Health care costs in persons with asthma and comorbid mental disorders: a systematic review

Factors associated with physical and psychological wellness of American adults with asthma

Objective: The study objective was to investigate the factors associated with the physical and psychological wellness of United States (US) adults with asthma.Methods: This cross-sectional analysis used a sample of 2329 US adults with asthma in the 2021 Medical Expenditure Panel Survey data. A logistic regression model investigated the association of the following factors and the dependent variables (physical wellness and psychological wellness): age, sex, race, ethnicity, education, employment, healthcare provision, marriage, income, regular physical activity, current smoker, pain, and limitations. Nationally representative estimates were produced through a weighted analysis. The data structure was maintained using cluster and strata variables. The alpha limit was 0.05.Results: Factors associated with higher odds of reporting good physical wellness included: private (versus no) healthcare provision (odds ratio [OR] = 2.63, 95% confidence interval [CI] = 1.10-6.26), good (versus poor) psychological wellness (OR = 6.83, 95% CI = 4.35-10.72), regular (versus no regular) physical activity (OR = 2.18, 95% CI = 1.42-3.34), little/moderate (versus quite a bit/extreme) pain (OR = 3.51, 95% CI = 2.38-5.15) and no (versus any) limitation (OR = 3.73, 95% CI = 2.30-6.06). In the psychological wellness model, those aged ≥70 (OR = 6.18, 95% CI = 2.72-14.07), 60-69 (OR = 4.64, 95% CI = 2.13-10.10), and 50-59 (OR = 4.96, 95% CI = 2.24-11.02) versus those aged 18-29, and good (versus poor) physical wellness (OR = 6.89, 95% CI = 4.34-10.94) were associated with higher odds of reporting good versus poor psychological wellness.Conclusion: These results may be helpful at targeting resources to optimize the wellness of US adults with asthma. Additional studies are needed to determine any temporal associations between these findings.

Outpatient Psychotherapy in Germany

BACKGROUND

A structural reform of the German psychotherapy guideline in 2017 was intended to facilitate access to outpatient guideline psychotherapy. In the present study, we evaluate the effects of this reform in particular for patients with a comorbidity of mental disorders and chronic physical conditions (cMP).

METHODS

Pre-post analyses of the two primary endpoints "percentage of mentally ill persons who have made an initial contact with a psychotherapist" and "waiting time for guideline psychotherapy" were carried out employing population-based and weighted routine statutory health insurance data from the German BARMER. The secondary endpoints included evaluations from the patients' perspective, based on a representative survey of patients in psychotherapy, and an overview of the health care situation based on data from the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, KBV) (study registration number: DRKS00020344).

RESULTS

From 2015 to 2018, the percentage of mentally ill persons who had made an initial contact with a psychotherapist rose moderately, from 3.7% (95% confidence interval, [3.6; 3.7]) to 3.9% [3.8; 3.9] among persons with cMP and from 7.3% [7.2; 7.4] to 7.6% [7.5; 7.7] among those with mental disorders but without any chronic physical condition (MnoP). The new structural elements were integrated into patient care. The interval of time between the initial contact and the beginning of guideline psychotherapy became longer in both groups, from a mean of 80.6 [79.4; 81.8] to 114.8 [113.4; 116.2] days among persons with complex disease and from 80.2 [79.2; 81.3] to 109.6 [108.4; 111.0] days among persons with non-complex disease; most patients considered the waiting time. Approximately 8% of the patients who sought psychotherapy reported that they had not obtained access to a psychotherapist.

CONCLUSION

Neither in general nor for patients with cMP did the introduction of the structural reform appreciably lower the access barriers to psychotherapy. Further steps are needed so that outpatient care can meet the needs of all patients and particularly those with cMP.

Exploring the relationship between asthma, its severity and anxiety symptoms in pediatric patients: a case-control study

BACKGROUND

Asthma is a global health concern, especially among children, and is associated with various underlying mechanisms. Childhood exposure to early life stress and anxiety can potentially exacerbate asthma symptoms and complicate its management. While some studies have suggested the benefits of psychological therapies as adjuncts to medication in asthma management, evidence remains inconsistent, emphasizing the need for rigorous evaluation.

METHOD

This case-control study involved 120 children aged 5-15, with 60 children having asthma and 60 healthy controls. Asthma severity was assessed based on EPR3 guidelines, while anxiety symptoms were measured using the Spence Children's Anxiety Scale (SCAS). Demographic data and asthma-related information were collected via questionnaires. Statistical analyses were conducted to explore the relationship between asthma and anxiety.

RESULTS

Children with asthma exhibited significantly higher anxiety symptoms compared to those without asthma (p < 0.001). Subdomain analysis revealed elevated scores in separation anxiety (SA; p = 0.025), social phobia (SP; p < 0.001), agoraphobia (p = 0.004), and fears of physical injury (p < 0.001) in children with asthma. Furthermore, increased need for SABA, frequency of nocturnal symptoms, and asthma severity were associated with higher anxiety levels in pediatric asthma patients.

CONCLUSIONS

This study highlights a significant association between asthma and heightened anxiety symptoms in children, particularly in domains, such as SA, SP, agoraphobia, and fears related to physical injury. However, limitations include reliance on self-evaluation questionnaires and the observational nature of the study, emphasizing the need for cautious interpretation.

Association between asthma and generalized anxiety disorder-7 (GAD-7) in Korean adolescents

BACKGROUND

Asthma is known to be associated with a variety of psychological disorders, such as anxiety, but the association between adolescent asthma and anxiety has not been investigated in detail.

METHODS

We analyzed 2,322 physician-diagnosed adolescent asthma patients and 38,696 non-asthmatic adolescent participants from the 2020 Korean Youth Risk Behavior self-administered Survey. Anxiety status was assessed using the Generalized Anxiety Disorder-7 (GAD-7) questionnaires. Multiple logistic regression analyses with complex sampling was performed with adjustments for multiple confounding variables (socioeconomic, health behavior, and psychological factors) to explore the association between GAD-7 scores and adolescent asthma.

RESULTS

The asthma group had higher rates of anxiety (GAD-7 score ≥ 10) than the non-asthma group (5.0% and 6.7%, respectively; p < 0.001). After adjustment for multiple confounders, asthma was significantly associated with an increased risk of anxiety (GAD-7 score ≥ 10) (odds ratio [OR]: 1.09; 95% confidence interval [CI]: 1.06-1.12).

CONCLUSION

Asthma is associated with an increased prevalence of anxiety in Korean adolescents.

The health care cost of comorbidity in individuals with mental disorders: A Danish register-based study

AIM

The aim of the study was to estimate the annual health care cost by number of comorbid mental and somatic disorders in persons with a mental disorder.

METHODS

All persons living in Denmark between 2004 and 2017 with a hospital diagnosis of a mental disorder were identified. We investigated the cost of different health care services: psychiatric hospitals, somatic hospitals, primary health care (e.g. general practitioners, psychologists and so on) and subsidised prescriptions. Within those with at least one mental disorder, we examined the costs for people with (a) counts of different types of mental disorders (e.g. exactly 1, exactly 2 and so on up to 8 or more) and (b) counts of different types of somatic disorders (e.g. no somatic disorders, exactly 1, exactly 2 and so on up to 15 or more). The estimates are reported in average cost per case and nationwide annual cost in Euro 2017.

RESULTS

In total, 447,209 persons (238,659 females and 208,550 males) were diagnosed with at least one mental disorder in the study period. The average annual health care cost per case and nationwide cost was 4471 Euros and 786 million Euro, respectively, for persons with exactly one mental disorder, and 33,273 Euro and 3.6 million Euro for persons with eight or more mental disorders. The annual health care cost was 4613 Euro per case and 386 million Euro for persons without any somatic disorders, while the cost per case was 16,344 Euro and 0.7 million Euro in nationwide cost for persons with 15 or more disorders. The amount and proportion of the different health care costs varied by type of comorbidity and count of disorders.

CONCLUSIONS

The annual health care cost per case was higher with increasing number of comorbid mental and somatic disorders, while the nationwide annual health care cost was lower with increasing number of comorbid disorders for persons with a mental disorder in Denmark.

Evaluating effects of the structural reform of outpatient psychotherapy for patients with mental disorders in Germany: comparing patients with and without comorbid chronic physical condition - rationale and study protocol of the ES-RiP project

INTRODUCTION

In 2017, in Germany, a structural reform of the outpatient psychotherapy guideline took place, aiming to reduce waiting times, to facilitate flexible low-threshold access (eg, general reachability by phone) and to lower access barriers for specific patient groups. The reform included new service elements, such as the implementation of additional psychotherapeutic consultations, acute short-term psychotherapeutic interventions and relapse prophylaxis as well as the promotion of group therapies, the facilitation of psychotherapists' availability, and the installation of appointment service centres. The ES-RiP project aims to thoroughly evaluate the effects of the reform with a special focus on patients with a comorbidity of mental disorders and chronic physical conditions (cMPs) compared with patients with a mental disorder but no long-term physical condition (MnoP). The project aims to evaluate (a) the extent to which the reform goals were achieved in the large group of patients with cMPs compared with MnoP, (b) the barriers that might hinder the implementation of the new guideline and (c) the procedures required for further developing and improving outpatient psychotherapy.

METHODS AND ANALYSIS

A mixed-methods design (quantitative, qualitative) along with a multilevel approach (patients, service providers, payers) triangulating several data sources (primary and secondary data) will be applied to evaluate the reform from different perspectives.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the coordinating committee as well as one local ethics committee, Justus Liebig University Giessen and Marburg - Faculty of Medicine (approval number: AZ 107/20) and Heidelberg (approval number: S-466/2020). The results of this study will be disseminated through expert panels, conference presentations and publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

DRKS00020344.

Prevention of depression in adults with long-term physical conditions

BACKGROUND

Major depression is one of the world's leading causes of disability in adults with long-term physical conditions compared to those without physical illness. This co-morbidity is associated with a negative prognosis in terms of increased morbidity and mortality rates, increased healthcare costs, decreased adherence to treatment regimens, and a substantial decline in quality of life. Therefore, preventing the onset of depressive episodes in adults with long-term physical conditions should be a global healthcare aim. In this review, primary or tertiary (in cases of preventing recurrences in those with a history of depression) prevention are the focus. While primary prevention aims at preventing the onset of depression, tertiary prevention comprises both preventing recurrences and prohibiting relapses. Tertiary prevention aims to address a depressive episode that might still be present, is about to subside, or has recently resolved. We included tertiary prevention in the case where the focus was preventing the onset of depression in those with a history of depression (preventing recurrences) but excluded it if it specifically focused on maintaining an condition or implementing rehabilitation services (relapse prevention). Secondary prevention of depression seeks to prevent the progression of depressive symptoms by early detection and treatment and may therefore be considered a 'treatment,' rather than prevention. We therefore exclude the whole spectrum of secondary prevention.

OBJECTIVES

To assess the effectiveness, acceptability and tolerability of psychological or pharmacological interventions, in comparison to control conditions, in preventing depression in adults with long-term physical conditions; either before first ever onset of depressive symptoms (i.e. primary prevention) or before first onset of depressive symptoms in patients with a history of depression (i.e. tertiary prevention).

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register, CENTRAL, MEDLINE, Embase, PsycINFO and two trials registries, up to 6 February 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of preventive psychological or pharmacological interventions, specifically targeting incidence of depression in comparison to treatment as usual (TAU), waiting list, attention/psychological placebo, or placebo. Participants had to be age 18 years or older, with at least one long-term physical condition, and no diagnosis of major depression at baseline (primary prevention). In addition, we included studies comprising mixed samples of patients with and without a history of depression, which explored tertiary prevention of recurrent depression. We excluded other tertiary prevention studies. We also excluded secondary preventive interventions. Primary outcomes included incidence of depression, tolerability, and acceptability. Secondary outcomes included severity of depression, cost-effectiveness and cost-utility.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 11 RCTs, with one trial on psychological interventions, and 10 trials on pharmacological interventions. Data analyses on the psychological intervention (problem-solving therapy compared to TAU) included 194 participants with age-related macular degeneration. Data analyses on pharmacological interventions included 837 participants comparing citalopram (one trial), escitalopram (three trials), a mixed sample of fluoxetine/nortriptyline (one trial), melatonin (one trial), milnacipran (one trial), and sertraline (three trials), each to placebo. Included types of long-term physical conditions were acute coronary syndrome (one trial), breast cancer (one trial), head and neck cancer (two trials), stroke (five trials), and traumatic brain injury (one trial). Psychological interventions Very low-certainty evidence of one study suggests that problem solving therapy may be slightly more effective than TAU in preventing the incidence of depression, immediately post-intervention (odds ratio (OR) 0.43, 95% confidence interval (CI) 0.20 to 0.95; 194 participants). However, there may be little to no difference between groups at six months follow-up (OR 0.71, 95% CI 0.36 to 1.38; 190 participants; one study; very low-certainty evidence). No data were available regarding incidence of depression after six months. Regarding acceptability (drop-outs due to any cause), slightly fewer drop-outs occurred in the TAU group immediately post-intervention (OR 5.21, 95% CI 1.11 to 24.40; 206 participants; low-certainty evidence). After six months, however, the groups did not differ (OR 1.67, 95% CI 0.58 to 4.77; 206 participants; low-certainty evidence). This study did not measure tolerability. Pharmacological interventions Post-intervention, compared to placebo, antidepressants may be beneficial in preventing depression in adults with different types of long-term physical conditions, but the evidence is very uncertain (OR 0.31, 95% CI 0.20 to 0.49; 814 participants; nine studies; I2 =0%; very low-certainty evidence). There may be little to no difference between groups both immediately and at six months follow-up (OR 0.44, 95% CI 0.08 to 2.46; 23 participants; one study; very low-certainty evidence) as well as at six to 12 months follow-up (OR 0.81, 95% CI 0.23 to 2.82; 233 participants; three studies; I2 = 49%; very low-certainty evidence). There was very low-certainty evidence from five studies regarding the tolerability of the pharmacological intervention. A total of 669 adverse events were observed in 316 participants from the pharmacological intervention group, and 610 adverse events from 311 participants in the placebo group. There was very low-certainty evidence that drop-outs due to adverse events may be less frequent in the placebo group (OR 2.05, 95% CI 1.07 to 3.89; 561 participants; five studies; I2 = 0%). There was also very low-certainty evidence that drop-outs due to any cause may not differ between groups either post-intervention (OR 1.13, 95% CI 0.73 to 1.73; 962 participants; nine studies; I2 = 28%), or at six to 12 months (OR 1.13, 95% CI 0.69 to 1.86; 327 participants; three studies; I2 = 0%).

AUTHORS' CONCLUSIONS

Based on evidence of very low certainty, our results may indicate the benefit of pharmacological interventions, during or directly after preventive treatment. Few trials examined short-term outcomes up to six months, nor the follow-up effects at six to 12 months, with studies suffering from great numbers of drop-outs and inconclusive results. Generalisation of results is limited as study populations and treatment regimes were very heterogeneous. Based on the results of this review, we conclude that for adults with long-term physical conditions, there is only very uncertain evidence regarding the implementation of any primary preventive interventions (psychological/pharmacological) for depression.

Greater length of stay and hospital charges for severe asthma in children with depression or anxiety

RATIONALE

Asthma is one of the most common chronic disorders of childhood and is associated with significant healthcare utilization and costs. Comorbid psychiatric illnesses, specifically depression and anxiety, are more prevalent in patients with asthma and associated with worse asthma control, more emergency department visits, and increased hospitalization rates.

OBJECTIVES

We aimed to compare hospital outcomes and charges for children with severe asthma with and without comorbid depression and anxiety, hypothesizing that those with depression and anxiety would have longer hospitalizations and higher charges.

METHODS

Retrospective review of the 2000-2012 Healthcare Cost and Utilization Project's Kids' Inpatient Databases for admissions of patients aged 10-21 years with an ICD-9 code severe asthma (status asthmaticus or any asthma diagnosis with a procedure code for endotracheal intubation). Depression and Anxiety subgroups were created based on ICD-9 codes. Data collected included demographics, hospital outcomes and charges and comparisons made between groups.

RESULTS

There were 52,485 admissions for severe asthma: 45,094 (86%) with No Comorbid Psychiatric Illnesses, 1284 (2.4%) with depression, and 1297 (2.5%) with anxiety. Patients with depression or anxiety were older, had longer hospitalizations, and higher hospital charges (p < .001 for all).

CONCLUSIONS

Comorbid depression or anxiety is associated with significantly longer hospitalizations and higher charges for children with severe asthma. These findings add to prior reports of worse outcomes for children with asthma and comorbid depression or anxiety and suggest that improved screening for and management of these conditions in children with asthma could improve hospital outcomes and reduce costs.

How does the integration of collaborative care elements in a gatekeeping system affect the costs for mental health care in Germany?

Mental disorders are widespread, debilitating and associated with high costs. In Germany, usual care (UC) for mental disorders is afflicted by poor coordination between providers and long waiting times. Recently, the primary alternative to UC-the gatekeeping-based general practitioners (GP) program-was extended by the collaborative Psychiatry-Neurology-Psychotherapy (PNP) program, which is a selective contract designed to improve mental health care and the allocation of resources. Here, we assess the effects of the GP program and the PNP program on costs for mental health care. We analyzed claims data from 2014 to 2016 of 55,472 adults with a disorder addressed by PNP to compare costs and sick leave days between PNP, the GP program and UC. The individuals were grouped and balanced via entropy balancing to adjust for potentially confounding covariates. We employed a negative binomial model to compare sick leave days and two-part models to compare sick pay, outpatient, inpatient and medication costs over a 12-month period. The PNP program significantly reduced sick pay by 164€, compared to UC, and by 177€, compared to the GP program. Consistently, sick leave days were lower in PNP. We found lower inpatient costs in PNP than in UC (-194€) and in the GP program (-177€), but no reduction in those shares of inpatient costs that accrued in psychiatric or neurological departments. Our results suggest that integrating collaborative care elements in a gatekeeping system can favourably impact costs. In contrast, we found no evidence that the widely implemented GP program reduces costs for mental health care.

Antidepressant Target Dose Optimization and Control of Severe Asthma Exacerbations in Uninsured and Underinsured Patients with Anxiety and/or Depression

BACKGROUND

Generalized anxiety disorder (GAD) and major depressive disorder (MDD) are prevalent in patients with asthma. These disorders may increase asthma severity and decrease asthma control. No studies have evaluated the impact of achieving antidepressant target dose optimization compared with not achieving antidepressant target doses on asthma control in uninsured and underinsured patients.

OBJECTIVE

To evaluate the impact of achieving antidepressant target dose optimization in uninsured and underinsured adult asthma patients with GAD and/or MDD on the risk of severe asthma exacerbations and number of asthma-related outcomes.

METHODS

We conducted a retrospective cohort study of uninsured and underinsured adult asthma patients with GAD and/or MDD who have been initiated on a single antidepressant and maintained on a stable dose for 8 weeks (index date). Eligible patients were followed for 12-24 months after the index date and separated into those who achieved a target dose (target group) and those who did not (control group). Poisson regression was used to compare the risk of severe exacerbations, and analysis of covariance was used to compare the number of severe exacerbations and other asthma-related outcomes between the target and control groups during the 1- and 2-year post-index periods.

RESULTS

A total of 61 patients (24 in the target group and 37 in the control group) met inclusion criteria. The target group had a reduced risk of severe asthma exacerbations compared with the control group during the 1-year post-index (adjusted risk reduction [RR] 0.46, 95% confidence interval [CI] 0.26-0.82) and 2-year post-index (adjusted RR 0.5, 95% CI 0.3-0.82) periods. The target group also experienced a lower number of severe asthma exacerbations and other asthma-related outcomes during the 1- and 2-year post-index periods compared with the control group after adjusting for confounders.

CONCLUSIONS

Among uninsured and underinsured asthma patients with GAD and/or MDD who were initiated on a single antidepressant, those who were titrated to achieve target doses had a reduced risk of severe asthma exacerbations and a lower number of asthma-related outcomes than those who were not optimized to achieve target doses.

Association of Mental Health Disorders With Health Care Utilization and Costs Among Adults With Chronic Disease

IMPORTANCE

A population-based study using validated algorithms to estimate the costs of treating people with chronic disease with and without mental health disorders is needed.

OBJECTIVE

To determine the association of mental health disorders with health care costs among people with chronic diseases.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study in the Canadian province of Alberta collected data from April 1, 2012, to March 31, 2015, among 991 445 adults 18 years and older with a chronic disease (ie, asthma, congestive heart failure, myocardial infarction, diabetes, epilepsy, hypertension, chronic pulmonary disease, or chronic kidney disease). Data analysis was conducted from October 2017 to August 2018.

EXPOSURES

Mental health disorder (ie, depression, schizophrenia, alcohol use disorder, or drug use disorder).

MAIN OUTCOMES AND MEASURES

Resource use, mean total unadjusted and adjusted 3-year health care costs, and mean total unadjusted 3-year costs for hospitalization and emergency department visits for ambulatory care-sensitive conditions.

RESULTS

Among 991 445 participants, 156 296 (15.8%) had a mental health disorder. Those with no mental health disorder were older (mean [SD] age, 58.1 [17.6] years vs 55.4 [17.0] years; P < .001) and less likely to be women (50.4% [95% CI, 50.3%-50.5%] vs 57.7% [95% CI, 57.4%-58.0%]; P < .001) than those with mental health disorders. For those with a mental health disorder, mean total 3-year adjusted costs were $38 250 (95% CI, $36 476-$39 935), and for those without a mental health disorder, mean total 3-year adjusted costs were $22 280 (95% CI, $21 780-$22 760). Having a mental health disorder was associated with significantly higher resource use, including hospitalization and emergency department visit rates, length of stay, and hospitalization for ambulatory care-sensitive conditions. Higher resource use by patients with mental health disorders was not associated with health care presentations owing to chronic diseases compared with patients without a mental health disorder (chronic disease hospitalization rate per 1000 patient days, 0.11 [95% CI, 0.11-0.12] vs 0.06 [95% CI, 0.06-0.06]; P < .001; overall hospitalization rate per 1000 patient days, 0.88 [95% CI, 0.87-0.88] vs 0.43 [95% CI, 0.43-0.43]; P < .001).

CONCLUSIONS AND RELEVANCE

This study suggests that mental health disorders are associated with substantially higher resource utilization and health care costs among patients with chronic diseases. These findings have clinical and health policy implications.

[Influence of post-traumatic stress disorder on asthma]

INTRODUCTION

Exposure to a traumatic event may not only lead to a large variety of mental disorders, such as post-traumatic stress disorder (PTSD) but also respiratory symptoms and/or respiratory diseases, as asthma.

OBJECTIVES

Systematic literature review of data on the impact of post-traumatic stress disorder on asthma.

DOCUMENTARY SOURCES

Medline, on the period 1980-2018 with the following keywords: "PTSD" or "post-traumatic stress disorder" or "post-traumatic stress disorder" and "asthma", limits "title/abstract"; the selected languages were English or French. Among 141 articles, 23 abstracts have given use to a dual reading to select 14 studies.

RESULTS

While PTSD may develop 4 weeks after being exposed to a traumatic event during which the physical integrity of the person has been threatened, it might also develop several months or years later. PTSD has been reported to be a risk factor for asthma and also a factor that might enhance a preexisting asthma. It is also important to note that this relation has been highlighted among several populations, traumatic events and regardless the gender and/or cultural factors. Despite its impact on the development of asthma, in asthmatic patients, PTSD may be responsible for poor asthma control, increased rates of healthcare use (visit in the emergency department and/or hospitalization for asthma) and poor asthma-related quality of life. The study of the association between PTSD and asthma have to take into account some potentially confounding factors, such as smoking status and dust exposure (e.g.: asthma following the terrorist attacks of the World Trade Center). Less is known regarding the potential mechanisms involved in the association between PTSD and asthma. Several factors including the nervous system, the hypothalamo-pituitary-adrenal axis, the inflammatory response and the immune system may explain the association.

CONCLUSION

PTSD is a risk factor for the development of asthma and for the worsening of preexisting asthma. In asthmatic patients, it is of primary importance to systematically screen potential PTSD that might be developed after a traumatic event or a preexisting traumatic condition. Moreover, after exposure to a traumatic event, a special attention needs to be paid to somatic reactions such as asthma. The majority of studies having been conducted on American samples, replicating studies among European samples appears of prime importance in order to add a body of knowledge on the association between somatic and psychiatric conditions.

Nonallergic Triggers and Comorbidities in Asthma Exacerbations and Disease Severity

Asthma triggers are exogenous or endogenous factors that could worsen asthma acutely to cause an exacerbation, or perpetuate chronic symptoms and airflow limitation. Because it is well known that recent asthma exacerbations and poor symptom control are strong predictors of future disease activity, it is not surprising that the number of (allergic or nonallergic) asthma triggers in the environment correlates with the disease-related quality of life. There is a need to identify and avoid specific triggers as the centerpiece of disease management, especially in those with heightened sensitivity to certain factors.

Effectiveness of cognitive behavioural therapy in reducing anxiety in adults and children with asthma: A systematic review

OBJECTIVE

Asthma and anxiety are known to interact, leading to exacerbations for both conditions. This systematic review summarised evidence regarding the effectiveness of cognitive behavioural therapy (CBT) in reducing anxiety in individuals with asthma, with results presented separately for adults and children.

DATA SOURCES

PRISMA and CRD guidance were followed to conduct and report the current review. Three major electronic databases (Ovid Medline, PsycINFO, and EMBASE) and manual searches were used to find relevant published and unpublished research.

STUDY SELECTIONS

Sixteen trials (12 adult- and four child-focused) met inclusion criteria, and were evaluated with adapted quality criteria. Both controlled trials and repeated-measures designs were eligible. All CBT intervention formats were eligible (group, individual, computerised, and self-help). Nine studies (eight adult and one child) focused upon participants with either an anxiety diagnosis or with above-threshold anxiety scores on a validated measure at baseline.

RESULTS

The review provides tentative preliminary support for the use of CBT for anxiety in adults with asthma, with the evidence base for interventions with children appearing promising, but under-developed. Studies were more likely to indicate beneficial effects where anxiety-focused (rather than illness-focused) intervention protocols were utilised, asthma-related education was provided and where the trials focused on individuals with likely clinical levels of anxiety at baseline.

CONCLUSION

Whilst further high-quality research is needed, available evidence is supportive of anxiety-focused CBT interventions tailored to target the particular mechanisms thought to maintain this comorbidity in asthma.

Leukotriene Receptor Antagonists for the Treatment of Asthma in Elderly Patients

Elderly asthma (EA) is regarded as a distinct phenotype of asthma and is associated with age-related changes in airway structure and alterations in lung function and immune responses. EA is difficult to diagnose because of aging and co-morbidities, and overlaps with fixed airway obstructive disease. Novel modalities to differentiate between EA and chronic obstructive pulmonary disease (COPD) are necessary. A multifaceted approach, including clinical history, smoking habits, atopy, and measurement of lung function, is mandatory to differentiate asthma from COPD. There are a variety of co-morbidities with EA, of which COPD, upper airway diseases, depression, obesity, and hypertension are the most common, and these co-morbidities can affect the control status of EA. However, leukotriene receptor antagonists (LTRAs) can facilitate the management of EA, and thus addition of an LTRA to inhaled corticosteroid (ICS) monotherapy or ICS plus long-acting β₂-agonist therapy improves symptoms in EA patients. LTRA treatment is safe and beneficial in patients who are unable to use inhalation devices properly or who have co-morbid diseases. Therefore, clinical studies targeting a specific population of EA patients are warranted to help achieve a better therapeutic strategy in EA patients.

Anxiety Contributes to Poorer Asthma Outcomes in Inner-City Black Adolescents

BACKGROUND

The factors associated with poor asthma control, exacerbations, and health care utilization in black adolescents are complex and not well understood. Although psychological comorbidities such as anxiety are common in patients with asthma, these have not been studied in this population.

OBJECTIVE

This study characterized anxiety and associated asthma features in a cohort of black inner-city adolescents with persistent asthma and determined the association between anxiety symptoms, persistent uncontrolled asthma, and prospective health care utilization over 1 year.

METHODS

Eighty-six black adolescents were enrolled, phenotyped, and screened for anxiety symptoms with the Hospital Anxiety and Depression Scale anxiety subscale (HADS-A). Participants were telephoned every 2 months and a second study visit was completed at 1 year. Primary outcomes included persistent uncontrolled asthma, asthma exacerbations requiring systemic corticosteroids, and unscheduled health care utilization during the 1-year study period.

RESULTS

A total of 31% (n = 27) of adolescents had probable anxiety (ie, HADS-A score >7) and 27% (n = 23) had possible anxiety (ie, HADS-A score 5-7) at the baseline visit. Anxiety symptoms were associated with poorer asthma control, more impaired quality of life, and more insomnia symptoms. Adolescents with probable anxiety disorders also had increased odds of persistent uncontrolled asthma and emergency department utilization, with no differences in physician visits or systemic corticosteroid receipt.

CONCLUSIONS

Inner-city black adolescents with persistent asthma have a high prevalence of anxiety symptoms associated with poorer asthma control, impaired quality of life, insomnia, and increased prospective emergency department utilization for asthma. Routine screening for anxiety disorders may be useful in the clinical management of adolescents with asthma.

Cluster Analysis of Acute Care Use Yields Insights for Tailored Pediatric Asthma Interventions

STUDY OBJECTIVE

We undertake this study to understand patterns of pediatric asthma-related acute care use to inform interventions aimed at reducing potentially avoidable hospitalizations.

METHODS

Hospital claims data from 3 Camden city facilities for 2010 to 2014 were used to perform cluster analysis classifying patients aged 0 to 17 years according to their asthma-related hospital use. Clusters were based on 2 variables: asthma-related ED visits and hospitalizations. Demographics and a number of sociobehavioral and use characteristics were compared across clusters.

RESULTS

Children who met the criteria (3,170) were included in the analysis. An examination of a scree plot showing the decline in within-cluster heterogeneity as the number of clusters increased confirmed that clusters of pediatric asthma patients according to hospital use exist in the data. Five clusters of patients with distinct asthma-related acute care use patterns were observed. Cluster 1 (62% of patients) showed the lowest rates of acute care use. These patients were least likely to have a mental health-related diagnosis, were less likely to have visited multiple facilities, and had no hospitalizations for asthma. Cluster 2 (19% of patients) had a low number of asthma ED visits and onetime hospitalization. Cluster 3 (11% of patients) had a high number of ED visits and low hospitalization rates, and the highest rates of multiple facility use. Cluster 4 (7% of patients) had moderate ED use for both asthma and other illnesses, and high rates of asthma hospitalizations; nearly one quarter received care at all facilities, and 1 in 10 had a mental health diagnosis. Cluster 5 (1% of patients) had extreme rates of acute care use.

CONCLUSION

Differences observed between groups across multiple sociobehavioral factors suggest these clusters may represent children who differ along multiple dimensions, in addition to patterns of service use, with implications for tailored interventions.

Effectiveness of the management of major depressive episodes/disorder in adults with comorbid chronic physical diseases: a protocol for a systematic review and meta-analysis

INTRODUCTION

Depression is a global-scale public health problem, and a significant association has been established between depression and chronic physical diseases. This growing comorbidity poses a challenge to healthcare systems. We aim to assess the effectiveness of the management of major depressive episodes/disorder in adults with comorbid chronic physical diseases.

METHODS AND ANALYSIS

We will conduct a systematic review and meta-analysis of randomised clinical trials. Two databases MEDLINE and Cochrane Library (Cochrane Database for Systematic Reviews and CENTRAL), as well as the reference lists of the included articles, will be searched for studies either in English or Spanish with published results within the 2005-2015 period. Studies must fulfil the following conditions: (1) participants aged 18 years or older, diagnosed as having a major depressive episodes/disorder according to standardised criteria and chronic physical diseases; (2)interventions (be it pharmacological, psychological, psychosocial or a combination) must be compared with control conditions (other 'active' intervention, treatment as usual, waiting list or placebo); (3)and must report reduction in depressive symptoms after treatment, response to treatment, remission of major depressive episodes/disorder and significant improvement in quality of life. Data extraction, risk of bias evaluation, results summarisation and quality of the evidence (GRADE) will be performed as recommended by the Cochrane Collaboration. A qualitative synthesis and a random effects meta-analysis will be carried out. Effect sizes will be calculated (relative risk and Cohen's d), I² and Q statistics will be employed to study heterogeneity and publication bias analysis will be performed. Subgroup analyses and meta-regression will be carried out.

ETHICS AND DISSEMINATION

Results are expected to be published in specialised peer-reviewed journals (preferred topics: Mental Health, Psychology, Psychiatry and/or Systematic Reviews) and dissemination activities will be targeted to all the healthcare providers.

TRIAL REGISTRATION NUMBER

International Prospective Register of Systematic Reviews (CRD42016029166) submitted on 11 January 2016.

The pro-inflammatory cytokines, salivary cortisol and alpha-amylase are associated with generalized anxiety disorder (GAD) in patients with asthma

Generalized anxiety disorder (GAD) is common in patients with asthma. High levels of GAD may lead both to exacerbation of the condition and poor management. However, the physiological mechanisms of GAD in asthma patient is unclear. This study investigated the associations between the diurnal rhythm of sputum cytokines, salivary cortisol, α-amylase and GAD in asthma patients. Patients with co-morbid GAD and asthma showed higher sputum IL-1 AUC, sputum IL-6 AUC and sAA AUC. And there were positive correlations between Hamilton anxiety scale (HAMA) scores and sputum IL-1 AUC concentrations (r=0.37, P=0.002), HAMA scores and sputum IL-6 AUC (r=0.56, P<0.001), HAMA scores and sAA AUC (r=0.75, P<0.001). Also, there were positive correlations between Sputum IL-1 AUC and sAA AUC (r=0.40, P<0.001), between Sputum IL-6 AUC and sAA AUC. Stepwise multiple regression analyses showed the combination of sputum sAA AUC, IL-1 AUC, IL-6 AUC and cortisol AUC was the best predictor of HAMA scores (ΔR²=0.439, F(4,63)=14.086, p<0.001). Therefore, pro-inflammatory cytokines, salivary cortisol and alpha-amylase may all be involved in the occurrence of GAD in asthma patients.

Mental Health Services Claims and Adult Onset Asthma in Ontario, Canada

BACKGROUND

Living with asthma is associated with a decrease in quality of life due to reductions in activities of daily living and increased psychological stress, both of which are associated with poor mental health outcomes.

OBJECTIVE

The objective of this study was to quantify the burden of mental disorders on the adult asthma population and compare the risk of mental health services claims (MHSCs) in the 1 year before and 1 year after asthma diagnosis.

METHODS

Ontario residents aged 25 to 65 years with incident physician-diagnosed asthma between April 1, 2005, and March 31, 2012, were included. MHSCs, which consisted of hospitalizations, emergency department (ED), and outpatient physician visits, were identified from universal health administrative data. Poisson regression models with repeated measures were used to estimate the relative risk (RR) of MHSCs for 2 time periods: 1 year after asthma diagnosis compared with the 1 year before and 2 years after compared with 2 years before.

RESULTS

A total of 145,881 adults had incident asthma. In the 1 year after asthma diagnosis, 27% had an MHSC. The risk of ED visits for any mental disorders increased by 13% in the 1 year after asthma diagnosis compared with the 1 year before (adjusted RR [aRR], 1.13; 95% confidence interval [CI], 1.06-1.21). This increased risk of ED visits was not found when comparing 2 years after asthma diagnosis with 2 years before. The risk for outpatient physician visits for substance-related disorders increased by 21% at 1 year (aRR, 1.21; 95% CI, 1.14-1.28) and 37% at 2 years (aRR, 1.37; 95% CI, 1.28-1.46).

CONCLUSIONS

The significant comorbid burden of mental disorders in adults with newly diagnosed asthma highlights the need for primary care physicians to assess mental health needs and provide appropriate care.

The asthma-anxiety connection

BACKGROUND

The literature reports a significant association between various mental disorders and asthma, in particular depression and/or anxiety, with some more robust data regarding anxiety disorders. However, the nature of this association remains largely unclear.

OBJECTIVES

(1) To test the hypothesis of a specific association of anxiety and depressive disorder (according to the DSM-IV) with asthma and (2) to test the bidirectional hypothesis of causality between asthma and psychiatric disorders.

METHODS

Ninety-six adults were compared with 96 control subjects matched according to main socio-demographic variables (i.e., gender, age, marital status, cohabiting/non-cohabiting, and BMI). Subjects with asthma were divided according to GINA and ACT classifications. All subjects underwent Structured Clinical Interviews for DSM-IV Axis I (SCID-I) diagnosis.

RESULTS

Significant association between asthma and lifetime anxiety disorders emerged (OR 3.03; p = 0.003); no significant association with other psychiatric diagnosis emerged. Moreover, lifetime and current anxiety were associated with asthma severity levels (p < 0.01 and p = 0.001 based on age). Asthma preceded anxiety in 48% of cases; in 52% of cases, anxiety preceded asthma, without significant group differences. The risk of asthma, particularly of severe, uncontrolled forms (p < 0.01), resulted higher in lifetime anxiety disorder patients (p = 0.003 and p = 0.001 based on age at onset). Current anxiety increased the risk of asthma, and that of an uncontrolled form (p < 0.05). Asthma increased the risk of lifetime anxiety disorders (p = 0.002 and p = 0.018 using ages). Intermittent asthma increased the risk of lifetime and current anxiety disorders (p < 0.01).

CONCLUSIONS

Anxiety disorders, in particular Lifetime Anxiety Disorders, represent the only psychiatric disorder significantly associated with asthma, with a possible bidirectional, anxiety-asthma relationship, each of which can be caused or result from the other.

Mental-Physical Comorbidity in Korean Adults: Results from a Nationwide General Population Survey in Korea

OBJECTIVE

The aims of this study were to estimate the prevalence of mental-physical comorbidity and health-threatening risk factors in subjects with mental disorders, and the risks of mental disorders in those with physical diseases for the last 12 months in the general Korean population.

METHODS

Korean Epidemiologic Catchment Area study replication (KECA-R) was conducted for 6,510 adults between August 2006 and April 2007. The Korean version of Composite International Diagnostic Interview 2.1 (K-CIDI) was used in the survey. Prevalence of mental and physical disorders, and risk factors for physical health were calculated, and their associations were evaluated with adjustment for age and sex.

RESULTS

Subjects with any mental disorder showed significantly higher prevalence of chronic physical conditions (adjusted odds ratio, AOR=1.5 to 2.8, p<0.001) and medical risk factors including smoking, heavy drinking, overweight, and hypertension (AOR=1.5 to 4.0, p<0.001). Of those with chronic physical conditions, 21.6% had one or more comorbid mental disorder compared with 10.5% of the subjects without chronic physical disorders (AOR=2.6, p<0.001). Contrary to expectations, depressive disorders did not show significant association with hypertension and prevalence of obesity was not influenced by presence of mental disorders. Further studies should assess these findings.

CONCLUSION

This is the first identification of significant mental-physical comorbidity in the general Korean population. Clinicians and health care officials should keep in mind of its potential adverse effects on treatment outcome and aggravated disease-related socioeconomic burden.

Emerging Comorbidities in Adult Asthma: Risks, Clinical Associations, and Mechanisms

Asthma is a heterogeneous disease with many phenotypes, and age at disease onset is an important factor in separating the phenotypes. Most studies with asthma have been performed in patients being otherwise healthy. However, in real life, comorbid diseases are very common in adult patients. We review here the emerging comorbid conditions to asthma such as obesity, metabolic syndrome, diabetes mellitus type 2 (DM2), and cardiac and psychiatric diseases. Their role as risk factors for incident asthma and whether they affect clinical asthma are evaluated. Obesity, independently or as a part of metabolic syndrome, DM2, and depression are risk factors for incident asthma. In contrast, the effects of comorbidities on clinical asthma are less well-known and mostly studies are lacking. Cross-sectional studies in obese asthmatics suggest that they may have less well controlled asthma and worse lung function. However, no long-term clinical follow-up studies with these comorbidities and asthma were identified. These emerging comorbidities often occur in the same multimorbid adult patient and may have in common metabolic pathways and inflammatory or other alterations such as early life exposures, systemic inflammation, inflammasome, adipokines, hyperglycemia, hyperinsulinemia, lung mechanics, mitochondrial dysfunction, disturbed nitric oxide metabolism, and leukotrienes.

The Influence of Asthma Exacerbations on Health-Related Quality of Life

The purpose of this study was to determine the influence of asthma on the quality of life (QoL) of patients hospitalized for an exacerbation of the disease and those with controlled asthma receiving outpatient treatment, and to establish the patients' somatic status and the level of health care utilization. This study involved 239 adults with asthma (123 hospitalized patients and 116 outpatients of family physicians). The authors used: WHOQOL-BREF questionnaire and a questionnaire measuring health care utilization. There were no differences in QoL levels between the patients with severe and controlled asthma. The psychological domain was assessed higher by hospitalized patients (p = 0.02). QoL levels correlated negatively with age, place of residence, and marital status, and positively with education. The general QoL level was most strongly influenced by gender, age, education, the number of home visits and interventions of a district nurse, and the somatic index (p < 0.05). Somatic symptoms were more severe in hospitalized patients. The QoL assessment of asthma patients in relation to somatic symptoms, health care services and socio-demographic variables allows better understanding of the complex health situation of patients at various stages of the disease, and tailoring the therapy to individual needs. Patients receiving outpatient treatment require professional psychotherapeutic support.

Burden of mental illness on hospital and patient outcomes among asthma hospitalizations

OBJECTIVE

Empirical evidence demonstrates the comorbidity of asthma and mental illness, though limited studies have evaluated the patient and hospital outcomes associated with such conditions. As such, this study evaluated the burden of this comorbidity on health resource utilization and patient disposition among asthma hospitalizations.

METHODS

A secondary analysis of the Nationwide Inpatient Sample (2009-2011) was conducted, with study population of asthma hospitalizations limited to those 18 years of age and older. International Classification of Disease, 9th Revision, Clinical Modification codes were utilized to identify asthma and mental illness discharges. Length of stay was defined as number of days stayed in the hospital, total charges were inflation-adjusted, and patient disposition was defined as routine versus not routine. All analyses were survey-weighted and adjusted for patient and hospital characteristics.

RESULTS

Approximately 29% of the asthma hospitalizations reported mental illness. Any mental illness was associated with increased length of stay in the hospital (10% increase), total costs (11% increase), and lower odds of routine disposition (21% decrease). Substance-related disorder also increased length of stay in the hospital (4% increase), costs (9% increase), and lower odds of routine disposition (29% decrease). Age-stratified analyses further demonstrated similar trends among most age groups.

CONCLUSION

The results of this study complement the extant literature by demonstrating the burden of the asthma-mental health nexus on health resource utilization and patient outcomes. The increased length of stay, cost, and decreased likelihood of routine disposition associated with mental illness highlight the need for integrated care to address mental illness as part of routine care.

Impact of psychiatric illness upon asthma patients' health care utilization and illness control. Are all psychiatric comorbidities created equal?

The impact of psychiatric illnesses upon asthma patients' functioning is not well understood. This study examined the impact of psychiatric comorbidity upon illness management in asthma patients using empirically-derived psychiatric comorbidity groups. Participants were a clinic sample of Greek-speaking asthma patients (N = 212) assessed using the Patient Health Questionnaire (PHQ) Somatoform, Depression, Panic Disorder (PD), Other Anxiety Disorder, Eating Disorder (ED) and Alcohol sub-scales. The associations between sub-scales were examined using multiway frequency analysis. The following groups were derived: Somatoform disorder and/or Any Depressive disorder (n = 63), Somatoform disorder and/or Other Anxiety disorder (n = 51), Somatoform disorder and/or Any ED (n = 60), and Any Anxiety group including PD and/or Other Anxiety disorder (n = 24). Across all groups, psychiatric illness was associated with significantly worse asthma control (p < .01). Participants in Any Anxiety group, OR = 4.61, 95% CI [1.90, 11.15], Somatoform and/or Any Depressive disorder, OR = 2.06, 95% CI [1.04, 4.09] and Somatoform and/or Other Anxiety disorder, OR = 2.75, 95% CI [1.35, 5.60] were at higher risk for asthma-related Emergency Room (ER) visits compared to controls. However only Somatoform and/or Any Depressive disorder, OR = 3.67, 95% CI [1.60, 8.72], Somatoform and/or Other Anxiety disorder, OR = 5.50, 95% CI [2.34, 12.74], and Somatoform and/or Any ED, OR = 4.98, 95% CI [2.14, 11.60] group membership were risk factors for asthma-related hospitalizations. Results suggest that while comorbid psychiatric disorders generally negatively impact asthma illness management, different psychiatric comorbidities appear to have disparate effects upon illness management outcomes.

The Influence of Comorbid Mood and Anxiety Disorders on Outcomes of Pediatric Patients Hospitalized for Pneumonia

OBJECTIVES

Mood and anxiety disorders are associated with greater inpatient care utilization in children with chronic illness. We sought to investigate the association of mood or anxiety disorders and outcomes for hospitalized pediatric patients, using pneumonia as a model.

METHODS

We conducted a retrospective, cross-sectional study of pneumonia hospitalizations in patients 5 to 20 years old, using the nationally representative Healthcare Cost and Utilization Project's 2012 Kids' Inpatient Database. We used multivariable logistic and linear regression models stratified by age group to determine the independent association of mood or anxiety disorders with complications and length of stay, adjusted for clinical, demographic, and hospital characteristics.

RESULTS

Of 34,794 pneumonia hospitalizations, 3.5% involved a patient with a comorbid mood or anxiety disorder. Overall incidence of complications was 13.1%. Mean length of stay was 4.5 days. In adjusted models, comorbid mood or anxiety disorders were associated with greater odds of pneumonia complications in school-aged children (odds ratio 1.80; 95% confidence interval, 1.20-2.71) and adolescents (odds ratio 1.63; 95% confidence interval, 1.31-2.02). Hospitalizations with an associated mood or anxiety disorder were longer than those without, by 11.2% in school-aged children and 13.6% in adolescents (P < .001). The association of mood and anxiety disorders with longer hospital stay was not modified by the presence of pneumonia complications.

CONCLUSIONS

In pediatric patients hospitalized for pneumonia, a comorbid mood or anxiety disorder is associated with greater odds of complications and longer hospital stay. The presence of pneumonia complications did not influence the relationship between mood or anxiety disorders and length of stay.

Impact of comorbid depression on medication adherence and asthma-related healthcare costs in Texas Medicaid patients with asthma

Objectives

To compare: (1) rates of adherence to asthma controllers (ACs) between patients with asthma alone (A) and patients with asthma and comorbid depression (A + D); (2) rates of adherence to AC between patients who adhere to antidepressants and patients who do not adhere to antidepressants; and (3) asthma-related healthcare costs between the A and A + D groups.

Methods

Texas Medicaid insurance claims from 1 January 2007 to 31 October 2011 were extracted for adults (18–63 years) diagnosed with asthma with at least two fills of the same AC (inhaled corticosteroids, long-acting beta agonists, fixed-dose combinations (FDC) and leukotriene modifiers) in the A group, and at least two antidepressant claims in the A + D group. Proportion of days covered (PDC) was used to assess adherence to antidepressants and AC, while controlling for demographics, chronic disease score (CDS) and AC therapy type (monotherapy, FDC, dual therapy). Asthma-related healthcare costs included asthma-related prescriptions, inpatient and outpatient costs. Descriptive statistics, Wilcoxon test and regression analyses were used.

Key findings

The patients (n = 3626) were 40.1 ± 14.0 years, primarily women (75.0%), Caucasians (37.3%), FDC therapy users (56.3%), with CDS = 0 (74.2%). Results showed that compared to the A group (n = 3400), patients in the A + D group (n = 226) were 1.6 times more likely to adhere (PDC ≥50%) to their AC (odds ratio (OR) = 1.596; 95% confidence interval (CI) = 1.198–2.128; P &lt; 0.001). Compared to patients who do not adhere to antidepressants (PDC &lt; 80%) (n = 140), patients who adhered to antidepressants (PDC ≥80%) (n = 86) were 2.5 times more likely to adhere (PDC ≥50%) to AC, while controlling for covariates (OR = 2.517; 95% CI = 1.304–4.855; P = 0.006). After controlling for covariates, compared to the A group, the A + D disorder group had significantly lower total asthma-related healthcare costs (P &lt; 0.001).

Conclusions

In the A + D group, the higher costs of asthma-related prescriptions was offset by the lower costs of inpatient and outpatient claims. Patients in the A + D group should be encouraged to adhere to both their ACs and antidepressants.

Inpatient and outpatient costs in patients with coronary artery disease and mental disorders: a systematic review

Background

To systematically review in- and outpatient costs in patients with coronary artery disease (CAD) and comorbid mental disorders.

Methods

A comprehensive database search was conducted for studies investigating persons with CAD and comorbid mental disorders (Medline, EMBASE, PsycINFO, Psyndex, EconLit, IBSS). All studies were included which allowed a comparison of in- and outpatient health care costs (assessed either monetarily or in terms of health care utilization) of CAD patients with comorbid mental disorders (mood, anxiety, alcohol, eating, somatoform and personality disorders) and those without. Random effects meta-analyses were conducted and results reported using forest plots.

Results

The literature search resulted in 7,275 potentially relevant studies, of which 52 met inclusion criteria. Hospital readmission rates were increased in CAD patients with any mental disorder (pooled standardized mean difference (SMD) = 0.34 [0.17;0.51]). Results for depression, anxiety and posttraumatic stress disorder pointed in the same direction with heterogeneous SMDs on a primary study level ranging from −0.44 to 1.26. Length of hospital stay was not increased in anxiety and any mental disorder, while studies on depression reported heterogeneous SMDs ranging from −0.08 to 0.82. Most studies reported increased overall and outpatient costs for patients with comorbid mental disorders. Results for invasive procedures were non-significant respectively inconclusive.

Conclusions

Comorbid mental disorders in CAD patients are associated with an increased healthcare utilization in terms of higher hospital readmission rates and increased overall and outpatient health care costs. From a health care point of view, it is requisite to improve the diagnosis and treatment of comorbid mental disorders in patients with CAD to minimize incremental costs.

Multimorbidity and healthcare utilisation among high-cost patients in the US Veterans Affairs Health Care System

OBJECTIVES

To investigate the relationship between multimorbidity and healthcare utilisation patterns among the highest cost patients in a large, integrated healthcare system.

DESIGN

In this retrospective cross-sectional study of all patients in the U.S. Veterans Affairs (VA) Health Care System, we aggregated costs of individuals' outpatient and inpatient care, pharmacy services and VA-sponsored contract care received in 2010. We assessed chronic condition prevalence, multimorbidity as measured by comorbidity count, and multisystem multimorbidity (number of body systems affected by chronic conditions) among the 5% highest cost patients. Using multivariate regression, we examined the association between multimorbidity and healthcare utilisation and costs, adjusting for age, sex, race/ethnicity, marital status, homelessness and health insurance status.

SETTING

USA VA Health Care System.

PARTICIPANTS

5.2 million VA patients.

MEASURES

Annual total costs; absolute and share of costs generated through outpatient, inpatient, pharmacy and VA-sponsored contract care; number of visits to primary, specialty and mental healthcare; number of emergency department visits and hospitalisations.

RESULTS

The 5% highest cost patients (n=261,699) accounted for 47% of total VA costs. Approximately two-thirds of these patients had chronic conditions affecting ≥3 body systems. Patients with cancer and schizophrenia were less likely to have documented comorbid conditions than other high-cost patients. Multimorbidity was generally associated with greater outpatient and inpatient utilisation. However, increased multisystem multimorbidity was associated with a higher outpatient share of total costs (1.6 percentage points per affected body system, p<0.01) but a lower inpatient share of total costs (-0.6 percentage points per affected body system, p<0.01).

CONCLUSIONS

Multisystem multimorbidity is common among high-cost VA patients. While some patients might benefit from disease-specific programmes, for most patients with multimorbidity there is a need for interventions that coordinate and maximise efficiency of outpatient services across multiple conditions.

Multiple chronic conditions and asthma: implications for practice and research

At least half of US adults with asthma have at least 1 other chronic condition. Having asthma and other chronic conditions are associated with poorer asthma outcomes. Several studies considered the relationship between asthma and other specific chronic conditions; results of these studies indicated that having depression or anxiety and/or panic disorder is associated with an increased risk of developing a new asthma diagnosis and with poorer asthma outcomes. In addition, results of these studies indicated that having asthma is associated with an increased risk of developing a new depression or anxiety and/or panic disorder diagnosis. Theoretical models for understanding multiple chronic conditions have emerged, with models that include a balance between patient workload and capacity; classification of specific conditions as concordant and/or discordant and/or dominant; and identification of the gap between what a patient needs and what health care services are able to offer. Potential implications for clinical providers include screening for chronic conditions not yet recognized, such as mental health disorders, promoting and tracking medication adherence in those who have multiple chronic conditions, and simplifying treatment regimens to reduce patient workload.

Coexisting chronic conditions associated with mortality and morbidity in adult patients with asthma

OBJECTIVE

Many asthma patients suffer from chronic conditions other than asthma. We investigated the specific contribution of common comorbidities on mortality and morbidity in adult asthma.

METHODS

In an observational study of adults with incident asthma identified between 1999 and 2003 using National Veterans Affairs and Centers for Medicare and Medicaid Services encounter databases (n = 25 975, follow-up 3.0 ± 1.7 years), association between 13 most prevalent comorbidities (hypertension, ischemic heart disease (IHD), osteoarthritis, rheumatoid arthritis, diabetes, mental disorders, substance/drug abuse, enlarged prostate, depression, cancer, alcoholism, HIV and heart failure) and four conditions previously associated with asthma (sleep apnea, gastroesophageal reflux disease (GERD), rhinitis and sinusitis) and mortality, hospitalizations and asthma exacerbations were assessed using multivariate regression analyses adjusted for other clinically important covariates.

RESULTS

HIV followed by alcoholism and mental disorders among 18-45-years old, and heart failure, diabetes, IHD and cancer among those ≥ 65 years old were associated with an increased risk of all-cause mortality. Many conditions were associated with increased risk for all-cause hospitalizations, but the increased risk was consistent across all ages for mental disorders. For asthma exacerbations, mental disorder followed by substance abuse and IHD were associated with increased risk among those 18-45 years old, and chronic sinusitis, mental disorder and IHD among those ≥ 65-years old. GERD was associated with decreased risk for asthma exacerbation in all ages.

CONCLUSIONS

Many comorbidities are associated with poor outcome in adult asthmatics and their effect differs by age. Mental disorders are associated with increased risk of mortality and morbidity across ages.

Major comorbid conditions in asthma and association with asthma-related hospitalizations and emergency department admissions in adults: results from the German National Health Telephone Interview Survey (GEDA) 2010

BACKGROUND

It remains unclear to what extent asthma in adults is linked to allergic rhinitis (AR), gastroesophageal reflux disease (GERD), and acetylsalicylic acid exacerbated respiratory disease (AERD), and how these comorbidities may affect asthma outcomes in the general population. We therefore aimed to assess the prevalence of these major comorbidities among adults with asthma and examine their impact on asthma exacerbations requiring hospital care.

METHODS

A total of 22,050 adults 18 years and older were surveyed in the German National Health Telephone Interview Survey (GEDA) 2010 using a highly standardized computer-assisted interview technique. The study population comprised participants with self-reported physician-diagnosed asthma, among which the current (last 12 months) prevalence of AR and GERD-like symptoms (GERS), and life-time prevalence of AERD was estimated. Weighted bivariate analyses and logistic regression models were applied to assess the association of each comorbid condition with the asthma outcome (any self-reported asthma-related hospitalization and/or emergency department (ED) admission in the past year).

RESULTS

Out of 1,136 adults with asthma, 49.6% had GERS and 42.3% had AR within the past 12 months; 14.0% met the criteria of AERD, and 75.7% had at least one out of the three conditions. Overall, the prevalence of at least one exacerbation requiring emergency room or hospital admission within the past year was 9.0%. Exacerbation prevalence was higher among participants with comorbidities than among those without (9.8% vs. 8.2% for GERS; 11.2% vs. 7.6% for AR, and 22.2% vs. 7.0% for AERD), but only differences in association with AERD were statistically significant. A strong association between asthma exacerbation and AERD persisted in multivariable logistic regression analyses adjusting for sex, age group, level of body mass index, smoking status, educational attainment, and duration of asthma: odds ratio (OR) = 4.5, 95% confidence interval (CI) = 2.5-8.2.

CONCLUSIONS

Data from this large nation-wide study provide evidence that GERS, AR and AERD are all common comorbidities among adults with asthma. Our data underline the public health and clinical impact of asthma with complicating AERD, contributing considerably to disease-specific hospitalization and/or ED admission in a defined asthma population, and emphasize the importance of its recognition in asthma care.

Indirect costs in patients with coronary artery disease and mental disorders: a systematic review and meta-analysis

OBJECTIVES

The aim of the present study was to systematically review the association of comorbid mental disorders with indirect health care costs in patients with coronary artery disease (CAD).

MATERIALS AND METHODS

A comprehensive database search was conducted for studies investigating persons with CAD and comorbid mental disorders (Medline, EMBASE, PsycINFO, Psyndex, EconLit, IBSS). All studies were included, which allowed for a comparison of indirect health care costs between CAD patients with comorbid mental disorders and CAD patients without mental disorders.

RESULTS

The literature search revealed 4962 potentially relevant studies, out of which 13 primary studies met the inclusion criteria. Depression was investigated most often (N = 10), followed by anxiety disorders (N = 3) and any mental disorder not further specified (N = 3). All studies focused on return to work as indirect cost outcome. CAD patients with depression showed diminished odds for return to work, compared to CAD patients without depression (OR = 0.37; 95% CI: 0.27-0.51). The findings for comorbid anxiety and any mental disorder were inconsistent. Indirect health care costs were exclusively assessed by a patient self-report (N = 13).

CONCLUSIONS

There is strong evidence for diminished odds of return to work in CAD patients with comorbid depression, highlighting the need for integrated CAD and depression care. With regard to other comorbid mental disorders, however, the evidence is sparse and inconclusive.

Collaborative care for depression in medically ill patients

PURPOSE OF REVIEW

Depression is common in medically ill patients and associated with a negative prognosis. Recent findings indicate that single interventions have little effect on outcomes in these patients. Alternatively, complex interventions based on a collaborative care model are promising. This review summarizes recent findings regarding collaborative care in medically ill patients with comorbid depression.

RECENT FINDINGS

Recent trials provide evidence for a significantly beneficial effect on depression outcomes with moderate effect sizes regarding depressive symptoms [standardized mean differences (SMDs): -0.46 to -0.74, n = 5] and depression response [odds ratios (ORs): 1.29 to 4.75, n = 6]. Psychosocial quality of life (SMDs: 0.09 to 0.54, n = 5) and satisfaction with care (ORs: 2.55-7.43, n = 3; SMDs: 0.05 and 0.2, n = 1) were increased in intervention patients compared with usual care, whereas physical quality of life (SMDs: -0.17 to 0.06) was not. The evidence regarding medication adherence and somatic, disease-specific outcomes is sparse and conclusions cannot be drawn so far.

SUMMARY

Collaborative care interventions are efficacious in medically ill patients with depression. However, there is no data concerning their cost-effectiveness. Furthermore, as trials on collaborative care comprise a heterogeneous set of components, the most effective characteristics should be identified. Moreover, these interventions should be adapted to other healthcare systems than the United States.

Direct and indirect costs in persons with chronic back pain and comorbid mental disorders--a systematic review

OBJECTIVE

Direct inpatient and outpatient healthcare costs as well as indirect costs (e.g. productivity losses) are hypothesized to be increased in chronic back pain (CBP) patients with mental disorders. The aim of this systematic review is to examine this hypothesis by comparing costs in CBP patients with and without mental disorders.

METHODS

A comprehensive literature search (Medline, EMBASE, PsycINFO, Psyndex, EconLit, IBSS) was conducted. All studies were included which allowed for a comparison of direct and indirect costs between CBP patients with and without mental disorders.

RESULTS

Of 2283 potentially relevant articles, 10 studies fulfilled the inclusion criteria. Total healthcare costs (SMD=0.16 [SE=0.06]; n=1), CBP-related healthcare costs (SMD=0.21 [0.06]; n=1), CBP-related primary care visits (OR=1.6 [95%-CI:1.2-2.3]; n=1), CBP-related specialty care visits (OR=1.4 [1.0-2.0];n=1), CBP-related radiologic procedures (OR=1.6 [1.0-2.5]; n=1) and mental health visits (OR=8.1 [7.3-9.1]; n=2) were increased in CBP patients with depression. The incidence of new surgeries was increased in CBP patients with PTSD (OR=4.2 [1.6-10.8]; n=1). Pain-related healthcare use (n=1) in CBP patients with both depression and anxiety and CBP-related hospital admissions (n=1) in CBP patients with depression were not increased. Regarding indirect costs results were inconsistent for both return to work rates (n=3) and work absence (n=2).

CONCLUSION

The results indicate increased direct but not indirect costs in CBP patients with mental disorders. However, the evidence is limited due to the low number of studies per outcome. This is all the more problematic, since the adequate allocation of healthcare resources will become a major topic of health care policy due to limited resources.