Ding Y, Chen TY, Wang SH, Chen XY, Zhang L, Huang-Fu JK, Zhou J, Guan SH. Correlation between positive degree and psychological distress in patients with interstitial lung disease. World J Psychiatry 2026; 16(6): 116796 [DOI: 10.5498/wjp.v16.i6.116796]
Corresponding Author of This Article
Shu-Hong Guan, Department of Respiratory and Critical Care Medicine, The First People’s Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, No. 185 Qianqian Street, Changzhou 212003, Jiangsu Province, China. 15651200712@163.com
Research Domain of This Article
Psychiatry
Article-Type of This Article
research-article
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Ying Ding, Tian-Yu Chen, Xi-Yao Chen, Long Zhang, Jun-Kang Huang-Fu, Jun Zhou, Shu-Hong Guan, Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital of Soochow University, The First People’s Hospital of Changzhou, Changzhou 212003, Jiangsu Province, China
Su-Hong Wang, Department of Clinical Psychology, The Third Affiliated Hospital of Soochow University, The First People’s Hospital of Changzhou, Changzhou 212003, Jiangsu Province, China
Co-corresponding authors: Jun Zhou and Shu-Hong Guan.
Author contributions: Ding Y and Chen TY contributed equally to this work as co-first authors, they conceived the study design and framework development, and contributed to the statistical analysis and manuscript drafting; Wang SH helped with data collection and scale validation; Chen XY and Zhang L contributed to clinical collaboration, data entry, cleaning and standardization; Huang-Fu JK helped with the preliminary verification; Zhou J and Guan SH contributed equally to this work as co-corresponding authors. they contributed to conceptualization, supervision, and manuscript revision and finalization.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of The First People’s Hospital of Changzhou.
Informed consent statement: All study participants or their legal guardians provided written informed consent before study enrollment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: The data used in this study can be obtained from the corresponding author upon request.
Corresponding author: Shu-Hong Guan, Department of Respiratory and Critical Care Medicine, The First People’s Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, No. 185 Qianqian Street, Changzhou 212003, Jiangsu Province, China. 15651200712@163.com
Received: December 26, 2025 Revised: January 22, 2026 Accepted: March 2, 2026 Published online: June 19, 2026 Processing time: 153 Days and 0.4 Hours
Abstract
BACKGROUND
Extant studies have explored the independent influencing factors of positivity or psychological distress in patients with interstitial lung disease (ILD); however, few studies have hitherto systematically analyzed the correlation between positivity or psychological distress in these patients.
AIM
To explore the correlation between disease management positivity and psychological distress in patients with ILD.
METHODS
Convenience sampling was used to select 370 patients with ILD treated in The First People’s Hospital of Changzhou (The Third Affiliated Hospital of Soochow University) from July 2023 to January 2025. We obtained data via a general information questionnaire, the Patient Activation Measure (PAM), and Kessler Psychological Distress Scale (K10). Pearson’s correlation analysis was conducted to assess the correlation between positivity and psychological distress. Multiple linear regression analyzed the factors that affected psychological distress. A restricted cubic spline model examined the dose-response relationship between the PAM and K10 scores.
RESULTS
The total PAM and K10 scores were 50.51 ± 5.48 and 32.62 ± 5.60, respectively. Significant differences were observed in the K10 scores among patients based on education level, dyspnea level, and the Perceived Social Support Scale score (P < 0.05). Psychological distress was negatively correlated with cognition, action, belief, skill, and the PAM score (all P < 0.05). Multiple linear regression analysis identified education level, dyspnea, Perceived Social Support Scale score, and PAM score as the main factors that influenced psychological distress (P < 0.05). Restricted cubic spline curve fitting indicated a negative linear relationship between the PAM and K10 scores, adjusted for covariates (P for overall < 0.001, P for non-linear = 0.188).
CONCLUSION
Positivity is negatively correlated with psychological distress in patients with ILD. Clinically, attention should be paid to patients’ psychological state to enhance their positivity.
Core Tip: Interstitial lung disease is a rare type of lung disease. It has physiological symptoms such as progressive dyspnea and also results in great psychological pressure due its long course and difficult treatment. This study aimed to explore the correlation between disease management positivity and psychological distress in 370 patients with interstitial lung disease. The results provide a basis for improving patients’ psychological status.
Citation: Ding Y, Chen TY, Wang SH, Chen XY, Zhang L, Huang-Fu JK, Zhou J, Guan SH. Correlation between positive degree and psychological distress in patients with interstitial lung disease. World J Psychiatry 2026; 16(6): 116796
Interstitial lung disease (ILD) is a type of lung disease characterized by diffuse lung parenchyma, alveolar inflammation, and interstitial fibrosis. Furthermore, it has more than 200 subtypes, such as interstitial pneumonia, idiopathic pulmonary fibrosis (IPF), connective tissue disease-associated ILD, and pulmonary sarcoidosis[1]. It primarily affects the pulmonary interstitium. Common clinical manifestations include dyspnea, coughing, abnormal fatigue or fatigue, clubbing fingers. Some patients may experience symptoms for months or even years before diagnosis[2]. The global prevalence of IPF is 7-1650 cases per 100000 people; furthermore, the prevalence of systemic sclerosis associated ILD and rheumatoid arthritis associated ILD are 26.1%-88.1% and 0.6%-63.7%, respectively[3]. These diseases lead to progressive dyspnea and restrictive ventilatory dysfunction and cause long-term physical pain and psychological pressure due to their irreversible pathological processes and lack of effective treatment.
Although recent advancements in medical technology have improved the therapeutic effect of ILD, its long-term and unpredictable course leads to many challenges in the treatment process; thus, patients suffer from physical pain and great psychological burdens[4,5]. Extant studies have revealed that the incidence of anxiety and depression in patients with ILD to be as high as 73.03%, significantly higher than in the general population. Psychological distress is a key factor affecting the prognosis of the disease and the related quality of life[6]. Activation, a core concept in health behavior theory, refers to an individual’s ability to actively participate in health management, disease treatment, and self-care. In chronic diseases, positivity has been positively correlated with treatment compliance, symptom control, and quality of life[7,8]. However, patients with ILD often exhibit low levels of positivity due to a lack of disease awareness, heavy symptom burden, and lack of social support[9]. This physical and mental interaction is particularly significant in patients with ILD, suggesting a dynamic correlation between positivity and psychological distress. Although studies have explored the independent factors influencing positiveness or psychological distress in patients with ILD, few have systematically analyzed their correlation. Therefore, this study explores the relationship between positivity and psychological distress in patients with ILD based on the influencing factors, thus providing a basis for promoting their mental health.
MATERIALS AND METHODS
Patient characteristics
Convenience sampling was used to select 370 patients with ILD treated at The First People’s Hospital of Changzhou (The Third Affiliated Hospital of Soochow University) from July 2023 to January 2025. Inclusion criteria included patients: (1) Who had a diagnostic criterion of ILD[10], confirmed by high-resolution computed tomography, pulmonary function, and/or lung biopsy; (2) Aged ≥ 18 years, had clear consciousness, and could independently complete the questionnaire; (3) Had the disease for ≥ 3 months (excluding acute onset of ILD subtypes); and (4) Provided complete clinical data. Exclusion criteria included: (1) Those with combined with severe heart, liver, kidney, or other organ failure; (2) A history of mental illness or cognitive impairment; (3) Other serious chronic diseases (such as advanced malignant tumor, severe heart failure); (4) Had an acute respiratory failure or pulmonary infection within 1 month; and (5) Could not complete the pulmonary function test. According to Kendall’s sample size estimation[11], this study included 14 independent variables. Considering 20% invalid questionnaires, a sample size of at least 296 cases was required. We included all 370 cases. This study was approved by the Ethics Committee of The First People’s Hospital of Changzhou.
Research instruments
A general information questionnaire was designed by the authors and included age, gender, education level (junior high school and below, secondary/high school, college degree or above), marital status (with/without spouse), family monthly income (< 3000, 3000-5000, > 5000 yuan), smoking (yes, no), disease, (IPF, non-IPF), taking hormones (yes, no) immunosuppressive agents (yes, no), dyspnea (level 0, level 1, level 2, level 3, level 4), and social support level via the Perceived Social Support Scale (PSSS)[12]. The PSSS includes 12 items categorized under three dimensions: Family, friends, and other support. The maximum score was 84 points. The higher the score was, the higher was the patient’s social support level. A total score of ≥ 37 points represented a middle and high support state, and vice versa.
Patient Activation Measure: The simplified Patient Activation Measure (PAM) scale developed by Hibbard et al[13,14] was used to evaluate the patient’s positivity degree. It includes 13 items on four dimensions: Cognition, skill, action, and belief. Responses are rated on a five-point Likert scale ranging from 1 (very disagree) to 4 (very agree), with 0 as not applicable. The scores were added to the original total score of the patient’s positivity. Subsequently, a patient’s positive conversion score was obtained based on a conversion table provided by the original author. Scores ranged from 0 point to 100 points. The higher the score was, the higher was the patient’s positivity.
Kessler Psychological Distress Scale: The Kessler Psychological Distress Scale (K10) scale by Kessler et al[15] was used to evaluate psychological distress in patients. This 10-item single-dimensional scale measures the frequency of anxiety, depression, and other related non-specific psychological diseases experienced over the past 4 weeks. Responses are rated on a five-point Likert scale ranging from 1 (never) to 5 (all the time). The maximum score was 50 points and sum of the scores was the patient’s total psychological distress score. The higher the score was, the more severe was the patient’s psychological distress.
Data collection
A face-to-face survey was conducted during outpatient follow-up or hospitalization (24-48 hours after admission, stable condition) by two trained respiratory nurses. Before the investigation, the purpose and content and privacy protection measures were explained to each patient. The questionnaire was administered after informed consent was obtained. The questionnaire took approximately 20-30 minutes to complete. The investigator checked its integrity and reminded the patients to complete any missing and incorrect entries to ensure an effective recovery rate of 100%. Of the 370 questionnaires distributed, all were valid (effective recovery rate of 100%).
Statistical analysis
EpiData 3.1 was used to create the database and SPSS software (version 29.0) for statistical analysis. Measurement data with normal distribution were expressed as mean ± SD and t-test and one-way analysis of variance (ANOVA) were used for comparison between groups. Qualitative data were expressed as a n (%) and the χ2 test was used for comparison between groups. Pearson’s correlation was used to analyze the correlation between the positive degree and psychological distress in patients with ILD. Furthermore, stepwise multiple linear regression was used to analyze the influence of the positive degree on psychological distress. A restricted cubic spline (RCS) model was used to analyze the dose-response relationship between the PAM and K10 scores. Statistical significance was set at P < 0.05.
RESULTS
Clinical data of patients with ILD
From July 2023 to January 2025, the target hospital treated a total of 1086 patients with ILD (including 742 outpatients and 344 inpatients). This study actually included 370 cases, with an inclusion rate of 34.07% (370/1086), among which 226 outpatient patients were included, with an inclusion rate of 30.46% (226/742), as well as 144 inpatient patients, with an inclusion rate of 33.14% (114/334). Patients’ ages ranged from 18 years to 80 years, with an average age of 57.56 ± 13.55 years. Table 1 presents baseline patient data.
Scores of positive degree and psychological distress in patients with ILD
The total positive, standardized, and psychological distress score was 16.01 ± 2.53 points, 50.51 ± 5.48 points, and 32.62 ± 5.60 points, respectively (Table 2).
Table 2 Patients’ positive degree and psychological distress score, mean ± SD.
Single factor analysis of psychological distress in patients with ILD
Significant differences were observed in the K10 scores among patients with ILD with different education levels, dyspnea levels, and PSSS scores (P < 0.05; Table 3).
Table 3 Single factor analysis of psychological distress in patients with interstitial lung disease, mean ± SD.
Correlation analysis of patients' psychological distress and positive degree
Psychological distress was negatively correlated with cognition, action, belief, skill, and the PAM (r = -0.216, r = -0.301, r = -0.197, r = -0.255, and r = -0.446, P < 0.05), as shown in Figure 1.
Figure 1 Correlation analysis between psychological distress and positivity degree in patients with interstitial lung disease.
A-D: Illustrate the relationship between the Kessler Psychological Distress Scale and cognitive, action, belief, and skill dimension, respectively; E: Illustrates the relationship between the Kessler Psychological Distress Scale and Patient Activation Measure. K10: Kessler Psychological Distress Scale; PAM: Patient Activation Measure.
Multiple linear regression analysis of psychological distress in patients with ILD
Multiple linear regression analysis was conducted with psychological distress as the dependent variable, and sex, age, marital status, education level, monthly income, smoking, disease type, use of hormones, immunosuppressive agents, dyspnea, PSSS score, and PAM score as the independent variables (the specific assignments are shown in Table 4). Analysis was performed by setting α(in) = 0.05 and α(out) = 0.10. The results revealed that the education level, dyspnea, PSSS score, and PAM score were the main factors that influenced psychological distress in patients with ILD (P < 0.05; Table 5).
Dose-response relationship between PAM score and K10 score patients with ILD
RCS was used to further explore the dose-response relationship between the PAM and K10 scores in patients with ILD, and the number of nodes was four. RCS curve fitting was performed after adjusting for covariates such as sex, age, marital status, education level, family monthly income, smoking, disease type, taking hormones, immunosuppressive agents, dyspnea, and the PSSS score. Results revealed a negative linear relationship between the PAM and K10 scores in patients with ILD (P for overall < 0.001, P for non-linear = 0.188), as shown in Figure 2.
Figure 2 Dose-response relationship between the Patient Activation Measure and Kessler Psychological Distress Scale score in patients with interstitial lung disease.
The solid line represents the predicted value and the spline range represents the 95% confidence interval; β (regression coefficient) is the amount of change in the Kessler Psychological Distress Scale total score for each unit of change in the Patient Activation Measure total score. PAM: Patient Activation Measure; CI: Confidence interval.
DISCUSSION
ILD is a heterogeneous group of diseases characterized by pulmonary interstitial inflammation and fibrosis. Its clinical manifestations include progressive dyspnea, dry cough, and decreased exercise endurance[2]. With the recent progresses in diagnosis and treatment technology, the diagnosis rate of ILD has gradually increased; however, patients still face a heavy burden of disease and poor prognosis[16]. More importantly, patients with ILD suffer from physical symptoms and psychological distress. Previous studies have reported that depression and anxiety are very common in patients with ILD compared with the general population, with depression and anxiety prevalence of 14%-49% and 21%-60%, respectively[17]. This psychological distress reduces treatment compliance and may aggravate the inflammatory response by activating the neuroendocrine system, forming a “psychological-physiological” vicious circle[18]. Therefore, psychological problems in patients with ILD have become an important public health challenge that affects disease prognosis.
We found that the standardized total and psychological distress score of patients with ILD was 50.51 ± 5.48 points and 32.62 ± 5.60 points, respectively. A significant negative correlation was observed between the two (r = -0.446, P < 0.05). Patients’ active participation consciousness and skills in disease management are obviously insufficient and a significant psychological burden exists as well. This finding emphasizes the importance of paying attention to patients’ psychological state and improving enthusiasm of disease management among patients with ILD. Relevant studies have reported that anxiety and depression are significantly associated with insufficient social support and disease uncertainty in patients with ILD[19,20]. As a core indicator of patients’ active participation in disease management, positivity may alleviate psychological stress by enhancing self-efficacy and reducing helplessness[21]. In addition, the negative correlation between positive degree and cognitive, behavioral, belief, and skill dimensions suggests that patients’ disease knowledge, self-care behavior, and confidence in treatment goals can help reduce psychological distress. Vandenbos et al’s study[22] on pulmonary rehabilitation found that the improvement in pulmonary function was accompanied by a significant decrease in anxiety and depression scores. Thus, active participation in the pulmonary rehabilitation process could improve psychological state through physiological and psychological mechanisms.
Multiple linear regression analysis revealed that the education level, dyspnea degree, PSSS score, and PAM score were independent factors that influenced psychological distress in patients with ILD (P < 0.05). Extant studies have shown that patients with higher education levels tend to have higher levels of health literacy, can more accurately understand and apply disease-related information, are more proactive in communicating with doctors, can more effectively obtain and understand the doctor’s advice, and have a stronger sense of self-efficacy[23]. These factors allow patients to learn more about the disease, have a higher level of awareness of the disease, be more likely to accept knowledge education, improve bad living habits, improve compliance behavior, and are easier to cooperate with treatment, and be more mentally healthy[23]. Conversely, patients with lower education levels may have understanding obstacles when communicating with doctors due to their limited ability to obtain disease information and relatively low health literacy. Moreover, their self-efficacy is weak, which is more likely to make them misunderstand the treatment and lead to increased psychological distress. In clinical practice, patients with ILD with lower education levels should strengthen their disease-related knowledge, improve compliance behavior, and reduce depression. The more severe the degree of dyspnea is, the higher is the patient’s depression score. This result was consistent with those of previous studies possibly because dyspnea is accompanied by subjective symptom perception during the different stages[24,25]. Patients may regard the degree of dyspnea as a main indicator of disease severity. It can also affect the patient’s judgment of disease severity. Patients may associate the severity of dyspnea with serious consequences of the disease, forming a vicious circle. Studies have revealed that respiratory discomfort exceeds a certain threshold and is prone to emotional reactions such as anxiety or depression. These may be related to increased activation of the marginal and paramarginal centers in the brain and excessive activation of the sympathetic nervous system[26]. Therefore, health knowledge education and certain functional exercises is essential so that patients can better understand the relationship between dyspnea and the disease. Furthermore, they can improve their degree of dyspnea through functional exercise. Previous studies have shown that simple Tai Chi exercises and other interventions[27,28] can significantly improve dyspnea in patients with chronic obstructive pulmonary disease (COPD). Given that ILD and COPD are both chronic respiratory diseases and share certain similarities in symptom manifestation, with dyspnea being a primary symptom in both cases, the improvement effect of simple Tai Chi exercises on dyspnea in patients with ILD remains to be further confirmed through research. PSSS refers to external resources that patients can access. For both ILD and COPD patients, the level of social support plays a crucial role. Patients with COPD with good social support can receive relatively abundant material and spiritual support from family, friends, colleagues, or the surrounding community. As a result, when facing the disease, they are more inclined to adopt a positive attitude in coping with it, resulting in a lower level of psychological distress. By contrast, COPD patients with low social support receive less care and support from their families or the outside world, having to confront the disease on their own. Over time, they are highly likely to develop negative emotions such as pessimism, depression, and loneliness, as well as experience severe psychological distress[29,30]. Similarly, patients with ILD with good social support are also likely to receive comparable positive impacts, gaining more support to deal with the disease and reducing their level of psychological distress. Conversely, those with low social support may face a higher risk of psychological distress. However, this still requires more research specifically targeting patients with ILD for further verification. Nursing staff should communicate with patients’ family members, inform them on how to accompany and care for the patient, talk to the patient regarding the topics they are interested in, guide the patient to recall past beautiful things to stimulate confidence in treatment. This can promote the patients to actively respond to the disease, which may reduce their psychological distress level.
In this study, the RCS model analysis revealed that the PAM score had a negative linear relationship with the K10 score (P for overall < 0.001). The degree of psychological distress decreased significantly for every unit increase in the patients’ positive degree. To further explain the clinical relevance of this dose-response relationship, it is necessary to interpret it in combination with the consensus of the minimum clinically important difference value, that is, a PAM score increase ≥ 4 points is usually considered clinically significant[31], while a K10 score reduction ≥ 5 points is often regarded as the threshold for meaningful relief of psychological distress[15]. This finding provides a quantitative basis for clinical intervention, that is, through health education, self-management skills training and other intervention measures, the patient’s positive degree can be improved with clinical significance, so as to achieve substantial relief of psychological distress. In addition, the non-linear test result was not significant (P for non-linear = 0.188), suggesting that the relationship between positivity and psychological distress was stable and not significantly affected by other unmeasured factors.
Although this study revealed a correlation between positivity and psychological distress in patients with ILD, there are still limitations as follows. First, the cross-sectional design of a single center makes it difficult to determine causal relationships. Future studies should conduct multicenter longitudinal studies to dynamically track the long-term impact of changes in positivity on psychological distress. Second, this study adopted convenience sampling and, while the sample size is adequate, sample representativeness remains limited. Only the patients in the respiratory Department of Respiratory of one hospital were selected, while the characteristics of patients with ILD in different regions and hospital levels of hospitals might differ. Moreover, the characteristics of the patients in our hospital may be difficult to represent the whole. Convenience sampling may make included patients’ treatment time and disease type concentrated, such as more patients with stable condition and regular follow-up, while ignoring patients with serious condition and irregular visit, so that the results are biased. However, the research process strictly screened patients and considered confounding factors in the analysis to reduce the impact. Furthermore, this study analyzes ILD as a whole and did not subdivide the positivity and psychological distress of patients with different ILD subtypes. Different ILD subtypes have differences in etiology, pathophysiological mechanism and clinical manifestations, which may have different effects on the psychological state of patients. Follow-up studies can further refine the grouping for analysis or include disease subtypes as regulatory variables in the study.
CONCLUSION
Positivity is negatively correlated with psychological distress in patients with ILD. Clinically, structured measures can be taken to address patients’ psychological distress: Embed the simplified K10 or PAM in the electronic follow-up system, regularly collect and analyze data to identify patients with potential psychological problems, set reasonable thresholds and trigger referral to the psychiatry department when the standards are exceeded, and train respiratory nurses to master brief psychological support techniques and provide timely psychological care to patients. By enhancing coping training to improve positive coping, the prognosis of patients can be improved.
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