Association of Anxiety With Asthma: Subjective and Objective Outcome Measures

Biofeedback Training to Increase P co2 in Asthma With Elevated Anxiety: A One-Stop Treatment of Both Conditions?

OBJECTIVE

Anxiety is highly prevalent in individuals with asthma. Asthma symptoms and medication can exacerbate anxiety, and vice versa. Unfortunately, treatments of comorbid anxiety and asthma are largely lacking. A problematic feature common to both conditions is hyperventilation. It adversely affects lung function and symptoms in asthma and anxiety. We examined whether a treatment to reduce hyperventilation, shown to improve asthma symptoms, also improves anxiety in asthma patients with high anxiety.

METHOD

One hundred twenty English- or Spanish-speaking adult patients with asthma were randomly assigned to either Capnometry-Assisted Respiratory Training (CART) to raise P co2 or feedback to slow respiratory rate (SLOW). Although anxiety was not an inclusion criterion, 21.7% met clinically relevant anxiety levels on the Hospital Anxiety and Depression Scale (HADS). Anxiety (HADS-A) and depression (HADS-D) scales, anxiety sensitivity (Anxiety Sensitivity Index [ASI]), and negative affect (Negative Affect Scale of the Positive Affect Negative Affect Schedule) were assessed at baseline, posttreatment, 1-month follow-up, and 6-month follow-up.

RESULTS

In this secondary analysis, asthma patients with high baseline anxiety showed greater reductions in ASI and PANAS-N in CART than in SLOW ( p values ≤ .005, Cohen d values ≥ 0.58). Furthermore, at 6-month follow-up, these patients also had lower ASI, PANAS-N, and HADS-D in CART than in SLOW ( p values ≤ .012, Cohen d values ≥ 0.54). Patients with low baseline anxiety did not have differential outcomes in CART than in SLOW.

CONCLUSIONS

For asthma patients with high anxiety, our brief training designed to raise P co2 resulted in significant and sustained reductions in anxiety sensitivity and negative affect compared with slow-breathing training. The findings lend support for P co2 as a potential physiological target for anxiety reduction in asthma.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT00975273 .

The COVID-19 pandemic: asthma control, tobacco use, and mental health among African American and Latinx college students

OBJECTIVE

This study investigated the impact of COVID-19 on tobacco use and mental health in US African American and Latinx college students with asthma. Associations among asthma control, tobacco use, and mental health were also examined.

METHODS

105 African American and Latinx college students with asthma (18-23 years) completed two online questionnaires (June 2019-March 2020 for Time 1; August 2020-October 2020 for Time 2). Participants completed the Epidemic-Pandemic Impacts Inventory (measure of COVID-19 impact), Asthma Control Test, Generalized Anxiety Disorder scale, Patient Health Questionnaire (measure of depression), Perceived Stress Scale, and items related to tobacco use.

RESULTS

Asthma control improved (t = -3.326, p = 0.001) from Time 1 to 2, and e-vapor product use decreased (χ²₁₀₄ = 6.572, p = 0.010). COVID-19 impact was positively associated with students' symptoms of anxiety, depression, and perceived stress (B = 0.201, p < 0.001; B = 0.179, p < 0.001; and B = 0.199, p = 0.001, respectively) at Time 2. These results remained significant with the Benjamini-Hochberg correction. Asthma control at Time 1 was negatively associated with anxiety symptoms at Time 2 (B = -0.418, p = 0.023); however, associations with perceived stress (B = -0.514, p = 0.019) and all other tobacco product use (B = -0.233, p = 0.030) did not remain significant with the Benjamini-Hochberg correction.

CONCLUSIONS

As hypothesized, a higher COVID-19 impact score was associated with students endorsing more mental health symptoms. Better control of asthma symptoms before the pandemic predicted fewer anxiety symptoms during the pandemic.

Psychological distress, social support, and use of outpatient care among adult men and women with coronary artery disease or other non-cardiovascular chronic disease

OBJECTIVES

Psychological distress, as defined by elevations in symptoms of depression, anxiety, and/or perceived stress, is frequent in patients with chronic diseases, such as coronary artery disease (CAD). While psychological distress is known to impact disease outcomes, less is known about its influence on health care utilization, or on the factors that may modify these relationships. This prospective study examined whether 1) psychological distress predicts greater use of outpatient care services over a period of up to eight years in middle-aged to older individuals with CAD or other non-cardiovascular chronic diseases; 2) this relationship differs according to sex, presence of CAD, and/or social support.

METHODS

Men and women (N = 1236; aged 60.85 ± 6.95 years) with and without CAD completed validated questionnaires on symptoms of depression, anxiety, perceived stress, and social support. Number of medical outpatient visits was obtained from the Régie de l'assurance maladie du Québec. Analyses included bivariate correlations, hierarchical regressions, and moderation analyses, controlling for sociodemographic and lifestyle variables.

RESULTS

Psychological distress, social support, and yearly outpatient visits were significantly correlated (ps < 0.05). In regression analyses, only depressive symptoms were associated with significantly greater use of outpatient care (b = 0.048, p = .004), particularly among CAD patients (b = 0.085, p < .001). Neither sex nor social support moderated this relation.

CONCLUSION

Depression predicted greater outpatient visits in patients with chronic disease, especially CAD patients. More research is needed to determine whether psychosocial interventions may have an impact on health care utilization.

Psychometric validation of the Chinese version of the Adolescent Asthma Self-Efficacy Questionnaire

Background

Self-efficacy was considered as a promising target for the self-management of symptoms for adolescents with asthma. The measurement of self-efficacy in adolescents with asthma requires effective self-report tools, which have not been met with at present. So, the aim of this study was to cross-culturally validate the Adolescent Asthma Self-Efficacy Questionnaire (AASEQ).

Methods

As many as 408 adolescents with asthma were invited to take up the psychometric properties test between July 2021 and June 2022. We conducted the confirmatory factor analysis (CFA) to determine the structure of the AASEQ. The relationship between the AASEQ and General Self-Efficacy Scale was tested to evaluate the construct validity. The reliability was evaluated by retest reliability, internal consistency, and interfactor correlation.

Results

The results of the present study showed that the confirmatory factor analysis indicated a significantly good fit for a four-factor model, which explained 62.697% of the total variance. The fit indices of the four-factor model were acceptable, and the standardized factor loading ranged from 0.631 to 0.880. The C-AASEQ showed an acceptable internal consistency (Cronbach's α = 0.810-0.927) and test-retest reliability (intraclass correlation coefficient = 0.64-0.89). Content validity index at the scale level was 0.96, and content validity index at the item level was 0.86 to 1.

Conclusion

The Chinese version of Adolescent Asthma Self-Efficacy Questionnaire showed consistently acceptable positive psychometric properties and can be used as an instrument to assess the self-efficacy of adolescents with asthma in China, as corroborated in the present study.

Patients' and physicians' attitudes and perception about asthma in the Gulf: A subset analysis from the Asthma Insights and Management Survey in the Gulf and Russia

Background: Asthma is a prevalent disorder in the Gulf region. However, available data concerning asthma control and patients' perception with regard to their disease are still insufficient. Objective: To investigate patients' perception and behavior with regard to the asthma-related burden, the level of asthma control, and asthma management in three Gulf countries. Methods: This study presented a subset analysis of the Asthma Insights and Management survey about the asthma burden and management in the Gulf region and Russia. In this subset analysis, we retrieved the data of the patients from Saudi Arabia, United Arab Emirates, and Kuwait. Results: The current survey's population was composed of 452 patients. One hundred fifty-four patients (34.1%) rated themselves as having poorly controlled asthma, whereas 60.3% of the patients perceived their asthma as completely or well controlled. However, only two patients (0.4%) had controlled asthma according to the global asthma guidelines criteria for asthma control. Most of the patients (67.7%) reported that their asthma got worse when outdoors. Almost 70% of the patients on daily control plus a quick relief regimen reported that their asthma got worse when they were outdoors. Over the past 12 months, 95 patients (21%) reported asthma exacerbation. More than half of the included patients experienced an asthma attack that stopped their activities, whereas 54.2% of the patients were forced to leave work or school due to an asthma attack, and 53.1% had to cancel an appointment or had to go to bed due to the severity of the attack. With concern to asthma management, only 30.5% of the patients were given a lung function test for the assessment of their asthma. A written action plan for asthma treatment was developed by the physician or the practice nurse for only 21.7% of the patients. Conclusion: In the Gulf region, asthma exerts a substantial burden on patients who are affected. Such a burden significantly impacted patients' quality of life.

Asthma control and psychological health in pediatric severe asthma

OBJECTIVES

Psychological comorbidities have been associated with asthma in adults and children, but have not been studied in a population of children with severe asthma. The aim of this study was to test the hypothesis that symptoms of anxiety or depression are highly prevalent in pediatric severe asthma and negatively effects asthma control.

METHODS

Longitudinal assessments of anxiety or depression symptoms (Patient Health Questionnaire-4 [PHQ-4]), asthma control (Asthma Control Test [ACT]), and lung function were performed in a single-center pediatric severe asthma clinic. Participant data were collected during routine clinical care. Primary outcomes were ACT and forced expiratory volume in 1 s per forced vital capacity (FEV1/FVC).

RESULTS

Among 43 subjects (with total 93 observations), 58.1% reported at least one anxious or depressive symptom and 18.6% had a PHQ-4 more than 2, the threshold for an abnormal test result. After adjusting for age, sex, race, and asthma medication step, there was a significant reduction in ACT for girls with PHQ-4 more than 2 (adjusted mean [SE] ACT for PHQ-4 > 2: 13.64 [0.59], ACT for PHQ-4 ≤ 2: 20.64 [1.25], p = .02) but not boys. Moreover, there was a significant differential effect of mental health impairment for girls than boys. ACT for girls with PHQ more than 2: 13.64 (0.59) compared with boys with PHQ-4 more than 2: 17.82 (0.95), adjusted mean difference ACT by sex = 4.18 points; 95% confidence interval, 0.63-7.73; p = .033. In adjusted models, there was no association between PHQ-4 more than 2 and FEV1/FVC.

CONCLUSIONS

Symptoms of anxiety and depression are common. In children with severe asthma, a PHQ-4 score more than 2 is associated with worse asthma symptom control in girls, but not boys.

The Interaction Between Asthma and Anxiety: An Interpretative Phenomenological Analysis of Young People's Experiences

Asthma and anxiety are highly co-morbid, and their interaction leads to exacerbations for both conditions. This study explored the interplay between these two conditions from the perspective of children and adolescents. The objective was to identify potential mechanisms of interaction between asthma and anxiety, and to derive improvements for prevention and treatment. Eleven semi-structured interviews of young people (aged 11-15), who met criteria for both asthma and anxiety, were analysed using interpretative phenomenological analysis. Well-established qualitative research recommendations were followed to promote credibility and rigour in the findings. Eight themes emerged that were organised in three domains: (i) asthma affecting anxiety by inhibiting coping activities or developmental tasks and by triggering unhelpful thinking and behaviour; (ii) anxiety affecting asthma by impairing self-care and triggering hyperventilation; (iii) interactions between asthma and anxiety, including self-perpetuating feedback cycles and symptom confusion. The proposed mechanisms could help tailor cognitive-behavioural interventions to reduce anxiety and asthma complications.

Discomfort Intolerance in Relation to Asthma Outcomes

Anxiety symptoms and disorders are common among those with asthma and contribute to poorer health outcomes. Building on work examining anxiety-related cognitive-affective risk factors in asthma, the current study sought to explore associations between discomfort intolerance (i.e., the inability to withstand or tolerate unpleasant bodily sensations) in relation to lung function, asthma control, and quality of life. Participants were 61 adults with asthma (61.9% female; 54.8% African American; M age = 34.72, SD = 13.58) who were administered a self-report assessment battery and a lung function assessment. We found that, above and beyond the effects of anxiety sensitivity-physical concerns, greater discomfort intolerance was significantly associated with poorer lung function (9.5% variance), asthma control (9.9% variance), and overall asthma-related quality of life (11.7% variance) as well as the specific quality of life domains of activity limitations (12.6% variance) and asthma symptoms (6.8% variance). Thus, individuals with asthma who are unable to tolerate physical discomfort may be at risk for poor asthma outcomes and interventions to reduce discomfort intolerance could potentially be useful in this population.

Attentional Bias in Children with Asthma with and without Anxiety Disorders

Children with asthma have a high prevalence of anxiety disorders, however, very little is known about the mechanisms that confer vulnerability for anxiety in this population. This study investigated whether children with asthma and anxiety disorders display attentional biases towards threatening stimuli, similar to what has been seen in children with anxiety disorders more generally. We also examined the relationships between attentional biases and anxiety symptomatology and asthma control for children with asthma. Ninety-three children, aged 8-13, took part in the study and were recruited into one of four conditions (asthma/anxiety, asthma, anxiety, control). Asthma was medically confirmed and anxiety was assessed through clinical interview. We used self- and parent-report questionnaires to measure child asthma (ATAQ) and anxiety (SCAS, CASI) variables. Participants completed a visual dot-probe task designed to measure attentional bias towards two types of stimuli: asthma related words and general threat words, as well as tasks to assess reading ability and attentional control. Results showed that attentional biases did not differ between the groups, although children with anxiety disorders displayed poorer attentional control. A significant correlation was found between poor asthma control and an attentional bias of asthma stimuli. While we found no evidence that anxiety disorders in children with asthma were associated with threat- or asthma-related attentional biases, preliminary evidence suggested that children with poor asthma control displayed biases towards asthma-specific stimuli. Future research is needed to explore whether these attentional biases are adaptive.

Understanding the Impact of Paediatric Asthma on Families: Development of a Theoretical Model

The experience of paediatric asthma is associated with increased stress and emotional difficulties for both the child and family. The current study aimed to qualitatively explore parents’ views of their child's asthma experience, from initial diagnosis onwards, to enhance our understanding of how families emotionally adjust and adapt to the diagnosis and management of asthma. Semi-structured interviews were conducted with 17 parents of children (<18 years) with physician-diagnosed asthma. Questionnaires were used to capture demographic information and anxiety symptom status of parents (State Trait Anxiety Inventory — Form Y [STAI-Y1/Y2]) and children (Spence Children's Anxiety Scale — Parent reported [SCAS-P]). Grounded theory was used to analyse the results. Analysis saw three themes emerge as important in understanding the impact of asthma on the family: (1) the experience of obtaining an asthma diagnosis, (2) parents’ belief in their competence to manage asthma, and (3) parents’ behaviour in response to the asthma. A model was developed that posits adaptive parental adjustment to asthma is determined in part by the circumstances around the time of diagnosis, the level of knowledge and skills, and the controllability of the asthma. This model can guide medical and allied health professionals to specific areas where intervention may reduce stress and emotional difficulties associated with asthma and its management for affected families.

Assigning Clinical Significance and Symptom Severity Using the Zung Scales: Levels of Misclassification Arising from Confusion between Index and Raw Scores

BACKGROUND

The Zung Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) are two norm-referenced scales commonly used to identify the presence of depression and anxiety in clinical research. Unfortunately, several researchers have mistakenly applied index score criteria to raw scores when assigning clinical significance and symptom severity ratings. This study examined the extent of this problem.

METHOD

102 papers published over the six-year period from 2010 to 2015 were used to establish two convenience samples of 60 usages of each Zung scale.

RESULTS

In those papers where cut-off scores were used (i.e., 45/60 for SDS and 40/60 for SAS), up to 51% of SDS and 45% of SAS papers involved the incorrect application of index score criteria to raw scores. Inconsistencies were also noted in the severity ranges and cut-off scores used.

CONCLUSIONS

A large percentage of publications involving the Zung SDS and SAS scales are using incorrect criteria for the classification of clinically significant symptoms of depression and anxiety. The most common error-applying index score criteria to raw scores-produces a substantial elevation of the cut-off points for significance. Given the continuing usage of these scales, it is important that these inconsistencies be highlighted and resolved.

Parent-child interactions in children with asthma and anxiety

Anxiety disorders are highly prevalent in children with asthma yet very little is known about the parenting factors that may underlie this relationship. The aim of the current study was to examine observed parenting behaviours - involvement and negativity - associated with asthma and anxiety in children using the tangram task and the Five Minute Speech Sample (FMSS). Eighty-nine parent-child dyads were included across four groups of children (8-13 years old): asthma and anxiety, anxiety only, asthma only and healthy controls. Overall, results from both tasks showed that parenting behaviours of children with and without asthma did not differ significantly. Results from a subcomponent of the FMSS indicated that parents of children with asthma were more overprotective, or self-sacrificing, or non-objective than parents of children without asthma, and this difference was greater in the non-anxious groups. The results suggest that some parenting strategies developed for parents of children with anxiety may be useful for parents of children with asthma and anxiety (e.g. strategies targeting involvement), however, others may not be necessary (e.g. those targeting negativity).

Impact of Panic Attacks on Bronchoconstriction and Subjective Distress in Asthma Patients With and Without Panic Disorder

OBJECTIVE

Panic disorder (PD) is common among asthma patients and is associated with worse asthma outcomes. This may occur because of psychophysiological factors or cognitive/affective factors. This study evaluated the impact of panic attacks (PAs) on bronchoconstriction and subjective distress in people who have asthma with and without PD.

METHODS

A total of 25 asthma patients (15 with PD who had a PA [PD/PA], 10 without PD who did not have a PA [no PD/no PA]) were recruited from an outpatient clinic. They underwent a panic challenge (one vital capacity inhalation of 35% carbon dioxide [CO2]) and completed the Panic Symptom Scale, the Subjective Distress Visual Analogue Scale, and the Borg Scale before and after CO2. Forced expiratory volume in 1 second was assessed pre- and post-CO2; respiratory (i.e., CO2 production, minute ventilation, tidal volume) was continuously recorded, and physiological measures (i.e., systolic and diastolic blood pressure [SBP/DBP]) were recorded every 2 minutes.

RESULTS

Analyses adjusting for age, sex, and provocative concentration of methacholine revealed no significant differences between groups in forced expiratory volume in 1 second change after CO2 inhalation (F(1, 23) < 0.01, p = .961). However, patients with PD/PA reported more panic (F(1, 22) = 18.10, p < .001), anxiety (F(1, 22) = 21.93, p < .001), worry (F(1, 22) = 26.31, p < .001), and dyspnea (F(1,22) = 4.68, p = .042) and exhibited higher levels of CO2 production (F(1, 2843) = 5.89, p = .015), minute ventilation (F(1, 2844) = 4.48, p = .034), and tidal volume (F(1, 2844) = 4.62, p = .032) after the CO2 challenge, compared with patients with no PD/no PA.

CONCLUSIONS

Results, presented as hypothesis generating, suggest that asthma patients with PD/PA exhibit increased panic-like anxiety, breathlessness, and a respiratory pattern consistent with hyperventilation that was not linked to statistically significant drops in bronchoconstriction.

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.

Chronic obstructive pulmonary disease and anxiety disorders: a nationwide population-based study in Taiwan

OBJECTIVE

Few studies have investigated the relationship between chronic obstructive pulmonary disease (COPD) and anxiety disorder outcomes. We sought to investigate the association in a large national sample.

METHODS

Cases were identified from Taiwan's National Health Insurance Research Database who were aged 15 years and above, with a new primary diagnosis of COPD (International Classification of Diseases, Ninth Revision codes: 491, 492, 494 and 496) between 2000 and 2007. The 29,951 cases identified were compared to 29,951 controls matched on sex, age, urban/rural residence and socioeconomic status based on insurance premium. Both groups were followed until the end of 2008 for instances of anxiety disorders. Competing risk-adjusted Cox regression analyses were applied, adjusting for matching variables, Charlson comorbidity index, hospital admission days and daily dose of prednisone.

RESULTS

Of the 59,902 subjects, 3951 were found to have anxiety disorders during a mean (SD) follow-up period of 5.5 (2.5) years. COPD, female, urban residence, lower dose of prednisone use, depressive disorders and higher outpatient visits were independent predictors of incident anxiety disorder.

CONCLUSIONS

COPD was associated with increased risk of an anxiety disorder diagnosis, independent of a number of potential confounding factors.

Determinants and impact of suboptimal asthma control in Europe: The INTERNATIONAL CROSS-SECTIONAL AND LONGITUDINAL ASSESSMENT ON ASTHMA CONTROL (LIAISON) study

Background

According to the Global Initiative of Asthma, the aim of asthma treatment is to gain and maintain control. In the INTERNATIONAL CROSS-SECTIONAL AND LONGITUDINAL ASSESSMENT ON ASTHMA CONTROL (LIAISON) study, we evaluated the level of asthma control and quality of life (QoL), as well as their determinants and impact in a population consulting specialist settings.

Methods

LIAISON is a prospective, multicentre, observational study with a cross-sectional and a 12-month longitudinal phase. Adults with an asthma diagnosis since at least 6 months, receiving the same asthma treatment in the 4 weeks before enrolment were included. Asthma control was assessed with the 6-item Asthma Control Questionnaire (ACQ) and QoL with the MiniAsthma Quality of Life Questionnaire (MiniAQLQ).

Results

Overall, 8111 asthmatic patients were enrolled in 12 European countries. Asthma control was suboptimal in 56.5 % of patients and it was associated with poorer asthma-related QoL, higher risk of exacerbations and greater consumption of healthcare resources.

Variables associated with suboptimal control were age, gender, obesity, smoking and comorbidities. Major determinants of poor asthma control were seasonal worsening and persisting exposure to allergens/irritants/triggers, followed by treatment-related issues.

Conclusions

The cross-sectional phase results confirm that suboptimal control is frequent and has a high individual and economic impact.

Trial registration

The clinicaltrials.gov identifier is NCT01567280.

Electronic supplementary material

The online version of this article (doi:10.1186/s12931-016-0374-z) contains supplementary material, which is available to authorized users.

Correlation of 5-HTT, BDNF and NPSR1 gene polymorphisms with anxiety and depression in asthmatic patients

Asthmatic patients are known to have a higher risk of anxiety and depression. In the present study, we aimed to explore the association of serotonin transporter (5-HTT), brain-derived neurotrophic factor (BDNF) and neuropeptide S receptor 1 (NPSR1) gene polymorphisms with anxiety and depression in asthmatic patients. This was a cross-sectional study conducted on 143 asthmatic patients and 175 healthy volunteers. Of the asthmatic patients, 49 suffered from anxiety and 12 exhibited signs of depression. Patients with a lower level of education were more prone to depression. Both anxiety and depression were associated with poor asthma control as evaluated by the Asthma Control Test (ACT) score. The association of single nucleotide polymorphisms of BDNF, NPSR1 and 5-HTT with anxiety and depression in asthamtic patients was evaluated. The distribution of 5-HTT gene polymorphisms in the healthy group, the group with asthma but without anxiety, and the group with asthma and anxiety had significant differences. Females with asthma and anxiety were more prone to BDNF polymorphism. Also, BDNF gene distribution exhibited significant differences among those in the healthy group, the group with asthma but no depression, and the group with asthma and depression; however, NPSR1 gene distribution did not vary greatly between the groups. The anxiety score was significantly affected by the interaction between 5-HTT (LL, S⁺) and BDNF (A⁺, GG) (H=5.99, P=0.015). The depression score was significantly affected by the interaction between BDNF (A⁺, GG) and NPSR1 (AA, T⁺). We noted that both anxiety and depression led to poor asthma control. The interaction between 5-HTT (LL) and BDNF (A⁺) increased the risk of anxiety, and the interaction between BDNF (A⁺, GG) and NPSR1 (AA, T⁺) increased the risk of depression in asthmatic patients.

Effects of poor asthma control, insomnia, anxiety and depression on quality of life in young asthmatics

OBJECTIVE

Asthma-related quality of life has previously been shown to be associated with asthma control. The aims of the present study were to further analyze this correlation, identify other variables with impact on asthma-related quality of life and investigate the covariance among these variables.

METHODS

Information was retrieved from a cohort of 369 patients, aged 12-35, with physician-diagnosed asthma requiring anti-inflammatory treatment for at least 3 months per year. Questionnaire data [including the mini-Asthma Quality of Life Questionnaire (mAQLQ), asthma control test (ACT) and Hospital Anxiety and Depression Scale (HADS)], quality of sleep, lung function data and blood samples were analyzed. Linear regression models with the mAQLQ score as the dependent scalar variable were calculated.

RESULTS

ACT was the single variable that had the highest explanatory value for the mAQLQ score (51.5%). High explanatory power was also observed for anxiety and depression (17.0%) and insomnia (14.1%). The population was divided into groups depending on the presence of anxiety and depression, uncontrolled asthma and insomnia. The group that reported none of these conditions had the highest mean mAQLQ score (6.3 units), whereas the group reporting all of these conditions had the lowest mAQLQ score (3.8 units).

CONCLUSIONS

The ACT score was the single most important variable in predicting asthma-related quality of life. Combining the ACT score with the data on insomnia, anxiety and depression showed considerable additive effects of the conditions. Hence, we recommend the routine use of the ACT and careful attention to symptoms of insomnia, anxiety or depression in the clinical evaluation of asthma-related quality of life.

Association of asthma and anxiety: A nationwide population-based study in Taiwan

BACKGROUND

Few studies have investigated the bidirectional relationship between asthma and anxiety; we sought to investigate asthma and anxiety in a large national sample.

METHODS

Cases were identified from Taiwan's National Health Insurance Research Database with a new primary diagnosis of asthma (ICD-9:493) aged more than 15 years between 2000 and 2007. Case status required the presence of any inpatient diagnosis of asthma and/or at least one year diagnosis of asthma in outpatient service. These 22,797 cases were compared to 22,797 sex-, age-, residence- and insurance premium-matched controls and both groups were followed until the end of 2008 for instances of anxiety, defined as ICD-9 codes 300.0, 300.01, 300.02, 300.2, 300.21, 300.23, 300.3. Competing risk adjusted Cox regression analyses were applied, adjusting for sex, age, residence, insurance premium, prednisone use, Charlson comorbidity index, cardiovascular disease, diabetes, depression disorder, and hospital admission days for any disorder. The effect of asthma on the risk of panic disorder and the effect of anxiety disorder on the risk of later asthma were also examined as competing risk adjusted Cox regression analyses

RESULTS

Of the 45,594 subjects, 2792 were ascertained as having anxiety during a mean (SD) follow-up period of 5.3 (2.5) years. Asthma, females, older age, rural residence, depression disorder, and prednisone use were independent risks on anxiety in the fully adjusted model. Anxiety, older age, rural residence, and prednisone use were independent risks on asthma in the fully adjusted model.

LIMITATIONS

The severity of asthma and anxiety disorder, the duration of prednisone treatment and adherence, stressful life events, smoking, family history and relationship were not evaluated.

CONCLUSIONS

Bidirectional relationship between asthma and anxiety disorder was confirmed in this population, in dependent of a number of potential confounding factors.

Do asthma patients with panic disorder really have worse asthma? A comparison of physiological and psychological responses to a methacholine challenge

BACKGROUND

Panic disorder (PD) has been linked to worse asthma outcomes. Some suggest that asthmatics with PD have worse underlying asthma; others argue that worse outcomes are a result of their tendency to over-report symptoms. This study aimed to measure physiological and psychological responses to a simulated asthma attack (methacholine challenge test: MCT) in asthmatics with and without PD.

METHODS

Asthmatics with (n = 19) and without (n = 20) PD were recruited to undergo a MCT. Patients completed subjective symptom questionnaires (Panic Symptom Scale, Borg Scale) before and after a MCT. Physiological measures including heart rate (HR), and systolic and diastolic blood pressure (SBP/DBP) were also recorded.

RESULTS

Analyses, adjusting for age and sex, revealed no difference in methacholine concentration required to induce a 20% drop in forced expiratory volume in one second (FEV1: F = 0.21, p = .652). However, PD patients reported worse subjective symptoms, including greater ratings of dyspnea (F = 8.81, p = .006) and anxiety (F = 9.44, p = .004), although they exhibited lower levels of physiological arousal (i.e., HR, SBP/DBP). An interaction effect also indicated that PD, relative to non-PD, patients reported more panic symptoms post-MCT (F = 5.05, p = .031).

CONCLUSIONS

Asthmatics with PD report higher levels of subjective distress, despite exhibiting lower levels of physiological arousal, with no evidence of greater airway responsiveness. Results suggest that worse outcomes in PD patients may be more likely due to a catastrophization of bodily symptoms, rather than worse underlying asthma. Interventions designed to educate patients on how to distinguish and manage anxiety in the context of asthma are needed.

Practical guidance on the recognition of uncontrolled asthma and its management

PURPOSE

To highlight the significance of asthma in primary care and offer a practitioner-friendly interpretation of the asthma guidelines for the busy provider, while introducing new treatment options currently in clinical trials, such as the once-daily long-acting anticholinergic bronchodilator tiotropium Respimat.

DATA SOURCES

Articles with relevant adult data published between 2004 and 2015 were identified via PubMed. Additional references were obtained by reviewing bibliographies from selected articles.

CONCLUSIONS

In the United States, uncontrolled or symptomatic asthma is common, with rates of 46%-78% in primary care. Uncontrolled asthma has a substantial impact on patients' quality of life and represents a significant healthcare burden. Nurse practitioners can improve patients' asthma control through education, monitoring, assessment, and treatment. Although asthma management guidelines are readily available, the authors recognize that nurse practitioners see patients with multiple comorbidities, all of which have treatment guidelines of their own.

IMPLICATIONS FOR PRACTICE

Nurse practitioners have a compelling opportunity as frontline caregivers and patient educators to recognize and assess uncontrolled asthma, along with determining the steps necessary to help patients gain and maintain symptom control.

Asthma and odors: the role of risk perception in asthma exacerbation

OBJECTIVE

Fragrances and strong odors have been characterized as putative triggers that may exacerbate asthma symptoms and many asthmatics readily avoid odors and fragranced products. However, the mechanism by which exposure to pure, non-irritating odorants can elicit an adverse reaction in asthmatic patients is still unclear and may involve both physiological and psychological processes. The aim of this study was to investigate how beliefs about an odor's relationship to asthmatic symptoms could affect the physiological and psychological responses of asthmatics.

METHODS

Asthmatics classified as 'moderate-persistent', according to NIH criteria, were exposed for 15 min to a fragrance which was described either as eliciting or alleviating asthma symptoms. During exposure, participants were asked to rate odor intensity, perceived irritation and subjective annoyance while physiological parameters such as electrocardiogram, respiratory rate, and end tidal carbon dioxide (etCO₂) were recorded. Before, immediately after, and at 2 and 24h post-exposure, participants were required to subjectively assess their asthma symptom status using a standardized questionnaire. We also measured asthma status at each of those time points using objective parameters of broncho-constriction (spirometry) and measures of airway inflammation (exhaled nitric oxide, FeNO).

RESULTS

Predictably, manipulations of perceived risk altered both the quality ratings of the fragrance as well as the reported levels of asthma symptoms. Perceived risk also modulated the inflammatory airway response.

CONCLUSIONS

Expectations elicited by smelling a perceived harmful odor may affect airway physiology and impact asthma exacerbations.

Does anxiety predict the use of urgent care by people with long term conditions? A systematic review with meta-analysis

OBJECTIVE

The role of anxiety in the use of urgent care in people with long term conditions is not fully understood. A systematic review was conducted with meta-analysis to examine the relationship between anxiety and future use of urgent healthcare among individuals with one of four long term conditions: diabetes; coronary heart disease, chronic obstructive pulmonary disease and asthma.

METHODS

Electronic searches of MEDLINE, EMBASE, PSYCINFO, CINAHL, the British Nursing Library and the Cochrane Library were conducted These searches were supplemented by hand-searching bibliographies, citation tracing eligible studies and asking experts within the field about relevant studies. Studies were eligible for inclusion if they: a) used a standardised measure of anxiety, b) used prospective cohort design, c) included adult patients diagnosed with coronary heart disease (CHD), asthma, diabetes or chronic obstructive pulmonary disease (COPD), d) assessed urgent healthcare use prospectively. Data regarding participants, methodology, and association between anxiety and urgent care use was extracted from studies eligible for inclusion. Odds ratios were calculated for each study and pooled using random effects models.

RESULTS

8 independent studies were identified for inclusion in the meta-analysis, with a total of 28,823 individual patients. Pooled effects indicate that anxiety is not associated with an increase in the use of urgent care (OR=1.078, p=0.476), regardless of the type of service, or type of medical condition.

CONCLUSIONS

Anxiety is not associated with increased use of urgent care. This finding is in contrast to similar studies which have investigated the role of depression as a risk factor for use of urgent care.

Inhaler devices in asthma and COPD--an assessment of inhaler technique and patient preferences

BACKGROUND

Incorrect use of inhaler devices remains an obstacle for respiratory diseases management. We aimed to evaluate the frequency of inhaler technique errors; to determine the devices perceived as the easiest and favourite to use; to study the association of device type, demographics and patient preferences with inhaler technique (IT).

METHODS

Cross-sectional assessment of 301 adults, with asthma (194) or chronic pulmonary obstructive disease, undergoing treatment with Aerolizer®, Autohaler®, Breezehaler®, Diskus®, Handihaler®, MDI without spacer, Miat-haler®, Novolizer®, Respimat® and/or Turbohaler®. Patients completed self-assessment questionnaires and face-to-face interview, with demonstration of inhaler technique. The rate of wrong steps (number of wrong steps ÷ number of total steps; RWS) was the primary outcome. Adjusted odds ratio (aOR) (95% confidence intervals [CI]) for presenting ≥1 IT errors were computed.

RESULTS

From the 464 inhaler technique performances, the median RWS was 18%. Turbohaler® (21%) and Diskus® (19%) were chosen as easiest and Novolizer® (18%), Diskus® (18%), Turbohaler® (17%) as favourite for daily use. Females (aOR 2.68 [95% CI 1.55-4.65]; vs. males], patients with >64 yr (aOR 2.73 [95% CI 1.15-6.48]; vs <45 yr) and patients using Aerolizer® or Handihaler® (aOR 3.24 [95% CI 1.13-9.32] and aOR 3.71 [95% CI 1.38-10.2], respectively) were more likely to perform IT errors; otherwise, no association was found, including with using the favourite device (aOR 1.43 [95% CI 0.84-2.42]).

CONCLUSION

The frequency of inhaler technique errors was high and no device was clearly preferred over the others. Using the preferred inhaler device was not associated with less errors.

Prospective impact of panic disorder and panic-anxiety on asthma control, health service use, and quality of life in adult patients with asthma over a 4-year follow-up

Background Panic disorder (PD) is a common anxiety disorder among asthmatic patients with overlapping symptoms (e.g., hyperventilation). However, the longitudinal impact of PD on asthma control remains poorly understood. This study assessed the impact of PD and panic-anxiety on asthma control over a 4.3-year follow-up in 643 adult asthmatic patients. Methods Consecutive patients presenting to a tertiary asthma clinic underwent a sociodemographic, medical history, and psychiatric (Primary Care Evaluation of Mental Disorders) interview and completed questionnaires including the Anxiety Sensitivity Index (ASI) to assess panic-anxiety. At follow-up, patients completed the Asthma Control (ACQ) and Asthma Quality of Life (AQLQ) questionnaires and reported emergency department visits and hospitalizations during the follow-up. Results Baseline frequency of PD was 10% (n = 65). In fully adjusted models, analyses revealed that PD and ASI scores predicted worse follow-up ACQ total scores (β = 0.292, p = .037; β = 0.012, p = .003) but not AQLQ total scores. ASI scores also predicted greater nocturnal and waking symptoms, activity limitations, and bronchodilator use on the ACQ (β = 0.012-0.018, p < .05) as well as lower symptom (β = -0.012, p = .006) and emotional distress (β = -0.014, p = .002) subscale scores on the AQLQ. Neither PD nor ASI scores were associated with hospitalizations, although ASI scores (but not PD) were associated with an increased risk of emergency department visits (relative risk = 1.023, 95% confidence interval = 1.001-1.044). Conclusions PD and anxiety sensitivity are prospectively associated with poorer asthma control and may be important targets for treatment.

Determinants of quality of life in children with asthma

BACKGROUND

HRQoL in children with asthma depends on multiple factors, among which asthma severity and level of control are believed to play a vital role. The determinants of the connection between asthma severity and asthma control with quality of life remain unclear.

AIMS

Primary aim of the study was to evaluate the HRQoL in children with asthma and to determine the factors that affect it.

MATERIALS AND METHODS

In total 504 children and one of their parents were recruited during a regular follow up visit in an outpatient asthma clinic. The measures used were the DISABKIDS smiley measure (DSmM), chronic generic measure-long form (DCGM-37) and the Condition-specific modules for asthma along with a special form for collecting demographic and clinical characteristics.

RESULTS

Three hundred fifteen children with mean age 5.35 years (Group A) and 189 with mean age 10.79 years (Group B), were recruited. Children with controlled asthma had significant higher mean score than the other asthma control groups (P < 0.001). Corticosteroid use, asthma severity, number of visits in doctor's office and lack of asthma control were significantly associated with the DCGM-37 scores as well as Impact Scale and Worry Scale. Lack of Asthma Control was the only factor that was associated with negative HRQoL in all the multiple regression models, controlling for the effect of the other covariates, in both age groups.

CONCLUSIONS

In conclusion, the evaluation of asthma HRQoL independently reflects the asthma control state and a dimension of its severity. These results highlight the need to modify asthma management strategy.

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.

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.

Managing co-morbid depression and anxiety in primary care patients with asthma and/or chronic obstructive pulmonary disease: study protocol for a randomized controlled trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) and asthma are common chronic diseases that are frequently accompanied by depression and/or anxiety. However, symptoms of depression and anxiety are often not recognized and therefore not treated. Currently, only a few studies have tested new clinical approaches that could improve the treatment of co-morbid depression and anxiety in these groups of patients.

METHODS/DESIGN

The present randomized controlled study will be conducted within the framework of PoZoB (Praktijk Ondersteuning Zuid-Oost Brabant), a large primary care organization in the Netherlands. Patients with asthma/COPD and co-morbid anxiety/depression will be included in order to test the effectiveness of a disease management approach to treat these co-morbid disorders. Important elements of this approach are: 1) systematic screening to improve detection of anxiety and depression 2) treatment in case of positive screening 3) monitoring of anxiety and depression 4) intensified treatment in case of non-remission (stepped care).

DISCUSSION

The present study is a large primary care study on the treatment of co-morbid depression and anxiety in patients with asthma and COPD. Strengths of this study are its randomized design, the focus on implementation in primary care and the fact that it applies the latest findings on the treatment of depression and anxiety. First results are expected in 2012/2013.

Depression, Anxiety, and Health-Related Quality of Life in Adolescents and Young Adults With Allergies and Asthma

The current study sought to compare rates of depressive symptoms, anxious symptoms, and health-related quality of life (HRQOL) in adolescents and young adults (AYAs) with allergies, asthma, and healthy controls. Participants were undergraduate students aged 18 to 29 years with self-reported allergies (N = 79), asthma (N = 79), and with no history of a chronic illness (N = 79). Participants completed the Center for Epidemiologic Studies Depression Scale, the Zung Self-Rating Anxiety Scale, and the SF-36 Health Survey Questionnaire as self-report measures of depressive symptoms, anxious symptoms, and HRQOL, respectively. A series of ANCOVAs (analysis of covariance; allergies vs asthma vs healthy controls) was conducted to examine differences between the groups. The results of the current examination suggest that AYAs with allergies are indeed at risk for experiencing higher rates of depressive and anxious symptoms and poorer HRQOL than healthy AYAs. Furthermore, they are experiencing psychosocial concerns on par with or worse than those of AYAs with asthma. Allergies, often perceived as a relatively benign illness, have commonly been overlooked in discussions of psychosocial concerns related to chronic illnesses. The results of the current study suggest that young adults with allergies are also an important population to examine.

Tracheal occlusion modulates the gene expression profile of the medial thalamus in anesthetized rats

Conscious awareness of breathing requires the activation of higher brain centers and is believed to be a neural gated process. The thalamus could be responsible for the gating of respiratory sensory information to the cortex. It was reasoned that if the thalamus is the neural gate, then tracheal obstructions will modulate the gene expression profile of the thalamus. Anesthetized rats were instrumented with an inflatable cuff sutured around the trachea. The cuff was inflated to obstruct 2-4 breaths, then deflated for a minimum of 15 breaths. Obstructions were repeated for 10 min followed by immediate dissection of the medial thalamus. Following the occlusion protocol, 588 genes were found to be altered (P < 0.05; log(2) fold change ≥ 0.4), with 327 genes downregulated and 261 genes upregulated. A significant upregulation of the serotonin HTR2A receptor and significant downregulation of the dopamine DRD1 receptor genes were found. A pathway analysis was performed that targeted serotonin and dopamine receptor pathways. The mitogen-activated protein kinase 1 (MAPK1) gene was significantly downregulated. MAPK1 is an inhibitory regulator of HTR2A and facilitatory regulator for DRD1. Downregulation of MAPK1 may be related to the significant upregulation of HTR2A and downregulation of DRD1, suggesting an interaction in the medial thalamus serotonin-dopamine pathway elicited by airway obstruction. These results demonstrate an immediate change in gene expression in thalamic arousal, fear, anxiety motivation-related serotonin and dopamine receptors in response to airway obstruction. The results support the hypothesis that the thalamus is a component in the respiratory mechanosensory neural pathway.

Anxiety and depression in asthma

PURPOSE OF REVIEW

there is growing awareness of the correlation between psychological factors, the course of asthma, and the outcomes of asthma treatment. However, the implications of this correlation are still poorly understood. Here, we review the role of anxiety and depression in asthma with a focus on recent literature.

RECENT FINDINGS

recent studies suggest an interaction between behavioral, neural, endocrine, and immune processes and suggest that psychological factors play an active role in the genesis of asthma. Notably, the role of chronic stress has been investigated, including the parental psychological state during pregnancy. There is evidence that in patients with asthma, such stress may induce hyporesponsiveness of the hypothalamus-pituitary-adrenal axis, resulting in reduced cortisol secretion.

SUMMARY

even though it is generally accepted that anxiety and depression are more common in asthmatic patients and that there is a close correlation between psychological disorders and asthma outcomes, such as poorer control of asthma symptoms, the implications and practical consequences of this link remain weak. New studies are introducing an intriguing model of the links between emotional stress, brain centers, the immune system, and the hypothalamus-pituitary-adrenal axis that is far removed from the original concept of 'asthma nervosa'.