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Mental Health Effects from Urban Bed Bug Infestation (Cimex Lectularius L.): a Cross-Sectional Study

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BMJ Open: first published as 10.1136/bmjopen-2012-000838 on 25 September 2012. Downloaded from Open Access Research Mental health effects from urban bed bug infestation (Cimex lectularius L.): a cross-sectional study Stephanie Rebecca Susser,1,2 Stéphane Perron,1,2,3 Michel Fournier,2 Louis Jacques,1,2 Geoffroy Denis,2 François Tessier,2 Pasquale Roberge4 To cite: Susser SR, Perron S, ABSTRACT et al ARTICLE SUMMARY Fournier M, . Mental Objective: To assess whether bed bug infestation was health effects from urban bed linked to sleep disturbances and symptoms of anxiety bug infestation (Cimex Article focus and depression. lectularius L.): a cross- ▪ Infestations with the common bed bug (Cimex sectional study. BMJ Open Design: Exploratory cross-sectional study. lectularius L.) have become problematic in many 2012;2:e000838. Setting: Convenience sample of tenants recruited in cities. doi:10.1136/bmjopen-2012- apartment complexes from Montreal, Canada. ▪ No epidemiological studies currently exist on the 000838 Participants: 39 bed bug-exposed tenants were mental health impacts of bed bug infestations. compared with 52 unexposed tenants. ▪ In this exploratory cross-sectional analysis, we ▸ Prepublication history for Main outcome measures: The effect of bed bug- assessed whether bed bug infestations were this paper are available exposed tenants on sleep disturbances, anxiety and linked to sleep disturbances and symptoms of online. To view these files depression symptoms measured using the Pittsburgh anxiety and depression among tenants in please visit the journal online Sleep Quality Index, 5th subscale, Generalised Anxiety Montreal, Quebec. (http://dx.doi.org/10.1136/ Disorder 7-item scale and Patient Health Questionnaire, bmjopen-2012-000838). Key messages 9-item, respectively. ▪ This study suggests that individuals exposed to Received 6 January 2012 Results: In adjusted models, bed bug infestation was bed bugs may be at risk of experiencing sleep Accepted 17 April 2012 strongly associated with measured anxiety symptoms disturbance and of developing anxious and pos- (OR (95% CI)=4.8 (1.5 to 14.7)) and sleep disturbance sibly depressive symptoms. This final article is available – (OR (95% CI)=5.0 (1.3 18.8)). There was a trend to ▪ Appropriate control of bed bug is required to for use under the terms of report more symptoms of depression in the bed bug- the Creative Commons manage the situation and its potential health http://bmjopen.bmj.com/ infested group, although this finding was not impacts. Attribution Non-Commercial statistically significant ((OR (95% CI)=2.5(0.8 to 7.3)). 2.0 Licence; see http://bmjopen.bmj.com Conclusions: These results suggest that individuals Strengths and limitations of this study exposed to bed bug infestations are at risk of ▪ The convenience sample presents a risk for experiencing sleep disturbance and of developing selection bias. symptoms of anxiety and possibly depression. Greater ▪ There is a possibility of misclassification biases clinical awareness of this problem is needed in order due to self-report even though the Cronbach α for patients to receive appropriate mental healthcare. values calculated from our data showed remark- These findings highlight the need for undertaking of able consistency with literature values for the ori- on September 24, 2021 by guest. Protected copyright. deeper inquiry, as well as greater collaboration between ginal instruments. medical professionals, public health and community ▪ These results are cross-sectional in nature and stakeholders. follow-up studies are required. 1Département de médecine sociale et préventive, be exterminated rapidly but extermination Université de Montréal, Montréal, Québec, Canada techniques are complex. In some settings bed 4 2Direction de santé publique INTRODUCTION bug infestation may become chronic. de l’agence de la santé et des Adult bed bugs are 4–6 mm long, oval and flat- Anecdotal and historical evidence suggests services sociaux de Montréal, tened insects that feed on human blood. that infestation by the common bed bug Montréal, Québec, Canada Cimex lectularius 3 Feeding sessions typically last 15 min and are ( L.) may be a stressor that Département de médecine 3 de famille, Université de followed by the departure of the bug towards has an emotional and psychological effect. Sherbrooke CHUS-Hôpital its harbourage site. Once fed, bed bugs do not Field workers and pest control managers in Fleurimont, Sherbrooke, remain attached to their prey.1 Bed bug bites, Montreal,5 Toronto4 and in 43 countries Québec, Canada. like mosquito bites are associated with local around the globe surveyed by the National 2 Correspondence to cutaneous allergic reactions. To date, there Pest Management Association have observed Dr Stéphane Perron; have been no reports of infectious disease psychological distress among individuals 6 [email protected] transmission via bed bug bites.23Bed bugs can living with infestation. There are reports of Susser SR, Perron S, Fournier M, et al. BMJ Open 2012;2:e000838. doi:10.1136/bmjopen-2012-000838 1 BMJ Open: first published as 10.1136/bmjopen-2012-000838 on 25 September 2012. Downloaded from Mental health effects from urban bed bug infestation people resorting to dangerous methods in order to rid other housing complexes is only recommended in cases their dwellings of bed bugs.7 Recently, Goddard and de where tenants experience a significant negative health Shazo8 noted that comments posted on bed bug-related impact due to water infiltration. Participants were recruited websites revealed symptoms of post-traumatic stress dis- from the two Montreal apartment complexes who were order. None of these studies, however, were performed subject to public health interventions targeting unfit in a clinical setting and there are currently no original housing conditions led by the MPH Department and their published epidemiological data available on the mental community partners between January and June 2010. This health impact of bed bug infestation. The objective of cross-sectional study is based on data provided by a con- this study was to conduct an exploratory cross-sectional venience sample of 91 tenants recruited. All participants analysis comparing individuals living with and without agreed to allow the data they provided to be used for bed bug infestations using three standardised clinical research purposes. mental health measures. Physicians and nurses familiar with unfit housing condi- tions and infestations collected all data. Culturally and lin- guistically competent translators were available and all METHODS questionnaire material was available in English, French Data collection and measures and Spanish. Ethical approval was provided by the research Unfit housing conditions due to water infiltration, mould ethics committee of the Montreal Agency for Health and and vermin infestation are frequently reported to the Social Services. The research has conformed to the princi- Montreal Public Health Department (MPH). Decision to ples embodied in the Declaration of Helsinki. intervene in such situations is taken by the environmental Data were obtained from an intervention health ques- health team that includes physicians and an experienced tionnaire. Symptoms of depression and anxiety were evalu- hygienist. The aim of field intervention, when mandated, is ated using the Brief Patient Health Questionnaire Mood to produce recommendations for remediation of the build- Scale (PHQ-9)9 and the Generalised Anxiety Disorder ings involved and to ensure healthcare for tenants who Screener (GAD-7)10 whicharebasedoncriteriafromthe may require attention. However, relocation of tenants to Diagnostic and Statistical Manual of Mental Disorders http://bmjopen.bmj.com/ on September 24, 2021 by guest. Protected copyright. Figure 1 Algorithm for attribution of a diagnosis of bed bug infestation based on the presence of characteristic lesions and environmental evidence. 2 Susser SR, Perron S, Fournier M, et al. BMJ Open 2012;2:e000838. doi:10.1136/bmjopen-2012-000838 BMJ Open: first published as 10.1136/bmjopen-2012-000838 on 25 September 2012. Downloaded from Mental health effects from urban bed bug infestation Figure 2 Participant flowchart. http://bmjopen.bmj.com/ (DSM)-IV and DSM-IV-TR, respectively. Sleep disturbances the unexposed group. Scores for the three instruments were measured using questions 1–8(5thsubscale)ofthe were dichotomised into ‘present/absent’. Scores corre- Pittsburgh Sleep Quality Index.11 Bed bug exposure status sponding to symptoms ‘present’ were: 10 and over on the was initially determined by self-report; participants were PHQ-9 of 27, (moderate symptoms of depression or asked to point to the culprit insect on an identification worse), 5 and over on the GAD-7 of 21(mild symptoms of tool containing pictures of bed bugs and other commonly anxiety or worse) and 10 and over 27 on the PSQI 5th sub- found insects in Montreal apartment buildings. Details scale. For any given participant, data from the GAD-7 or related to infestation (onset, corrective measures taken) PHQ-9weredisregardedifthreeormoreitemswereleft on September 24, 2021 by guest. Protected copyright. were recorded. This subjective evidence was supported by blank. Missing values for these scales were replaced with objective dermatological and/or environmental evidence the mean scores of the other subjects’ items response if the of infestation when available (figure 1). Individuals with number of missing responses was less than 3. past bed bug exposure—but
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