Similar psychological characteristics in mild and severe asthma

The role of inflammation in anxiety and depression in the European U-BIOPRED asthma cohorts

BACKGROUND

Growing evidence indicates high comorbid anxiety and depression in patients with asthma. However, the mechanisms underlying this comorbid condition remain unclear. The aim of this study was to investigate the role of inflammation in comorbid anxiety and depression in three asthma patient cohorts of the Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes (U-BIOPRED) project.

METHODS

U-BIOPRED was conducted by a European Union consortium of 16 academic institutions in 11 European countries. A subset dataset from subjects with valid anxiety and depression measures and a large blood biomarker dataset were analysed, including 198 non-smoking patients with severe asthma (SAn), 65 smoking patients with severe asthma (SAs), 61 non-smoking patients with mild-to-moderate asthma (MMA), and 20 healthy non-smokers (HC). The Hospital Anxiety and Depression Scale was used to measure anxiety and depression and a series of inflammatory markers were analysed by the SomaScan v3 platform (SomaLogic, Boulder, Colo). ANOVA and the Kruskal-Wallis test were used for multiple-group comparisons as appropriate.

RESULTS

There were significant group effects on anxiety and depression among the four cohort groups (p < 0.05). Anxiety and depression of SAn and SAs groups were significantly higher than that of MMA and HC groups (p < 0.05. There were significant differences in serum IL6, MCP1, CCL18, CCL17, IL8, and Eotaxin among the four groups (p < 0.05). Depression was significantly associated with IL6, MCP1, CCL18 level, and CCL17; whereas anxiety was associated with CCL17 only (p < 0.05).

CONCLUSIONS

The current study suggests that severe asthma patients are associated with higher levels of anxiety and depression, and inflammatory responses may underlie this comorbid condition.

Depressive and anxiety symptomatology among people with asthma or atopic dermatitis: A population-based investigation using the UK Biobank data

The present study investigated the association of depression and anxiety symptomatology (DAS) with asthma and atopic dermatitis (AD) diagnosis during mid-adult years. The study employed data from 502,641 participants in the UK Biobank. Neutrophils to Lymphocytes Ratios (NLRs) of patients with asthma and AD were calculated and evaluated in relation to DAS, measured via the Patient Health Questionnaire-4 (PHQ-4). Age of asthma or AD onset association with DAS were also estimated. Multivariable regression analyses were implemented among participants with asthma or AD, compared to those without these disorders. Out of 58,833 participants with asthma and 13,462 with AD, the prevalence of DAS was 11.7% and 2.7%, respectively. DAS increased among participants with either asthma or AD, being highest within patients having both (β = 0.41, 95% confidence interval (95%CI), 0.34,0.49). NLR showed a linear increase with PHQ scores in asthma patients, (tertile 1, β = 0.30, 95% CI, 0.27,0.34; tertile 2, β = 0.36, 95%CI, 0.32,0.39, and tertile 3, β = 0.43, 95%CI, 0.39,0.46). An inverted U-shaped association was seen between age of asthma onset and PHQ, with the 40-59 age group (β = 0.54, 95%CI, 0.48,0.59) showing the highest risk followed by the 60+ (β = 0.43, 95%CI, 0.34,0.51 and 20-39 groups (β = 0.32, 95%CI, 0.27,0.38). Similar patterns emerged within AD. Asthma and AD were associated with increased DAS during mid-adult years, being strongest among participants reporting both disorders. A dose-response relationship between NLR and DAS was observed. Asthma or AD onset during mid-adult years (40-59) were associated with the highest increment in DAS.

Symptoms and exacerbations in asthma: an apparent paradox?

Background:

There is a dearth of data on prospectively recorded symptoms in patients with uncontrolled asthma. Asthma symptoms and exacerbation rate are commonly thought to be associated. The aim of this study was to analyse asthma symptoms of cough, wheeze, chest tightness and breathlessness in an uncontrolled asthma cohort. We also examined the effect of maintenance and reliever therapy (MART) on these symptoms and its effect on exacerbation rate.

Methods:

Adults with uncontrolled asthma electronically recorded their asthma symptom severity scores twice-daily over a period of 48 weeks following randomisation to beclometasone/formoterol twice daily plus pro re nata (prn) salbutamol or MART. Subjects with symptom scores of ⩾2 (ranging from 0 to 3 for each symptom) were considered more symptomatic, whereas those below a score of 2 were considered less severe. The influence treatment on exacerbation frequency and symptom profiles were then correlated.

Results:

Of the 1701 subjects in the analyses, 1403 were symptomatic with ⩾100 symptom episodes for one symptom. The remaining 298 subjects were classified as pauci-symptomatic. There was poor association between the frequency and symptom severity score for each symptom. Surprisingly, wheeze was the least reported symptom. Females were more likely to be polysymptomatic. MART compared with prn salbutamol markedly attenuated severe asthma exacerbations. This effect was most notable in subjects with fewer symptoms.

Conclusions:

In uncontrolled asthma, there is a poor correlation between reported symptoms and exacerbation frequency. This post hoc analysis suggests that MART should not be reserved for symptomatic subjects but achieves the greatest benefit in pauci-symptomatic patients with asthma.

Trial registration:

ClinicalTrials.gov identifier: NCT00861926

Asthma

Asthma-one of the most common chronic, non-communicable diseases in children and adults-is characterised by variable respiratory symptoms and variable airflow limitation. Asthma is a consequence of complex gene-environment interactions, with heterogeneity in clinical presentation and the type and intensity of airway inflammation and remodelling. The goal of asthma treatment is to achieve good asthma control-ie, to minimise symptom burden and risk of exacerbations. Anti-inflammatory and bronchodilator treatments are the mainstay of asthma therapy and are used in a stepwise approach. Pharmacological treatment is based on a cycle of assessment and re-evaluation of symptom control, risk factors, comorbidities, side-effects, and patient satisfaction by means of shared decisions. Asthma is classed as severe when requiring high-intensity treatment to keep it under control, or if it remains uncontrolled despite treatment. New biological therapies for treatment of severe asthma, together with developments in biomarkers, present opportunities for phenotype-specific interventions and realisation of more personalised treatment. In this Seminar, we provide a clinically focused overview of asthma, including epidemiology, pathophysiology, clinical diagnosis, asthma phenotypes, severe asthma, acute exacerbations, and clinical management of disease in adults and children older than 5 years. Emerging therapies, controversies, and uncertainties in asthma management are also discussed.

A Case Series Evaluation of a Pilot Group Cognitive Behavioural Treatment for Children With Asthma and Anxiety

Anxiety disorders occur at an increased rate in children with asthma; however, there is only a small evidence base to support specific psychological treatments for these children. The current study evaluated the efficacy of a pilot cognitive behavioural treatment (CBT) group intervention for children with asthma and a comorbid anxiety disorder in a case series design. Five children (aged 8–11 years old) with asthma and a comorbid anxiety disorder and their mothers took part in eight 1-hour group treatment sessions. Primary outcomes measures were anxiety diagnosis and asthma-related quality of life. Secondary outcome measures were asthma symptom control and parent quality of life associated with caring for a child with asthma. Three of the participants no longer met diagnostic criteria for an anxiety disorder following treatment and three different participants reported a reliable improvement in asthma-related quality of life. Two participants reported a reliable improvement in asthma symptom control. Three mothers reported an improvement in caregiver quality of life. The findings provide preliminary proof of concept evidence for the efficacy of a CBT intervention for children with asthma and clinical anxiety.

Emotionally triggered asthma and its relationship to panic disorder, ataques de nervios, and asthma-related death of a loved one in Latino adults

OBJECTIVE

Research has demonstrated high comorbidity between asthma and panic disorder (PD). Less is known about the relationship between asthma and the Latino cultural idiom of distress of ataques de nervios, as well as the role that psychosocial stressors play. The current study tested the hypotheses that Latino asthma patients who experience PD, ataques de nervios, and/or asthma-related death of a loved one endorse greater psychological triggers of asthma, greater perceived impact of asthma triggers, and greater difficulty controlling such triggers than do those without these conditions.

METHODS

Data originated from an interview conducted prior to a randomized controlled trial in which 292 Latino adults with self-reported asthma were recruited from outpatient clinics in the Bronx, NY. The PRIME-MD Patient Health Questionnaire (PHQ) was used to screen for PD symptoms, while the Structured Clinical Interview for DSM-IV (SCID-I) was used to confirm diagnosis of PD. Lifetime history of ataques de nervios and asthma-related death of a loved one were based upon self-report. Asthma triggers were examined using the Asthma Trigger Inventory (ATI).

RESULTS

PD, ataques de nervios, and asthma-related death of a loved one each predicted a higher frequency of psychological asthma triggers, controlling for gender and comorbid medical conditions. Participants with PD also reported greater impact of asthma triggers than those without PD, while no significant differences in perceived control were observed.

CONCLUSION

Providers should screen for PD, ataques de nervios, and asthma-related death of a loved one in Latino asthma patients, given their observed association with emotionally triggered asthma.

Threat interpretation and parental influences for children with asthma and anxiety

Anxiety disorders are highly prevalent in children with asthma yet very little is known about the cognitive and parent factors that may underpin this relationship. The present study investigated interpretation biases in children with asthma and anxiety and their parents, and whether parent-child discussions influenced children's interpretations. Eighty-nine parent-child dyads were included across four groups: children with asthma and anxiety, children with anxiety only, children with asthma only and healthy children (aged between 8 and 13 years old). Interpretation bias was assessed using ambiguous scenarios. Children with anxiety showed an interpretation bias in the general threat scenarios, whereas children with asthma showed an interpretation bias in the asthma threat scenarios. Parental predictions of their child's responses showed similar results. Parent-child discussions increased avoidance for children with anxiety and no asthma across all scenarios, but only for children with asthma and anxiety in the asthma threat scenarios. The results provide partial support for a cognitive theory of asthma and anxiety in children and suggest that parents play a role in influencing children's thinking styles. Treatment programs could thus aim to target and modify interpretation biases in children with anxiety, and include parents as part of treatment.

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.

[How to consider triggers and comorbid conditions in severe asthma in adults]

Triggers and precipitating factors as well as comorbid conditions are associated with asthma and severe asthma. They interfere with the potential to control the disease and represent an additional burden for the patients. Allergen exposure is well known to induce loss of control and exacerbations. Comorbid conditions belong to various fields of medicines including cardiovascular diseases, osteoporosis, obesity and sleep apneas and GERD. They should be diagnosed and treated for themselves according to the best state of the art. Their precise role et their contribution to severe asthma pathophysiology is largely unknown and longitudinal cohort studies are needed to better understand and treat the patients with severe asthma.

Multidimensional Health Locus of Control: Comments on the Construct and its Measurement

In the present commentary, the theoretical construct of Multidimensional Health Locus of Control (MHLC) is described and evaluated in terms of its contributions to health psychology. This concept is compared to other control beliefs, in particular to perceived self-efficacy. It is argued that MHLC has supplied health psychology with essential insights and has offered a great deal of intellectual stimulation. Nevertheless, for some applications, different constructs might be more promising, in particular when it comes to predicting health behavior change. MHLC measurement, specifically its factorial structure, its proximity to health outcomes and health behaviors and its cultural sensitivity are addressed. Further refinement of the instrument is recommended, and the range of promising applications needs to be clearly defined.

Psychological characteristics of patients with asthma

INTRODUCTION

Psychological distress of patients with asthma may be reduced when they learned to live with their illness. Asthma can change the psychological and personality characteristics. We aim to investigate the psychological and personality characteristics of patients with asthma using MMPI (Minnesota Multiphasic Personality Inventory).

METHODS

Thirty-three adult patients with asthma (23 female and 10 male) and 20 healthy controls (14 females and 6 males) were enrolled in this study. Psychometric evaluation was made with the Turkish version of the MMPI. The patients were separated into two groups according to the duration of symptoms (recent-onset asthma < 10 years, long-standing asthma ≥10 years).

RESULTS

Patients with asthma compared with control group had significantly higher the rate of clinical elevation on depression, hysteria, psychasthenia and social introversion. Patients with recent-onset asthma compared with long-standing asthma have significantly higher the rate of clinical elevation on depression, hysteria, psychopathic deviate, psychasthenia and social introversion. MMPI mean t score in patients with recent-onset asthma was higher than patients with long-standing asthma. MMPI mean t score in patients with asthma was negatively associated with the symptom duration in multivariate model.

CONCLUSIONS

Patients with asthma have relatively more inactivity, anergia, guilt, pessimism, nonspecific physical complaints, irrational fears and introvert. Patients with long-standing asthma have less psychological distress, suggesting that learned to cope with his illness.

Do Panic Symptoms Affect the Quality of Life and Add to the Disability in Patients with Bronchial Asthma?

Background. Anxiety and panic are known to be associated with bronchial asthma with variety of impact on clinical presentation, treatment outcome, comorbidities, quality of life, and functional disability in patients with asthma. This study aims to explore the pattern of panic symptoms, prevalence and severity of panic disorder (PD), quality of life, and disability in them. Methods. Sixty consecutive patients of bronchial asthma were interviewed using semistructured proforma, Panic and Agoraphobia scale, WHO Quality of life (QOL) BREF scale, and WHO disability schedule II (WHODAS II). Results. Though 60% of the participants had panic symptoms, only 46.7% had diagnosable panic attacks according to DSM IV TR diagnostic criteria and 33.3% had PD. Most common symptoms were “sensations of shortness of breath or smothering,” “feeling of choking,” and “fear of dying” found in 83.3% of the participants. 73.3% of the participants had poor quality of life which was most impaired in physical and environmental domains. 55% of the participants had disability score more than a mean (18.1). Conclusion. One-third of the participants had panic disorder with significant effect on physical and environmental domains of quality of life. Patients with more severe PD and bronchial asthma had more disability.

Unrecognised psychopathology in patients with difficult asthma: major mental and personality disorders

BACKGROUND

Difficult asthma is a severe subgroup of asthma in which the main feature is uncontrollability of symptoms. Psychopathology is suggested to be prominent in patients with difficult asthma and considered important in its treatment; however, the evidence is scarce.

AIMS

To describe psychopathology in difficult asthma, both major mental and personality disorders, based on diagnostic interviews.

METHOD

This study was conducted in a specialised asthma care centre. A total of 51 patients with difficult asthma were diagnosed at the start of the treatment programme using two structured clinical interviews for both major mental (SCID-I) and personality disorders (SCID-II) according to DSM-IV-TR.

RESULTS

About 55% of the patients with difficult asthma had a psychiatric disorder of which 89% was undiagnosed and untreated before being interviewed. About 49% had a minimum of one major mental disorder of which the cluster of anxiety disorders was the most common cluster of major mental disorders, followed by somatoform disorders. About 20% were diagnosed with a personality disorder. Of the 10 patients with a personality disorder, 9 had an obsessive-compulsive personality disorder.

CONCLUSIONS

This study demonstrates that more than half of patients with difficult asthma had a psychiatric disorder of which 89% was unrecognised. This study highlights the importance of offering patients with difficult asthma a psychiatric diagnostic interview and/or a psychiatric consultation as part of their routine medical examination and provision of appropriate psychiatric treatment. Moreover, it highlights the urgency of further research into the role of psychopathology in the development of difficult asthma.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Anxiety, depression and personality traits in severe, prednisone-dependent asthma

BACKGROUND

Anxiety and depression are prevalent in patients with asthma, and associated with more exacerbations and increased health care utilization. Since psychiatric intervention might improve asthma control, we examined whether patients with severe, prednisone-dependent asthma are at higher risk of these disorders than patients with severe non-prednisone dependent asthma or mild-moderate asthma, and whether they exhibit different personality traits.

METHODS

Sixty-seven adults with severe prednisone-dependent asthma, 47 with severe non-prednisone dependent and 73 patients with mild-moderate asthma completed the HADS depression and anxiety subscale and the NEO-FFI for personality traits. In addition, asthma duration, body mass index and FEV1 were measured.

RESULTS

The prevalence of clinically significant depressive symptoms (9% vs. 0 vs. 0%; p = 0.009) and anxiety symptoms (19% vs. 6.4 vs. 5.5%; p = 0.01), was higher in patients with severe, prednisone-dependent asthma than in patients with severe non-prednisone dependent or mild-moderate asthma. Patients with prednisone-dependent asthma were respectively 3.4 (95%CI: 1.0-10.8 p = 0.04) and 3.5 (95%CI: 1.3-9.6 p = 0.01) times more likely to have significant depression symptoms and 1.6 (95%CI: 0.7-3.7, p = 0.2) and 2.5 (95%CI: 01.1-5.5, p = 0.02) times more likely to have symptoms of anxiety than patients with severe non-prednisone dependent or mild-moderate asthma. There were no differences found in personality traits between the 3 groups.

CONCLUSION

Patients with severe, prednisone-dependent asthma have more often psychological distress as compared to patients with severe non-prednisone dependent or mild-moderate asthma.

The relationship between asthma and self-reported anxiety in a predominantly healthy adult population

BACKGROUND

Numerous studies involving patients with severe asthma have cited a relation between asthma and anxiety; this relation is responsible for decreased quality of life, increased morbidity, and higher health care usage. However, whether a link between milder asthma and anxiety exists remains unclear.

OBJECTIVE

To determine whether asthma and anxiety share an association in a group of predominantly healthy adults.

METHODS

Adults seen at the Cooper Clinic in Dallas, Texas from March 2000 through January 2013 for preventive medical examinations that included an extensive medical history, including a questionnaire regarding anxiety history, a physician-based physical examination, and laboratory and spirometric testing were used in the analysis. Multiple logistic regressions were used to determine the relation between asthma and anxiety.

RESULTS

The sample consisted of 15,675 patients, of whom 1,403 (9%) had an asthma diagnosis. A sizeable majority of patients with asthma rated their health good or excellent, did not use an inhaler, and had a ratio of forced expiration volume in the first second to forced vital capacity greater than 70%. When controlling for covariates, milder asthma was significantly associated with anxiety (odds ratio 1.435, 95% confidence interval 1.238-1.663, P < .001). Smoking, a variable associated with asthma severity, was significantly associated with anxiety (odds ratio 1.432, 95% confidence interval 1.261-1.626, P < .001), although other variables, such as the ratio of forced expiration volume in the first second to forced vital capacity or use of an inhaled corticosteroid or combined inhaled corticosteroid and a long-acting β agonist, were not significantly associated with anxiety.

CONCLUSION

In this cohort of patients with predominantly mild asthma, there was a 43.5% increased risk of anxiety. All patients with asthma should be considered at a higher risk of anxiety and a target population for anxiety screening.

Asthma, life events and psychiatric disorders: a population-based study

PURPOSE

Although asthma and other chronic physical conditions have been shown to be associated with psychiatric symptoms, the relative contributions of negative life events to this association and impaired quality of life (QOL) are not clear.

METHODS

This is a cross-sectional study of a nationally representative sample of Singaporean adults aged 20-59 (n = 2,847). Individuals were grouped by asthma, other chronic physical conditions, and no chronic physical conditions. Participants were assessed life events (list of threatening experiences questionnaire), psychiatric disorders [schedule for clinical assessment in neuropsychiatry diagnoses of psychiatric disorder including any psychiatric disorder, major depressive disorder (MDD) and generalized anxiety disorder (GAD)], and QOL (medical outcomes study 12-item short form).

RESULTS

In multivariate analyses controlling for confounding variables, asthma and other chronic physical conditions, compared to no chronic physical conditions, both showed similarly (two- to four-fold) elevated odds ratio (OR) of association with MDD and GAD. However, the asthma group reported more life events as compared to other chronic physical conditions (OR = 4.33, 95 % CI: 2.09-8.95) or no chronic physical conditions (OR = 7.64, 95 % CI: 3.87-15.06). Life events accounted significantly for excess coexistence of psychiatric disorders with asthma over participants without chronic physical conditions. It also contributed significantly to relatively worse QOL observed among individuals with asthma.

CONCLUSIONS

In this cross-sectional study, life events among adults in Singapore appeared to mediate the co-occurrence of psychiatric disorders and functional impairment with asthma, more than with other chronic physical conditions. This should be further investigated in longitudinal studies.

A review of psychological dysfunction in asthma: affective, behavioral and cognitive factors

BACKGROUND

The research on psychological dysfunction in asthma is extensive but heterogeneous. We undertook a narrative review about the effects of psychological dysfunction on asthma.

METHODS

Electronic searches of MEDLINE, EMBASE, CINAHL and the Cochrane Library were conducted, supplemented by hand-searching bibliographies and seeking expert opinion.

RESULTS

The impact of psychological factors on asthma can be classified according to dysfunction in the domains of affect, behavior and cognition. Affective or emotional disturbance may lead to poor asthma control by directly modulating disease activity. Maladaptive behaviors may occur in asthma patients. These include maladaptive breathing behaviors, such as impaired voluntary drive to breathe and dysfunctional breathing, as well as impaired asthma health behaviors, that is, a coordinated range of activities performed to maintain good disease control. Dysfunctional cognitions (thoughts and beliefs) about asthma and impaired cognitive processing of the perception of dyspnea are associated with poorly controlled disease and asthma deaths, respectively. The three domains of psychological dysfunction are often closely intertwined, leading to vicious circles.

CONCLUSIONS

We have conceptualized psychological dysfunction in asthma using a framework consisting of affect, behavior and cognition. Their influences are intertwined and complex. Future research should focus on the formulation of a psychological assessment tool based on this framework and evaluating its efficacy in improving asthma outcomes.

Psychiatric morbidity in chronic respiratory disorders in an Indian service using GMHAT/PC

OBJECTIVE

The study aimed to assess psychiatric morbidity in stable chronic respiratory disorders and to examine the pattern of psychiatric illness in specific respiratory disorders in Northern India.

METHODS

All consecutive patients with stable chronic respiratory illnesses who attended the respiratory disease clinic were recruited in the study. Their healthy attendants were interviewed as a control group. The research clinician, trained in the use of the Global Mental Health Assessment Tool, Primary Care Version (GMHAT/PC), interviewed all the participants. The respiratory consultant made the respiratory illness diagnosis. The data were analyzed comparing the patient and the control group by using relative risk and adjusted odds ratios.

RESULTS

Of 391 patients with respiratory illness, 44.8% had a mental illness identified by GMHAT/PC interview compared with 24.3% of 177 attendants (controls). Anxiety (20.6%), depression (13.2%) and obsessive compulsive disorders (4.6%) were the most frequently identified mental disorders in the respiratory disease group. Chronic obstructive pulmonary disease and bronchial asthma when combined with rhinitis had a significantly higher prevalence of comorbid mental illness than those illnesses alone.

CONCLUSION

Patients with chronic respiratory illness have high mental health comorbidity. Physicians and practitioners can be trained to identify mental illness using computer-assisted tools such as GMHAT/PC (which is easy to use by clinicians and well accepted by patients). A holistic approach of providing care to such patients may improve their overall outcome and quality of life.

Prevalence of anxiety and depressive symptoms in adolescents with asthma: a meta-analysis and meta-regression

It remains unclear whether anxiety and depressive symptoms are more prevalent in adolescents with asthma when compared with healthy individuals. This meta-analysis aimed to evaluate the difference in the aggregate prevalence of depressive and anxiety symptoms between adolescents with asthma and healthy controls and to explore the underlying moderators that potentially explain the heterogeneity of the effect size. A meta-analysis of published work was performed using the random effects model. The differences in aggregate prevalence of depressive and anxiety symptoms between adolescents with asthma and healthy controls were determined. Meta-regression and subgroup analysis were performed to identify factors that may contribute to heterogeneity. A total of eight studies were eligible for analysis. The aggregate prevalence of depressive and anxiety symptoms was significantly higher among 3546 adolescents with asthma than that of 24,884 controls (depression, 0.27; 95% CI, 0.18.6-0.39 vs. 0.13; 95% CI, 0.09-0.19; anxiety, 0.33; 95% CI, 0.19-0.52 vs. 0.21; 95% CI, 0.12-0.33). The risk of developing depression and anxiety is significantly higher among adolescents with asthma when compared with controls (depression: pooled odds ratio, 2.09; 95% CI, 1.65-2.64; p < 0.001; anxiety: pooled odds ratio, 1.83; 95% CI, 1.63-2.07; p < 0.001). Meta-regression revealed that the proportions of Caucasian (p = 0.008) and smokers (p < 0.001) were significant moderators which explained the significant heterogeneity when comparing the risk of developing depressive symptoms among adolescent asthma patients vs. controls while age, gender, and severity of asthma were not significant. Family doctors, pediatricians, and healthcare providers should formulate strategies to detect depressive and anxiety symptoms in adolescents with asthma and offer psychological interventions to reduce the burden of psychiatric comorbidity.

The investigation of severe asthma to define phenotypes

Severe asthmatics often exhibit poor control despite high doses of inhaled corticosteroids with or without systemic corticosteroids and suffer from persistent symptoms and/or recurrent exacerbations. Five to ten percentage of the asthmatic population falls within this category. Patients with severe asthma are a heterogeneous group and should be investigated to confirm the diagnosis, identify comorbidities, exclude alternative diagnoses, together with an evaluation of treatment adherence and side-effects from medications. Optimization of asthma medications and monitoring the control and pattern of asthma usually takes place over a period of 6 months. In patients with confirmed severe refractory asthma, further evaluation is needed in terms of detailed lung function, of airway and lung structure using high resolution computed tomographic scanning, and of airway inflammatory processes and biomarkers using induced sputum or bronchial biopsies. Patients with severe asthma are best investigated and managed with a multidisciplinary team. Severe asthma consists of different phenotypes that need defining. Investigation of severe asthma should bring into the open the various characteristics of the disease that could point to particular phenotype. Inclusion of investigations based on transcriptomics and proteomics should expand, improve classification and understanding of severe asthma, with the ultimate hope of finding more effective treatments and a step towards personalized medicine.

Current control and future risk in asthma management

Despite international and national guidelines, poor asthma control remains an issue. Asthma exacerbations are costly to both the individual, and the healthcare provider. Improvements in our understanding of the therapeutic benefit of asthma therapies suggest that, in general, while long-acting bronchodilator therapy improves asthma symptoms, the anti-inflammatory activity of inhaled corticosteroids reduces acute asthma exacerbations. Studies have explored factors which could be predictive of exacerbations. A history of previous exacerbations, poor asthma control, poor inhaler technique, a history of lower respiratory tract infections, poor adherence to medication, the presence of allergic rhinitis, gastro-oesophageal reflux disease, psychological dysfunction, smoking and obesity have all been implicated as having a predictive role in the future risk of asthma exacerbation. Here we review the current literature and discuss this in the context of primary care management of asthma.

Cloninger's temperament and character dimension of personality in patients with asthma

OBJECTIVE

Psychosocial factors have been implicated as being important in the onset and/or exacerbation of asthma. This study was performed to evaluate the personality profiles of asthma patients.

METHOD

Ninety-five asthmatic, 98 psoriatic patients, and 96 healthy controls completed the Temperament and Character Inventory (TCI), Beck Anxiety Inventory (BAI), and Beck Depression Inventory (BDI). The relationships between asthma illness duration, asthma severity score, depression, anxiety, and temperament and character personality variables were evaluated.

RESULTS

Asthmatic patients had significantly higher mean scores on the BAI, Harm Avoidance, Persistence, and Self-transcendence dimensions and lower scores on the BDI, Novelty Seeking, and Reward Dependence dimensions of the TCI than the psoriatic patients. Significant group effect was found for the BDI and BAI scores in between groups. Significant differences in TCI scores were found across groups except for Persistence and Self-transcendence. Post hoc tests revealed significantly lower Novelty Seeking, higher Harm Avoidance, lower Reward Dependence, and higher Self-transcendence scores in patients with asthma. Regression analysis revealed a significant effect between duration of illness and Persistence and Self-transcendence. Illness severity had a significant effect on the Harm Avoidance. Anxiety scores had significant effect on the Harm Avoidance, Self-directedness, and Self-transcendence. Depression scores had no significant effect on any of the TCI dimensions.

CONCLUSIONS

Asthmatic patients can be distinguished by a specific pattern of temperament (low NS) and character (high ST) dimensions and compared with both psoriatic patients and healthy controls. Illness duration is associated with ST scores, and illness severity is associated with HA.

Psychologic distress and maladaptive coping styles in patients with severe vs moderate asthma

BACKGROUND

Though several biologic factors have been suggested to play a role in the development and persistence of severe asthma, those associated with psychologic factors remain poorly understood. This study assessed levels of psychologic distress and a range of disease-relevant emotional and behavioral coping styles in patients with severe vs moderate asthma.

METHODS

Eighty-four patients (50% women, mean [M] age 46 years) with severe (n = 42) and moderate (n = 42) asthma were recruited. Severe asthma was defined according to American Thoracic Society criteria. Patients underwent demographic and medical history interviews and pulmonary function and allergy testing. Patients also completed questionnaires measuring asthma symptoms and the Millon Behavioral Medicine Diagnostic Inventory, which assesses psychologic distress and emotional/behavioral coping factors that influence disease progression and treatment.

RESULTS

After adjustment for covariates and applying a correction factor that reduced the significant P level to < .01, patients with severe vs moderate asthma reported experiencing more psychologic distress, including worse cognitive dysfunction (F = 6.72, P < .01) and marginally worse anxiety-tension (F = 4.02, P < .05). They also reported worse emotional coping (higher illness apprehension [F = 9.57, P < .01], pain sensitivity [F = 10.65, P < .01], future pessimism [F= 8.53, P < .01], and interventional fragility [F = 7.18, P < .01]), and marginally worse behavioral coping (more functional deficits [F = 5.48, P < .05] and problematic compliance [F = 4.32, P < .05]).

CONCLUSIONS

Patients with severe asthma have more psychologic distress and difficulty coping with their disease, both emotionally and behaviorally, relative to patients with moderate asthma. Future treatment studies should focus on helping patients with severe asthma manage distress and cope more effectively with their illness, which may improve outcomes in these high-risk patients.

Severe asthma: what makes it so hard to manage?

Severe asthma presents significant management challenges. Patients can be difficult to control despite use of current standard-of-care therapy, including inhaled corticosteroids and long-acting beta-agonists. Alternative diagnoses, noncompliance, and comorbidities all can influence asthma control, future risk, and response to currently available therapy. Definitions of severe asthma evaluate and address these confounding variables, and yet patients are still symptomatic despite aggressive, appropriate therapy. Severe asthma has a distinct pathophysiology including airway remodeling that contributes to the decreased effectiveness of standard therapy. Multiple phenotypes exist within severe asthma that likely require distinct therapeutic approaches to achieve control and improve long-term health outcomes. New therapeutic approaches to these distinct phenotypes will improve our understanding and treatment of this difficult-to-manage disease.

Anxiety and the management of asthma in an adult outpatient population

BACKGROUND

Review of the literature suggests that anxiety is more common among patients with asthma than among the general population, yet it does not appear to be given the attention it deserves as part of the overall management of asthma. The aim of this study was to investigate the relationship between anxiety and asthma management, in terms of Global Initiative for Asthma steps, lung function and medication.

METHODS

A total of 201 consecutive patients with respiratory physician-diagnosed asthma were recruited from an adult outpatient asthma clinic. Participants underwent a sociodemographic review, and a medical interview which included a detailed drug history. Forced expiratory volume in 1 second (FEV(1)) and peak expiratory flow (PEF) values were recorded using a Micro Medical((R)) portable spirometer. The level of anxiety was assessed using the Beck Anxiety Inventory (BAI).

RESULTS

A total of 51.5% of participants registered clinically significant levels of anxiety. Of these only 21% had already been diagnosed and were receiving treatment. Females reported significantly higher BAI scores than males (p < 0.01). More females (66.3%) registered clinically significant levels of anxiety as compared with males (33.7%) (p < 0.05). There was a positive correlation between the BAI score and the prescribed dose of inhaled glucocorticoids (r(s) = 0.150, p < 0.05) and between anxiety and GINA treatment step (r(s) = 0.139, p < 0.05). There was also a positive correlation between anxiety and the number of medicines taken by patients (r(s) = 0.259, p < 0.001).

CONCLUSIONS

Physicians treating patients with asthma should be sensitised to the association between asthma and anxiety, and should also consider assessing patients for the possibility of anxiety disorders as part of asthma management plans.

Self-management plans for asthma control and predictors of patient compliance

OBJECTIVE

To evaluate the impact of peak flow or symptom-based self-management plans on asthma control and patients' quality of life and to determine the main psychosocial factors that affect compliance with these plans.

METHODS

The study sample consisted of 63 patients with persistent asthma outpatients. Data collection included demographics, pulmonary functions, symptom scores, and asthma control parameters recorded over the previous 2 consecutive years. A standard asthma self-management education program including personal action plans was given to the patients who were randomly divided into peak flow meter (PFM) (n = 31) or symptom-based (n = 32) action plan groups. Patients were then assessed prospectively for various study outcomes including symptoms, drug compliance, psychiatric co-morbidities, quality of life, and asthma control over the next 12 months. Psychiatric co-morbidities were assessed using Rotter's Internal and External Locus of Control Scale (RIELCS), Beck Depression Inventory (BDI), Structured Clinical Interview for DSM-IV (SCID-I), Spielberger State-Trait-Anxiety Inventory (STAI), and Short Form-36 (SF-36).

RESULTS

Of the 63 patients (79% female; mean age 43), 85% of them had moderately or severely persistent asthma. Baseline demographics, clinical parameters, psychiatric diagnosis, and quality of life were not different between groups. Personal asthma plans increased optimal asthma control significantly. Emergency visits, antibiotic treatments, systemic corticosteroid treatments, and unscheduled visits were fewer than the previous year. Control parameters were better in the PFM group. After the self-management education, the quality of life dimensions, i.e., vitality, total mental and general scores of both groups increased. Frequency of psychiatric co-morbidities decreased from 61.9% to 49.2%. However, state anxiety levels were increased in both groups. These increases were statistically significant in the PFM group. Compliance with the action plans was better in the PFM group. Higher BDI scores were associated with worse compliance. No statistically significant association was found between demographic parameters and the compliance. Although the compliance had decreased in both groups after 6 months, this decrease was greater in the symptom group. Higher RIELCS and mental health scores were associated with better compliance.

CONCLUSION

Introduction of self-management plans improved illness control and quality of life in asthma patients. Use of the PFM and the presence of higher RIELCS and lower BDI scores can be used to predict compliance with the action plans.

Specific psychiatric morbidity among a sample of asthmatics in south western Nigeria

OBJECTIVE

This study was to identify specific psychiatric morbidity among asthma patients and to compare their rates to controls.

METHOD

Hundred consecutive asthmatics were screened using the General Health Questionnaire (GHQ-30), and the Present State Examination (PSE). The same instruments were also administered to 75 healthy individuals, and 75 orthopaedic patients.

RESULTS

Patients with asthma had a higher occurrence of psychopathology. The specific psychiatric diagnoses among asthmatics were generalized anxiety disorder (23%), depressive disorder (11%), while 2% had panic disorder.

CONCLUSION

Psychiatric morbidity is more common among asthmatics, than the general population and other patient group.

[Severe asthma]

Severe asthma is diagnosed in patients with refractory asthma that is difficult to control despite a thorough reevaluation of the diagnosis and management and after more than 6 months of follow-up by a physician specializing in asthma. Respiratory function measurements and reversibility and bronchial provocation tests (except when contraindicated) are essential in the reevaluation of an asthma diagnosis. Factors that can influence asthma control, such as environmental exposures, comorbid conditions, treatment adherence, and in particular inhalation technique must be recognized and considered appropriately before confirming the diagnosis of severe asthma. Objective criteria are important in the follow-up evaluation of severe asthma. They must include the measurement of some disease components. During follow-up, it is recommended that patients be monitored by validated questionnaires about quality of life and asthma control and by pulmonary function measurements, airway inflammation assessment, and recording the frequency of exacerbations and healthcare system use (including whether planned or unexpected). Severe asthma is a heterogeneous condition that includes several phenotypes. Determining the phenotype of each case of severe asthma will improve our understanding of its underlying mechanisms, natural history and prognosis, will help guide the choice of current and future treatments and will provide useful indications for new therapeutic interventions.

Severe asthma in adults: what are the important questions?

The term severe refractory asthma (SRA) in adults applies to patients who remain difficult to control despite extensive re-evaluation of diagnosis and management following an observational period of at least 6 months by a specialist. Factors that influence asthma control should be recognized and adequately addressed prior to confirming the diagnosis of SRA. This report presents statements according to the literature defining SRA in order address the important questions. Phenotyping SRA will improve our understanding of mechanisms, natural history, and prognosis. Female gender, obesity, and smoking are associated with SRA. Atopy is less frequent in SRA, but occupational sensitizers are common inducers of new-onset SRA. Viruses contribute to severe exacerbations and can persist in the airways for long periods. Inflammatory cells are in the airways of the majority of patients with SRA and persist despite steroid therapy. The T(H)2 immune process alone is inadequate to explain SRA. Reduced responsiveness to corticosteroids is common, and epithelial cell and smooth muscle abnormalities are found, contributing to airway narrowing. Large and small airway wall thickening is observed, but parenchymal abnormalities may influence airway limitation. Inhaled corticosteroids and bronchodilators are the mainstay of treatment, but patients with SRA remain uncontrolled, indicating a need for new therapies.

Psychosocial factors and asthma in a community sample of older adults

OBJECTIVE

The objective of this study was to investigate the associations between psychosocial factors and asthma in a population-based cohort study of older adults.

METHODS

A total of 20,888 participants in the Norfolk cohort of the European Prospective Investigation into Cancer study completed assessments that included details of lifetime self-reported doctor-diagnosed asthma, mood disorder history, social adversity experience, and social support.

RESULTS

Doctor-diagnosed asthma was reported by 1699 (8.1%) participants. After adjusting for age, sex, preexisting myocardial infarction, stroke, diabetes, cancer, cigarette smoking, social class, and area deprivation, the psychosocial factors most strongly (and independently) associated with asthma were major depressive disorder (P=.0001), adverse childhood circumstances (P=.005), reported impact of life events experienced in adulthood (P=.003), long-term difficulties in adulthood (P=.04), and negative aspects of confidant support (P=.002).

CONCLUSION

These results demonstrate that adverse psychosocial factors cluster among older adults with asthma. These findings may have implications for guiding improvements in asthma management.

Interference of psychological factors in difficult-to-control asthma

BACKGROUND

Most patients with asthma can be controlled with suitable medication, but 5-10% of them remain difficult to control despite optimal management.

OBJECTIVE

We investigated whether patients with difficult-to-control asthma (DCA) or controlled asthma (CA) differ with respect to psychological factors, such as general control beliefs on life events.

METHODS

DCA was defined as an absence of control despite optimal management. Recent control was measured using the Asthma Control Questionnaire. General control beliefs were investigated using a Locus of Control scale (LOC).

RESULTS

Patients with DCA had a significantly higher external LOC as compared to patients with CA (P=0.01). In the DCA group, the hospital admission rate was highly significant in association with the external LOC (P=0.004) as compared to the internal LOC trend.

CONCLUSION

This study showed that patients with DCA had different general control beliefs which might have hampered their management and interfered with their therapeutic adherence. The present findings could enhance management of DCA in a clinical setting.

Anxiety, panic and adult asthma: a cognitive-behavioral perspective

A review of previous research suggests increased probability of the prevalence of anxiety disorders, and particularly panic disorder and panic attacks in patients with asthma, as compared to a normal population. Research also indicates significant levels of co-morbidity between asthma and anxiety as measured on dimensional scales of anxiety and panic. Clinical anxiety and panic manifestations affect symptom perception and asthma management through the effects of anxiety symptoms such as hyperventilation, and indirectly through self-management behavior and physician response. However, there is limited data on the impact of anxiety co-morbidity on asthma quality of life. Some studies indicate that individuals with co-morbid asthma and anxiety or panic report worse asthma quality of life both in general and in relation to their symptomatology, being limited in their daily activities, in response to environmental stimuli and in regard to feelings of emotional distress. Cognitive-behavioral therapy (CBT) is an effective and empirically supported treatment of choice for anxiety disorders and panic attacks. However, standard CBT protocols for anxiety and panic may need to be specifically targeted at improving asthma outcomes. Also, asthma research literature is lacking in randomized controlled trials applying CBT to patients with co-morbid asthma and clinical anxiety manifestations. Trials evaluating CBT interventions in individuals with clinical anxiety manifestations and asthma may provide evidence of these interventions as an effective adjunct to improve asthma management and control.

Personality characteristics of asthma patients

INTRODUCTION

Asthma, similarly to other chronic conditions, is strongly influenced by psychological factors. Previous studies have not established the personality characteristics of adult asthma patients as compared to non-patients.

OBJECTIVES

To study the psychological characteristics of adult asthma patients in comparison to a pattern drawn up for the Portuguese population. To study the relationships between the personality and the severity and duration of the disease.

METHODS

Outpatients of the Immunallergology and Pulmonology units of the São João Hospital suffering from asthma responded to the Revised NEO Personality Inventory (NEO-PI-R). Patients with co-morbidity factors were not excluded. The doctor who attended them classified the severity of the asthma according to the Global Initiative for Asthma (GINA). Relationships between the personality and the severity/duration of the disease were analysed using the ANOVA models.

RESULTS

300 asthma patients aged between 17 and 79 were studied. Of these, 75% were female; the great majority had intermittent/light persistent asthma (71%); 17% had moderate persistent asthma and 12% had severe persistent asthma. The duration of the disease was less than 10 years in 34% and over 23 years in 35%. The asthma patients had higher Neuroticism scores (p < 0.001), with the other facets (except impulsiveness) equally high. All the remaining domains--Extroversion, Openness to Experience, Conscientiousness and Agreeableness--had lower scores than the control group (p < 0.001). Both Extroversion and Openness to Experience decrease with growth in the severity (p = 0.003; p = 0.009) and the duration of the disease (p = 0.006; p = 0.013). Neuroticism increases in tandem with the severity of the disease.

CONCLUSION

This study shows the predominance of Neurotic characteristics and lowered Extroversion, Openness to Experience, Agreeableness and Conscientiousness characteristics in asthmatics as compared to the general Portuguese population. Decreased Extroversion and Openness to Experience are observed as the severity and duration of the disease increase. Further studies are necessary to clarify the relationships between personality and the severity and duration of the disease.

Psychiatric disorders and asthma outcomes among high-risk inner-city patients

OBJECTIVE

The purpose of this study was to examine the rate of psychiatric disorders among patients attending an ethnically diverse, inner-city asthma clinic for an initial visit and assess the association between psychiatric disorders and asthma morbidity.

METHODS

A semistructured psychological interview was conducted to assess for psychiatric diagnoses. A pulmonary physician, who was blind to psychiatric disorder, established diagnosis of asthma based on national guidelines.

RESULTS

Sixty-four percent of 85 participants received at least 1 psychiatric diagnosis. The pulmonary physician rated patients with a psychiatric disorder as achieving fewer goals (M = 2.3 +/- 1.3) for asthma control than patients without a psychiatric disorder (M = 3.6 +/- 1.5, p = .0002). Patients with a psychiatric diagnosis more frequently reported an emergency room visit for asthma during the past 6 months (OR = 4.89; 95% CI, 1.76-13.39) and greater use of short-acting beta2-agonist medication (M = 1.5 +/- 0.9 canisters per month) than patients without a psychiatric diagnosis (M = 0.9 +/- 0.8, p = .003). These findings were independent of demographics, health insurance, and asthma severity. No differences emerged between patients with and without a mental disorder on percent predicted FEV1. Patients with a psychiatric disorder reported a higher severity level for asthma symptoms than the severity level indicated by their pulmonary function in comparison to patients without a psychiatric diagnosis (OR = 3.52; 95% CI, 1.23-10.10). Health insurance appeared to be a confounding factor in this relationship.

CONCLUSION

A high rate of psychiatric disorders was found among inner-city asthma patients. Psychiatric diagnoses were associated with greater perceived impairment from asthma but not objective measurement of pulmonary function.

Severe Asthma in Adults

Severe asthma remains poorly understood and frustrating to care for, partly because it is a heterogeneous disease. Patients with severe asthma disproportionately consume health care resources related to asthma. Severe asthma may develop over time, or shortly after onset of the disease. The genetic and environmental elements that may be most important in the development of severe disease are poorly understood, but likely include both allergic and nonallergic elements. Physiologically, these patients often have air trapping, airway collapsibility, and a high degree of methacholine hyperresponsiveness. Specific phenotypes of severe asthma are only beginning to be defined. However, describing severe asthma by age at onset (early- vs. late-onset) appears to describe two phenotypes that differ at immunologic, physiologic, epidemiologic, and pathologic levels. In particular, early-onset severe asthma is a more allergic-associated disease than late-onset severe asthma. In addition, patients with severe asthma can be defined on the basis of presence and type of inflammation. Severe asthma with persistent eosinophilia (of either early or late onset) is more symptomatic and has more near-fatal events. However, at least 50% of patients with severe asthma have very little identifiable inflammation. Thus, "steroid resistance" may occur at numerous levels, not all of which are caused by a lack of effect of steroids on inflammation. Treatment remains problematic, with corticosteroids remaining the most effective therapy. However, 5-lipoxygenase inhibitors, anti-IgE, and immunomodulatory drugs are also likely to have a place in treatment. Improving therapy in this disease will require a better understanding of the phenotypes involved.

Psychological status and quality of life in elderly patients with asthma

The psychological status and quality of life of 70 stable patients with asthma age > or =60 years and 40 age-matched comparison subjects were examined. The patients with long-standing asthma (duration > or = 8 years) had lower quality-of-life scores than those with recent-onset asthma (duration < 8 years). In multivariate linear regression analysis with adjustment for age, gender duration of disease, and level of bronchial hyperreactivity, worse quality of life was predicted by anxiety, depression, and asthma severity scores. In elderly patients with long-standing asthma, disease severity significantly impairs quality of life. Impaired quality of life in these patients may be partly related to psychological status indicators.

Prevalence of psychiatric morbidity in a difficult asthma population: relationship to asthma outcome

INTRODUCTION

Psychiatric morbidity appears common in fatal and near-fatal asthma and may be a factor in difficult to control asthmatic subjects. We examined the prevalence of psychiatric morbidity (using psychiatric interview) in a cohort of sequentially referred poorly controlled asthmatics and related this to (a) asthma outcome (b) assessing chest physician opinion and (c) Hospital Anxiety Depression Scale (HADS).

METHODS

Patients were evaluated using a systematic evaluation protocol to identify and manage all co-morbidity. Psychiatric assessment was performed by experienced liaison psychiatrists and ICD10 diagnosis and treatment programme assigned. Subjects completed HADS at presentation and follow-up. Asthma was managed according to BTS/SIGN Guidelines.

RESULTS

Of 65 subjects who attended for psychiatric interview, 32 (49%) had an ICD10 diagnosis, (6 (9%) previously identified) with depression most common (59%). Physician assessment had poor discrimination for psychiatric illness. Anxiety scores (13.4+/-0.8 vs. 8.5+/-0.7) and depression scores (10.2+/-0.7 vs. 4.8+/-0.5) scores were significantly higher in subjects with ICD10 diagnosis (P<0.001), who were also more likely to be current smokers (P<0.01). HADS had a poor positive predictive value for psychiatric illness but a good negative predictive value for depression. There was no relationship between ICD10 diagnosis and asthma outcome. Subjects identified as therapy-resistant asthma after systematic evaluation, had significantly lower depression scores after treatment (P<0.05).

CONCLUSION

In difficult asthmatics, there is a high prevalence of undiagnosed psychiatric morbidity, with depression being particularly prevalent. A simple screening questionnaire such as HADS, has a high false positive rate when compared to psychiatric interview, but may be useful in excluding depressive illness. There appears to be little association between identification and management of co-existent psychiatry morbidity and asthma outcome.

Asthma and panic in young adults: a 20-year prospective community study

RATIONALE

Psychologic factors are increasingly recognized to influence the onset and course of asthma. Previous cross-sectional community-based studies have provided evidence for a relatively specific association between asthma and panic.

OBJECTIVES

To examine concurrent and longitudinal associations between asthma and panic in young adults.

MEASUREMENTS AND MAIN RESULTS

Prospective community-based cohort study of young adults (n = 591) followed between ages 19 and 40. Information was derived from six subsequent semistructured diagnostic interviews conducted by professionals. Cross-sectionally (over the whole study period), asthma was more strongly associated with panic disorder (odds ratio [OR] = 4.0; 95% confidence interval [CI], 1.7, 9.3) than with any panic, which included panic disorder and panic attacks (OR = 2.1; 95% CI, 1.1, 4.5). Longitudinally, after adjusting for potentially confounding variables, active asthma predicted subsequent panic disorder (OR = 4.5; 95% CI, 1.1, 20.1), and the presence of panic disorder predicted subsequent asthma activity (OR = 6.3; 95% CI, 2.8, 14.0). Asthma predicted any panic (OR = 2.7; 95% CI, 1.1, 7.1), whereas any panic did not predict subsequent asthma activity. Associations were stronger in smokers than in nonsmokers, and stronger in women than in men. Smoking, early-childhood anxiety, and a family history of allergy were important confounders of the asthma-panic association.

CONCLUSIONS

This is the first long-term follow-up study on asthma and panic. It showed dose-response-type relationships between panic and asthma, and bidirectional longitudinal associations between the two conditions. It provided evidence for familial factors and smoking as possible shared etiologic explanations.

The association of anxiety with asthma among a sample of asthmatics in Ile-Ife Osun State Nigeria

BACKGROUND

The association between asthma and anxiety has been a subject of various studies in developed countries, but there has been little work done in this area in developing countries. The goal of this study is to determine whether asthmatics are more anxious than orthopaedic patients and healthy individuals.

METHOD

Fifty consecutive asthmatics were assessed. All completed a sociodemographic questionnaire, the General Health Questionnaire (GHQ--30) and the State Trait Anxiety Inventory (STAI--1 and 2). Healthy individuals (30) and orthopaedic patients (30) were also recruited as controls; they also completed the GHQ and the STAI--1 and 2.

RESULTS

No significant difference was found in the sociodemographic variables such as age, sex, occupation, and marital status. The asthmatics had a mean GHQ score of 4.2 (SD+/-4.6) while orthopaedic and healthy control groups scored 1.6 (SD+/-1.8) and 2 (SD+/- 1.8), respectively. There was a significant difference in the mean score of the index population (Asthmatics) and the comparison groups (F=7.09, DF=2/107, P=0.004). With GHQ, cutoff point of > or =5.34% of asthmatics scored above 5 while 10% and 13.3% of the orthopaedic patients and healthy controls each scored > or =5. A significant difference was obtained in the mean scores on the STAI--1 questionnaire (F=4.6, DF=2/107, P=.012) indicating state anxiety whereas there was no significant difference on the STAI-2 questionnaire (F= 1.2, DF=2/107, P=0.31).

CONCLUSION

Although asthmatics have higher anxiety compared to controls, this is not an inherent problem or trait among them.

Norwegian versions of the Living with Asthma Questionnaire (LWAQ) and Asthma Bother Profile (ABP), validation and comparison of two asthma groups

The Living with Asthma Questionnaire (LWAQ) and the Asthma Bother Profile (ABP) were translated into Norwegian using conventional back translation procedures, and completed by 30 asthma outpatients and 30 asthma patients admitted to inpatient rehabilitation. Reliability (Cronbach's alpha and retest-reliability) was shown to be good for both scales. Validity was established by showing significantly poorer health in the rehabilitation sample, and correlations with state and trait anxiety. The Norwegian translations are reliable and valid versions of the original questionnaires.

Anxiety symptoms in allergic patients: identification and risk factors

OBJECTIVES

Multiple relationships between anxiety, allergic symptoms, and treatment difficulties have been observed. The aim of the present study was to estimate the prevalence of anxiety disorders in outpatients with various allergic diseases, to identify diagnostic cues or possible risk factors, and to test the usefulness of self-administered questionnaire screening at the allergy clinic.

METHODS

Six hundred forty-six (646) consecutive patients with rhinoconjunctivitis (59.3%), asthma (26.8%), or "other" allergy (13.9%), aged 16 to 65 years, completed self-administered questionnaires in six outpatient allergy clinics; 60 of the respondents also participated in structured psychiatric interviews. Anxiety was measured with the Spielberger State-Trait Anxiety.

RESULTS

According to the interviews, STAI-T > 52 predicted with 86% accuracy a current psychiatric diagnosis, without differentiating between anxiety and depression. Using this threshold, the rate of anxiety and/or depressive disorders is estimated as 19% (95% CI: 15.9-22.1) in our unselected allergic outpatient sample; 46% of these patients never received any psychopharmacological treatment, indicating that anxiety related disorders are underdiagnosed and undertreated. Risk indicators were female gender; asthma; perennial symptoms; sleep problems; nonspecific allergy triggers like strong emotions; stressful situations; and considerable limitation in everyday activities attributed to the allergic symptoms.

CONCLUSIONS

Our findings confirm a high rate of anxiety and/or depressive disorders in patients visiting the allergy clinic. Self-administered questionnaires such as STAI-T provide reliable help for the identification of these frequent psychiatric problems.

Predictors of repeat hospitalizations in children with asthma: the role of psychosocial and socioenvironmental factors

This study examined relationships between psychosocial factors and asthma rehospitalization patterns in 115 children (ages 4-15) who had > or = 1 hospitalization during the study period. Lifetime history of hospitalizations and new hospitalizations during a 1-year follow-up period were measured, controlling for baseline asthma symptoms and medications. Prospectively, caretaker characteristics (lower sense of mastery, being less emotionally bothered by asthma) predicted greater likelihood of future asthma hospitalizations. Lifetime history of hospitalizations was associated with family impacts (greater family strain and family conflict greater financial strain) as well as caretaker characteristics (greater personal strain, beliefs about not being able to manage one's child's asthma). These findings could help guide future interventions targeted at the subgroup of children who represent a high proportion of asthma hospitalizations.

Depressive Symptoms in Inner-City Children With Asthma

BACKGROUND: Asthma is a sometimes severe respiratory illness with an increased prevalence, especially in low-income, minority, and inner-city populations, over the past 2 decades. Prior reports have suggested a link between depression and asthma deaths. However, no studies have examined the relationship between objective measures of asthma severity and clinician-rated depressive symptom severity. METHOD: In this pilot study, 46 children receiving treatment at an inner-city asthma clinic were assessed with the Children's Depression Rating Scale, Revised (CDRS-R). The current percentage of forced expiratory volume in 1 second (FEV(1)%) predicted and the inhaled steroid dose were recorded, as were oral steroid use, emergency room visits, and hospitalizations in the preceding year. RESULTS: Depressive symptoms were common in this sample, with 30% (N = 14) of the participants having CDRS-R scores consistent with likely, very likely, or almost certain major depressive disorder. When mean CDRS-R scores were compared between the sample divided by these asthma severity measures, only hospitalizations in the past year was associated with higher depressive symptom scores (p =.03). CONCLUSION: These findings suggest that in the patient sample studied, depressive symptoms appear to be common. However, depressive symptom severity is related only to hospitalization, not other measures of asthma severity. Larger studies are needed to confirm these findings and determine if other variables such as family history of depression or subjective assessment of asthma severity explain the high prevalence of depressive symptoms in these patients.

Psychological aspects of asthma

Asthma can be affected by stress, anxiety, sadness, and suggestion, as well as by environmental irritants or allergens, exercise, and infection. It also is associated with an elevated prevalence of anxiety and depressive disorders. Asthma and these psychological states and traits may mutually potentiate each other through direct psychophysiological mediation, nonadherence to medical regimen, exposure to asthma triggers, and inaccuracy of asthma symptom perception. Defensiveness is associated with inaccurate perception of airway resistance and stress-related bronchoconstriction. Asthma education programs that teach about the nature of the disease, medications, and trigger avoidance tend to reduce asthma morbidity. Other promising psychological interventions as adjuncts to medical treatment include training in symptom perception, stress management, hypnosis, yoga, and several biofeedback procedures.