^Citation13	Veterans Health Survey of outpatient members attending four VA clinics (n=2,262*)	Cross-sectional survey design	PTSD checklist – Civilian version meeting criteria by symptom cluster criteria	Self-report of chronic lung disease	Associations between PTSD and chronic lung disease	18.4% of veterans with PTSD had CLD vs 12.7% without PTSD; adjusted OR, 1.67, 95% CI: 1.24–2.24
Weisberg et al^Citation25	Primary care sample of patients from multiple (15) clinics located in northeast USA. (n=502)	Prospective cohort design with clinical data collection	Structured clinical interview for DSM-IV indicating PTSD	Self-report of lung disease (asthma separate diagnosis)	Association with lifetime report of lung disease with clinician diagnosis of PTSD	Strong association between self- reported lung disease (not asthma) and PTSD, Cochran–Mantel–Haensze χ2 test =11.86; P<0.001
Laurin et al^Citation27	Pulmonary clinic sample of patients from single site (n=116)	Prospective cohort design with clinical data collection	Structured psychiatric interview using the Anxiety Disorders	COPD confirmed by physician referral to clinic	Association between PTSD and COPD by sex	No significant association was found limited by only one case of PTSD was verified by psychiatric interview
Yellowlees et al^Citation28	Sample of patients admitted to a respiratory unit at a single site (n=50)	Prospective cohort design with clinical data collection	Psychiatric interview	COPD confirmed by physician referral to respiratory unit	Association between PTSD and COPD	Only one case of PTSD was identified

Note:

* P>0.05.

Abbreviations: PTSD, posttraumatic stress disorder; COPD, chronic obstructive pulmonary disease; FVC, forced vital capacity; FEV₁, forced expiratory volume in 1 second; CI, confidence interval; OR, odds ratio; HR, hazard ratio; CLD, chronic lung disease.

Table 2 Studies examining the special population of first responders for the events of 9/11

Study	Population and sample size	Design/data source	PTSD definition or method of identification	COPD definition or method of identification	Reported associations of interest between COPD and PTSD	Summary of findings on the primary measured outcomes
Luft et al^Citation41	The World Trade Center Medical Monitoring and Treatment Program (WTC- MMTP) (n=8,508 police and n=12,333 non-traditional first responders)	Clinical data registry reflecting the care given by seven clinics in New York and New Jersey to qualified responders who participated in the WTC recovery effort	PTSD checklist (PCL); probable PTSD with a score of ≥50	Respiratory symptoms were assessed by self-report and FEV1 measured using spirometry	Rates of probable PTSD, respiratory symptoms, and abnormal FEV1; Structural equation models evaluated for the relationship between probable PTSD and abnormal FEV1 or lower respiratory symptoms (≥1)	Rates of probable PTSD differed by responder type; police 5.9% vs nontraditional responders 23.0%; P<0.001. Odds ratio for PTSD and respiratory symptoms was 1.4, 95% CI: 1.2–1.8 for police; whereas for non-traditional responders, OR, 1.2, 95% CI: 1.1–1.4 up to 2.0, 95% CI: 1.8–2.2; variable according to degree of dust cloud exposure and hours worked. Structural equation models showed correlation between probable PTSD and abnormal FEV1 and respiratory symptoms; P<0.05
Niles et al^Citation16	WTC-MMTP for the FDNY (n=5,363)	Clinical data registry reflecting FDNY firefighters reporting to WTC event within first 2 weeks of 9/11	PCL with probable PTSD with a score of ≥50	WTC cough syndrome	Rates of baseline probable PTSD, follow-up probable PTSD, PTSD score increase, and WTC cough syndrome, FEV1 % predicted, logistic regression models adjusting for demographics	Baseline WTC cough syndrome was associated with baseline probable PTSD OR, 3.59, 95% CI: 2.93–4.39; Follow up probable PTSD and PTSD score increase each were significantly associated with WTC cough syndrome at follow up and the delayed onset of the cough syndrome with all OR ranging from 1.78 to 2.14; and none of the 95% CI crossing 1. Baseline probable PTSD was not associated with abnormal baseline FEV1 % predicted
Webber et al^Citation42	WTC-MMTP for the FDNY (n=10,943)	Clinical data registry reflecting FDNY firefighters reporting to WTC event within first 2 weeks of 9/11	PCL-civilian version; probable PTSD with a score of ≥44	Obstructive Airway Disease (OAD), defined as at least three physician documented visits done every 12–18 months with either asthma, chronic bronchitis, COPD/emphysema or sinusitis	Association between WTC dust cloud exposure determined by arrival timing, first responder type (firefighter, EMS) and OAD; association between PTSD and OAD	41.8% with probable PTSD or depression self-reported an OAD diagnosis; total sample rates of OAD =15.5%. No statistical test for significance was reported. 33.3% with either probable PTSD or depression reported OAD

Abbreviations: EMS, emergency medical service; FEV₁, forced expiratory volume in 1 second; FDNY, Fire Department of the City of New York; CI, confidence interval; OR, odds ratio; PTSD, posttraumatic stress disorder.

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