Assessing Inflammatory and Behavioral Pathways Linking PTSD to Increased Asthma Morbidity in WTC Workers

Details

• Personal Author:
  Busse P ; Wisnivesky JP
• Description:
  Purpose: Asthma and post-traumatic stress disorder (PTSD) are the most common conditions in World Trade Center (WTC) rescue and recovery workers, affecting approximately 28% and 32% of individuals, respectively. A large number of local residents and passersby also suffer from these conditions. Moreover, a large number of workers with asthma continue to report symptoms years after exposure at the WTC site. Thus, asthma is a major cause of morbidity and compromised quality of life among the WTC rescue and recovery worker population. Several studies show a strong association of PTSD with increased asthma morbidity, including worse disease control, increased acute resource utilization, and poorer quality of life in the WTC worker population. However, the pathways underlying these associations are unknown and this knowledge gap is a major barrier for developing effective and highly needed interventions. PTSD is associated with systemic inflammation (increased levels of interleukin [IL]-1a, IL-2, IL-6, tumor necrosis factor-alpha [TNF-a] and decreased IL-4, IL-5). Some of these pro-inflammatory cytokines have been linked to more severe asthma phenotypes, potentially explaining the relationship between PTSD and worse asthma outcomes. But biological pathways are only part of the drivers of asthma morbidity. Several observations suggest that PTSD has a stronger association with subjective (asthma symptoms, use of rescue medication, and quality of life) than objective (airflow limitation) markers of asthma morbidity, suggesting over-perception of symptoms. Additionally, theory and empirical evidence suggest that inaccurate perception of asthma symptoms and maladaptive illness and medication beliefs in patients with PTSD may lead to lower adherence to asthma self-management behaviors (SMB), a key determinant of asthma outcomes. With adherence to controller medications being low among asthma patients in general, behavioral mechanisms may also contribute to the association between PTSD and increased asthma morbidity in WTC workers. Our goal was to examine the interaction of biology and behavior in WTC workers with asthma and PTSD and use this information to design and pilot test an intervention to improve their care. Methods: A cohort of WTC workers were recruited and enrolled. Participants were eligible if they: 1) were at least 18 years of age; 2) had a diagnosis of asthma made by a health care provider; and 3) spoke English or Spanish. WTC workers were excluded if they 1) had chronic obstructive lung disease (COPD) or other chronic respiratory illness; and/or 2) had a history of heavy smoking (≤15 pack-years) because of the possibility of undiagnosed COPD. Current smokers were eligible if their cumulative smoking history did not exceed this threshold. Eligible individuals were consented and completed surveys at the time of enrollment (baseline), at 6-month and 12-month follow-ups. A subset of participants completed an additional visit for sputum collection. Blood samples were collected and a clinical interview completed by a psychologist or trainee to assess PTSD and other psychiatric diagnoses. Additional data was collected using electronic devices to monitor medication adherence and actual versus perceived peak expiratory flow (PEF). A subset of participants from the cohort study were recruited for a pilot randomized controlled study to test a novel intervention for PTSD and asthma if they met the following criteria: 1) results of the Structured Clinical Interview for DSM-5 Disorders (SCID) and/or PTSD Checklist (PCL-5) survey showing evidence of PTSD; 2) poorly controlled asthma based on an Asthma Control Questionnaire (ACQ) score between 0.75-1.5; 3) an Asthma Quality of Life Questionnaire (AQLQ) score less than 4.7; and 4) completion of observational study 12-month visit. Results: In total, 361 participants completed a baseline interview. Of these, 101 (31%) met criteria for PTSD based on the SCID, and 61 (18%) met PTSD criteria based on the PCL-5. PTSD was significantly associated with worse asthma control (p=0.002), higher rates of emergency room (ER) visits (p=0.0002) and hospitalizations (p=0.03) and poorer asthma-related quality of life (p<0.0001). Participants with PTSD had different illness beliefs about asthma (p<0.001), believed their asthma medications were more necessary (p=0.003) and were more concerned about medication side effects (p<0.001) than those without PTSD, and had more catastrophic beliefs about asthma (p<0.001). Aim 1: We found no significant association between blood or sputum cytokines with PTSD diagnosis or PCL-5 scores both in unadjusted and adjusted analyses (all p>0.05). Aim 2: Adjusted analyses showed no significant differences in PEF among WTC workers with (351.9 +/- 143.3 liters per minute) vs. without PTSD (364.6 +/- 131.6 liters per minute, p=0.55). WTC workers with PTSD vs. those without PTSD had increased proportion of accurate perception (67% +/- 37% vs. 54% +/- 38%, p=0.01) and lower under-perception (23% +/- 32% vs. 39 +/- 38%, p=0.004) of airflow limitation during periods of airway obstruction. Similar results were obtained in adjusted analyses. Aim 3: PTSD was not significantly associated with medication adherence (mean difference: -0.15; 95% confidence interval [CI]: -0.5 to 0.2), inhaler technique (mean difference: -0.12; 95% CI: -0.7 to 0.5), use of action plans (odds ratio [OR]: 0.8; 95% CI: 0.4 to 1.8), or trigger avoidance (OR: 0.9; 95% CI: 0.4 to 1.8). Aim 4: There were no significant differences in asthma control, quality of life, medication adherence, medication beliefs, illness beliefs, PTSD, depression or anxiety symptoms between the intervention and control groups either before the trial, at 1-week follow-up, or at 3-month follow-up (all p>0.05). Conclusions: Aim 1: We found no major differences in asthma inflammatory markers in WTC workers with vs. without PTSD. These findings suggest that other mechanisms likely explain the association between PTSD and asthma control in WTC exposed individuals. Aim 2: We found that WTC workers with and without PTSD had similar degrees of airflow limitation as evidenced by PEF values, suggesting equal asthma control. WTC workers with PTSD were more likely to accurately and less likely to under-perceive airflow limitation. Anxiety sensitivity may influence asthma perception in WTC workers with coexisting PTSD, making these individuals more attuned to and hyper-focused on their asthma symptoms, which over time, may lead to more accurate perception of airflow limitation. Aim 3: PTSD was not significantly associated with medication adherence, inhaler technique, use of action, or trigger avoidance. Thus, behavioral pathways do not appear to mediate the association between PTSD and worse subjective asthma control. Aim 4: The intervention piloted in this study did not demonstrate any significant differences in asthma-related beliefs and behaviors or in PTSD symptoms compared to the control protocol. Further research is needed to explore effective ways of managing comorbid PTSD and asthma in this complex population. [Description provided by NIOSH]
• Subjects:
  Asthma Asthma, Occupational Cohort Studies Emergency Responders Mental Health Morbidity Nervous System Occupational Health Safety September 11 Terrorist Attacks
• Keywords:
  Cohort Studies Cytokines Emergency Responders Mental Health Morbidity Rates Post-traumatic Stress Disorder PTSD Rescue Workers World Trade Center WTC
• Series:
  Grant Final Reports
• Publisher:
  National Institute for Occupational Safety and Health
• Document Type:
  Text
• Funding:
  Cooperative Agreement
• Genre:
  Final Cooperative Agreement Report
• Place as Subject:
  New York ; OSHA Region 2
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Division:
  OEP - Office of Extramural Programs
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Pages in Document:
  1-38
• NIOSHTIC Number:
  nn:20067157
• Citation:
  Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, U01-OH-011312, 2022 Nov; :1-38
• Contact Point Address:
  Juan P. Wisnivesky, MD, MPH, DPH, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029-6574
• Email:
  juan.wisnivesky@mssm.edu
• Federal Fiscal Year:
  2023
• Performing Organization:
  Icahn School of Medicine at Mount Sinai, New York
• Peer Reviewed:
  False
• Start Date:
  20160901
• Source Full Name:
  National Institute for Occupational Safety and Health
• End Date:
  20210831
• Collection(s):
  National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:5e0f36222c2678a19856c65da0a04f2919df52ee994041fd2b02804a5d755fe32c6676fcfa419e1d707ca56836cc1cc92e0c3b6d3dbe2da427825f14cf991e0c
• Download URL:
  https://stacks.cdc.gov/view/cdc/219187/cdc_219187_DS1.pdf
• File Type:
  [PDF - 1.58 MB ]