Impact of depressive symptoms on adult asthma outcomes

Association between dimensions of trauma-related psychopathology and asthma in trauma-exposed women

Introduction

Exposure to traumatic events and stressful life experiences are associated with a wide range of adverse mental and physical health outcomes. Studies have found post-traumatic stress disorder (PTSD), depression, and anxiety sensitivity occurrence to be common in addition to inflammatory diseases like asthma, especially in women. Moreover, overlapping neurobiological mechanisms have been linked to both PTSD and asthma.

Methods

In the current study, n = 508 women reported on presence of lifetime asthma diagnosis and symptoms of trauma-related psychopathology including PTSD and depression. A separate group of female participants (n = 64) reported on asthma, PTSD, depression and anxiety sensitivity, and underwent functional MRI scans during a fearful faces task, and their anterior insula responses were analyzed.

Results

Overall, PTSD and depression severity were significantly higher in those with asthma versus those without asthma. There was a positive association between anterior insula response to social threat cues and depression symptoms only among individuals without a lifetime presence of asthma.

Discussion

These findings provide continued evidence on the interactions between stress, neural mechanisms involved in interoception and salience detection, and trauma-related psychopathology.

The prevalence of multiple chronic conditions and medical burden in asthma patients

BACKGROUND

The prevalence of multiple chronic conditions (MCC), defined as several coexisting chronic conditions, has increased with the aging of society. MCC is associated with poor outcomes, but most comorbid diseases in asthma patients have been evaluated as asthma-associated diseases. We investigated the morbidity of coexisting chronic diseases in asthma patients and their medical burdens.

METHODS

We analyzed data from the National Health Insurance Service-National Sample Cohort for 2002-2013. We defined MCC with asthma as a group of one or more chronic diseases in addition to asthma. We analyzed 20 chronic conditions, including asthma. Age was categorized into groups 1-5 (< 10, 10-29, 30-44, 45-64, and ≥ 65 years, respectively). The frequency of medical system use and associated costs were analyzed to determine the asthma-related medical burden in patients with MCC.

RESULTS

The prevalence of asthma was 13.01%, and the prevalence of MCC in asthmatic patients was 36.55%. The prevalence of MCC with asthma was higher in females than males and increased with age. The significant comorbidities were hypertension, dyslipidemia, arthritis, and diabetes. Dyslipidemia, arthritis, depression, and osteoporosis were more common in females than males. Hypertension, diabetes, COPD, coronary artery disease, cancer, and hepatitis were more prevalent in males than females. According to age, the most prevalent chronic condition in groups 1 and 2 was depression, dyslipidemia in group 3, and hypertension in groups 4 and 5. Older age, low income, and severe disability were independent risk factors for MCC in patients with asthma. The frequency of asthma-related medical system use and asthma-associated costs increased with increasing numbers of coexisting chronic diseases.

CONCLUSION

Comorbid chronic diseases in asthma patients differed according to age and sex. The asthma-related-medical burdens were highest in patients with five or more chronic conditions and groups 1 and 5.

Gender differences in the association between multimorbidity and depression in older Korean adults: an analysis of data from the National Survey of Older Koreans (2011-2017)

OBJECTIVES

Previous studies have shown that people with multimorbidity have a higher risk of depression than those without multimorbidity. However, few studies have examined the association between depression and multimorbidity in men and women separately. Since the rates of depression and multimorbidity are different in men and women, it is necessary to examine whether gender differences affect their association.

METHODS

This study included 30,138 participants (aged ≥ 65 years) from the National Survey of Older Koreans (2011-2017). Depression was defined using the Korean version of the Geriatric Depression Scale (SGDS-K). Multimorbidity was defined as people who had 2 or more chronic diseases, including arthritis, diabetes, heart disease, hypertension, pulmonary disease, cancer, stroke, or osteoporosis. Multiple logistic regression analysis was performed to determine the association between depression and multimorbidity.

RESULTS

In total, 22.2% and 30.7% of men and women, respectively, had depression. Those with multimorbidity had a higher risk of depression than those without chronic conditions; specifically, the difference in risk among men was greater than that among women. Age was considered a moderator for women. While the effects of pulmonary disease, stroke, and cancer were especially substantial in the integrated analysis, gender differences were observed related to various chronic conditions comorbid with heart disease.

CONCLUSIONS

There are gender differences in the association between multimorbidity and depression among older Korean adults. Therefore, gender-specific care should be provided to reduce depression in older adults with multimorbidity.

Prevalence and predictors of occupational asthma among workers in detergent and cleaning products industry and its impact on quality of life in El Asher Men Ramadan, Egypt

Cleaning products are mixtures of many chemical ingredients that are known to contain sensitizers, disinfectants, and fragrances, as well as strong airway irritants which associated with lower respiratory tract and asthma symptoms. The aim of this study is to assess the prevalence and possible risk factors of occupational asthma and its effect on quality of life among workers in detergent and cleaning products industries in El Asher men Ramadan city. This cross-sectional study was conducted on 780 workers. All participants were personally interviewed at their workplaces and were subjected to a questionnaire regarding sociodemographic, work characteristics and asthma symptoms, clinical examination, chest X-ray, spirometer, and bronchodilator test. The prevalence of occupational asthma among the studied workers was 35.4%. Multivariate logistic regression analysis revealed that female gender [odds ratio 1.397; 95% CI 1.09-1.96], manually working participants [odds ratio 3.067; 95% CI 1.72-5.46], and history of atopy [odds ratio 1.596; 95% CI 1.09-2.33] were risk factors for development of occupational asthma. The total mean score of asthma-specific quality of life was significantly lower in asthmatic (5.10 ± 0.49) than non-asthmatic workers (5.89 ± 0.46) (P < 0.01) indicating impairment of quality of life among asthmatic group. Workers in detergent and cleaning products industry are at higher risk for developing occupational asthma that adversely affects their general health and quality of life.

Do-not-resuscitate (DNR) status and major depressive disorder (MDD): Clinical association and hospitalization outcomes

OBJECTIVES

To understand (1) the association of Major Depressive Disorder (MDD) and do-not-resuscitate (DNR) status among hospitalized patients and (2) the association of MDD and hospitalization outcomes among DNR patients.

METHODS

This was a cross-sectional analysis of United States Healthcare Cost and Utilization Project, Nationwide Inpatient Sample data from 2009 to 2013 for patients >18 years. To address the first objective, we used multivariable logistic regression among all hospitalized patients to compute the adjusted odds ratio (aOR) of having DNR status if patients have active MDD of varying severities after controlling for age, sex, race, suicidal ideation, and Elixhauser Comorbidity Index. To address the second objective, we used multivariable regression among patients with DNR status to compute aOR of having hospitalization outcomes such as increased length of stay, higher total charges, leaving against medical advice, and mortality if patients have MDD.

RESULTS

Among all hospitalizations, 2.3% had DNR status. There was an inverse association between severity of MDD and having DNR status. Relative to those without MDD, patients with moderate recurrent MDD episode (aOR 0.74 (95% confidence interval (CI): 0.65-0.85) and severe recurrent MDD episode (aOR of 0.42 (95% CI: 0.37-0.48)) were significantly less likely to have DNR status. Among DNR patients, those with all severities of MDD except mild single episode MDD were >40% less likely to die during hospitalization. Among DNR patients, patients with MDD had 0.7 day longer length of stay, and >$4,500 higher total charges.

SIGNIFICANCE OF RESULTS

Patients are less likely to have DNR status if they have active MDD. Among patients with DNR status, those with MDD are less likely to die during hospitalization than those without MDD. With current practice, depression is not associated with increased likelihood of death due to foregoing resuscitation prematurely, though the exact mechanisms of these findings need further investigation.

Depression and unplanned secondary healthcare use in patients with multimorbidity: A systematic review

Background

Growing numbers of people with multimorbidity have a co-occurring mental health condition such as depression. Co-occurring depression is associated with poor patient outcomes and increased healthcare costs including unplanned use of secondary healthcare which may be avoidable.

Aim

To summarise the current evidence on the association between depression and unplanned secondary healthcare use among patients with multimorbidity.

Methods

We conducted a systematic review by searching MEDLINE, EMBASE, PsychINFO, Web of Science, CINAHL, and Cochrane Library from January 2000 to March 2021. We included studies on adults with depression and at least one other physical long-term condition that examined risk of emergency hospital admissions as a primary outcome, alongside emergency department visits or emergency readmissions. Studies were assessed for risk of bias using The National Institute of Health National Heart, Lung, and Blood Institute quality assessment tool. Relevant data were extracted from studies and a narrative synthesis of findings produced.

Results

Twenty observational studies were included in the review. Depression was significantly associated with different outcomes of unplanned secondary healthcare use, across various comorbidities. Among the studies examining these outcomes, depression predicted emergency department visits in 7 out of 9 studies; emergency hospital admissions in 19 out of 20 studies; and emergency readmissions in 4 out of 4 studies. This effect increased with greater severity of depression. Other predictors of unplanned secondary care reported include increased age, being female, and presence of greater numbers of comorbidities.

Conclusion

Depression predicted increased risk of unplanned secondary healthcare use in individuals with multimorbidity. The literature indicates a research gap in identifying and understanding the impact of complex multimorbidity combinations, and other patient characteristics on unplanned care in patients with depression. Findings indicate the need to improve planned care for patients with moderate-to-severe depression. We suggest regular reviews of care plans, depression severity monitoring and assessment of hospital admission risk in primary care settings.

Poor respiratory health outcomes associated with high illness worry and alexithymia: Eleven-year prospective cohort study among the working-age population

OBJECTIVE

Poor respiratory health outcomes have been associated with poorer physical health and higher psychological distress. The aim of this study was to investigate whether illness worry, alexithymia or low sense of coherence predict i) the onset of new respiratory disease, ii) respiratory symptoms or iii) lung function among the working-age population, independently of comorbidity mood-, anxiety, or alcohol abuse disorders.

METHODS

The study was conducted among a nationally representative sample of the Finnish population (BRIF8901) aged 30-54 years (N = 2310) in 2000-2001 and was followed up in 2011. Individuals with a diagnosed respiratory disease or a severe psychiatric disorder at baseline were excluded. Lung function was measured by a spirometry test and psychiatric disorders were diagnosed using a structured clinical interview. Structured questionnaires were used to measure self-reported respiratory symptoms and diseases, illness worry, alexithymia, and sense of coherence.

RESULTS

High illness worry predicted an 11-year incidence of asthma (OR 1.47, 95% CI 1.09-1.99, p = 0.01). Alexithymia predicted shortness of breath (OR 1.32, 95% CI 1.13-1.53, p < 0.01) and 11-year incidence of COPD (OR 2.84, 95% CI 1.37-5.88, p < 0.01), even after several adjustments for physical and mental health. Psychological dispositions did not associate with lung function in 2011.

CONCLUSIONS

In the general population, psychological factors that modify health behaviour predicted adverse respiratory health outcomes independently of lung function after 11 years of follow-up. This indicates that considering them part of personalized treatment planning is important for promoting health-related behaviour among the working-age population.

The Effectiveness of Cardiopulmonary Rehabilitation Programs on Psychosocial Factors in Patients With Pulmonary and Cardiac Disease

PURPOSE

Those with chronic cardiac and pulmonary diseases are predisposed to several psychosocial disorders. Tailored rehabilitation programs have been shown to improve physiological and psychosocial well-being. The purpose of this study was, first, to assess the psychosocial improvements among patients with cardiac and pulmonary diseases who have finished cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) programs; second, to assess the differences in psychosocial factors among those patients based on smoking status at the beginning and end of these programs.

METHODS

The CR and PR programs in hospital settings were retrospectively analyzed from 2013-2018. Before and after, all patients completed the sociodemographic characteristics along with the Psychosocial Risk Factor Survey that measures total distress, depression, anxiety, hostility, and social isolation.

RESULTS

There were 355 patients with cardiac and 244 patients with pulmonary disease who completed 6- to 12-wk CR or PR programs. There were significant improvements in all psychosocial symptoms among cardiac patients. Patients with pulmonary disease exhibited significant improvements in all psychosocial factors except for social isolation. Moreover, current smokers in the CR group reported elevated symptoms of several psychosocial scores.

CONCLUSION

These findings provide critical information about the effects of tailored rehabilitation programs among patients with chronic cardiac and pulmonary diseases on psychosocial levels. By using the Psychosocial Risk Factor Survey, we have found that total distress, depression, anxiety, and hostility were reduced among patients who completed the CR or PR programs. Current smokers exhibited the elevated mean scores on psychosocial symptoms in the cardiac group that may be a target for smoking cessation program. The advantages of tailored rehabilitation programs are significant, which may be of benefit for physical, social, behavioral, and psychological well-being.

Impact of psychological impairment on quality of life and work impairment in severe asthma

BACKGROUND

Psychological impairment, such as anxiety and depression, is common in severe asthma. However, the impact of psychological impairment on asthma-specific quality of life (ASQOL) and work impairment has not been assessed within Southeast-Asia. Furthermore, previous ASQOL questionnaires contained items overlapping with asthma control, making it challenging to isolate the relationship between psychological impairment with ASQOL and asthma control, respectively.

OBJECTIVE

To evaluate the relationship between psychological impairment with ASQOL and work impairment in severe asthma.

METHODS

This is a cross-sectional study of severe asthma at Singapore General Hospital. We assessed ASQOL, psychological impairment, work impairment and asthma control using validated questionnaires. An ASQOL questionnaire not containing items evaluating asthma symptoms was selected to reduce overlap with asthma control. Medical records were used to obtain other asthma characteristics and healthcare utilization patterns.

RESULTS

Amongst 111 patients, 37% had psychological impairment based on Hospital Anxiety and Depression Scale. Poorer ASQOL was associated with anxiety (p = .013) after controlling for demographic characteristics, asthma control and comorbidities. Anxiety symptoms were associated with greater health concerns while depression symptoms were associated with sleep difficulty and physical limitations. Having depressive symptoms was associated with an additional 16% impairment of total work hours (p = .038). Psychological impairment was not associated with spirometry results or healthcare utilization. Ethnicity significantly predicted both ASQOL and work impairment.

CONCLUSIONS

In severe asthma, patients with psychological impairment have poorer ASQOL and greater work impairment than those without psychological impairment. There is an urgent need to mitigate this problem.

Origin and Function of Stress-Induced IL-6 in Murine Models

Acute psychological stress has long been known to decrease host fitness to inflammation in a wide variety of diseases, but how this occurs is incompletely understood. Using mouse models, we show that interleukin-6 (IL-6) is the dominant cytokine inducible upon acute stress alone. Stress-inducible IL-6 is produced from brown adipocytes in a beta-3-adrenergic-receptor-dependent fashion. During stress, endocrine IL-6 is the required instructive signal for mediating hyperglycemia through hepatic gluconeogenesis, which is necessary for anticipating and fueling "fight or flight" responses. This adaptation comes at the cost of enhancing mortality to a subsequent inflammatory challenge. These findings provide a mechanistic understanding of the ontogeny and adaptive purpose of IL-6 as a bona fide stress hormone coordinating systemic immunometabolic reprogramming. This brain-brown fat-liver axis might provide new insights into brown adipose tissue as a stress-responsive endocrine organ and mechanistic insight into targeting this axis in the treatment of inflammatory and neuropsychiatric diseases.

Comorbid Obesity and Depressive Symptoms in Childhood Asthma: A Harmful Synergy

BACKGROUND

Overweight/obesity (OV/OB) and depression have each been separately associated with worsened childhood asthma severity and control. Pathways by which these factors may jointly affect childhood asthma have not been elucidated.

OBJECTIVE

To examine the interrelationship of OV/OB and depressive symptoms with childhood asthma and explore associated psychobiologic pathways. The present study investigated whether comorbid OV/OB and depressive symptoms are associated with impaired baseline lung function and increased airway resistance during emotional stress, and to assess whether such effects may be mediated by autonomic nervous system (ANS) dysregulation, specifically through predominance of vagal over sympathetic reactivity (vagal bias).

METHODS

A total of 250 children with asthma, aged 7 to 17, were assessed for OV/OB using body mass index, depressive symptoms using the Children's Depression Inventory (CDI), and asthma severity using National Asthma Education and Prevention Program Expert Panel Report 3 criteria. Baseline pulmonary function (forced expiratory volume in 1 second [FEV₁]) was assessed. The film "E.T. the Extra-Terrestrial" was used in a laboratory paradigm to evoke emotional stress/arousal. Airway resistance (R_int) was measured before and after the film to determine changes in airway function. ANS reactivity was assessed by measuring parasympathetic/vagal and sympathetic reactivity throughout the film.

RESULTS

In OV/OB children with asthma, depressive symptoms predicted lower baseline FEV₁ (β = -0.67, standard error [SE] = 0.24, P = .008), CDI predicted vagal bias under emotion stress/arousal (β = 0.27, SE = 0.09, P = .009), and vagal bias predicted increased R_int (β = 3.55, SE = 1.54, P = .023).

CONCLUSION

This study is the first to link OV/OB and depressive symptoms in their relationship to childhood asthma. In OV/OB children with asthma, depression may potentiate airway compromise, mediated by vagal bias. Use of antidepressant and anticholinergic therapies should be studied in this subgroup of patients.

Psychosocial treatments for employees with non-specific and persistent physical symptoms associated with indoor air: A randomised controlled trial with a one-year follow-up

OBJECTIVE

Persistent physical symptoms (PPS) associated with indoor air without an adequate pathophysiological- or environmental-related explanation may lead to work disability and decreased health-related quality of life (HRQoL). We attempted to assess the effect of cognitive behavioural therapy (CBT) for PPS and also psychoeducation (PE) on these symptoms involving disability.

METHOD

The intention-to-treat (ITT) sample included 52 employees recruited from an occupational healthcare service randomised as either controls undergoing treatment as usual (TAU) or TAU enhanced with CBT or PE. The primary outcome was HRQoL measuring the severity of symptoms and restrictions in everyday life caused by them. Secondary outcomes included depressive, anxiety and insomnia symptoms, and intolerance to environmental factors, assessed at baseline and at 3-, 6- and 12-month follow-ups.

RESULTS

At the 12-month follow-up assessment point, no statistically significant differences between treatments emerged following adjustment for gender, age, and HRQoL before the waiting period in the ITT analysis [F(2,46)=2.89, p=.07]. The secondary analysis revealed a significant improvement in HRQoL in the combined intervention group as compared with controls [F(1,47)=5.06, p=.03, g=0.41]. In total, 15% of participants dropped out during follow-up.

CONCLUSIONS

The results suggest that CBT for PPS or PE might not have a robust effect on HRQoL in PPS associated with indoor air, but the study did not achieve the planned power. Despite difficulties during the recruitment process, the final dropout rates remained low, and participants positively evaluated CBT, suggesting that it represents an acceptable treatment to them. Trial status This study was registered at the ClinicalTrials.gov registry (NCT02069002).

Observational study of mental health in asthmatic women during the prenatal and postnatal periods

Objective: We aimed to examine the prevalence and severity of psychological distress of women with asthma in both the prenatal and postnatal periods, and to determine whether asthmatic women with and without mental health problems differ in self-management, medications knowledge, and asthma symptoms.Methods: We assessed spirometry performance and asthma symptoms in 120 women (mean age 29.8 years) before 23 weeks gestation, as part of the Breathing for Life Trial (Trial ID: ACTRN12613000202763). Prenatal depression data was obtained from medical records. At 6 weeks postpartum, we assessed general health, self-reported asthma control, depression symptoms (with the Edinburgh Postnatal Depression Scale) and adaptive functioning (with the Achenbach System of Empirically Based Assessment scales).Results: Twenty percent of our sample reported having a current mental health diagnosis, 14% reported currently receiving mental health care, while 47% reported having received mental health care in the past (and may/may not have received a diagnosis). The sample scored high on the Aggressive Behavior, Avoidant Personality, and Attention Deficit/Hyperactivity scales. Poorer self-reported postnatal asthma control was strongly correlated with elevated somatic complaints, externalizing problems, antisocial personality problems, and greater withdrawal. Prenatal spirometry or asthma severity and control were largely not associated with measures of psychopathology.Conclusions: These findings indicate that pregnant women with asthma frequently report issues with psychopathology during the prenatal and postnatal periods, and that the subjective perception of asthma control may be more related to psychopathology than objective asthma measures. However, due to sample bias, these findings are likely to be understated.

Managing comorbid conditions in severe asthma

Asthma care has increasingly focused on personalised management for severe asthma, and recognition of the role and importance of comorbid conditions has increased. Severe asthma can be crippling; associated comorbid conditions often play a key role in the significant disease morbidity and frequently contribute to a severe and difficult-to-treat asthma phenotype. Comorbid conditions can be broadly grouped as being either airway-related or airway-unrelated. Airway-related comorbid conditions with the greatest impact are allergic rhinitis, chronic rhinosinusitis, vocal cord dysfunction, lung fungal sensitisation and underlying structural lung disease. The most important airway-unrelated comorbid conditions are obesity, obstructive sleep apnoea, gastro-oesophageal reflux disease and anxiety and depression. A diagnostic and management algorithm for comorbid conditions in severe asthma is outlined. It concentrates initially on the group with common comorbid conditions that can be managed in primary care. If asthma remains troublesome, emphasis can shift to identifying uncommon and more complex factors. The algorithm allows for personalised diagnostic and management pathways to be implemented. Personalised diagnosis and management of comorbid conditions are essential to achieving effective and improved outcomes for patients with severe asthma.

[Role of non pharmacological Interventions for asthma]

Smoking cessation remains a major issue for asthmatic smokers. Respiratory rehabilitation and respiratory physiotherapy have shown a benefit in controlling symptoms, preventing exacerbations and improving the quality of life. The control of the environment is crucial and must be approached in a global way. Management of obesity and psychological disorders should be systematically proposed. Allergen immunotherapy may be discussed in allergic persistent asthma to house dust mites. Certain dietary interventions or alternative medicines have not proved their worth.

Korean Youth with Comorbid Allergic Disease and Obesity Show Heightened Psychological Distress

OBJECTIVE

To explore psychological distress in Korean adolescents having allergic disease comorbid with obesity.

STUDY DESIGN

A total of 703 869 adolescents who completed the Korean Youth Risk Behavior Web-based Survey between 2007 and 2016 were analyzed. Participants were divided into 4 groups-healthy control, allergic disease only, obesity only, and comorbidity of allergic disease and obesity-and compared them to determine whether they showed differences in mental health.

RESULTS

Adolescents with both atopic dermatitis and obesity had significantly greater odds of experiencing unhappiness (OR, 1.17), stress (OR, 1.32), and suicidal ideation (OR, 1.25) than those without both conditions. The same was true of adolescents with obesity and allergic rhinitis (OR, 1.21, 1.37, and 1.27, respectively) or bronchial asthma (OR, 1.37, 1.39, and 1.37). The comorbidity groups also showed significantly greater odds of stress and suicidal ideation than the allergic disease-only (atopic dermatitis with obesity, 1.21 and 1.15, respectively; allergic rhinitis with obesity, 1.11 and 1.09; bronchial asthma with obesity, 1.17 and 1.14) and obesity-only groups (atopic dermatitis with obesity, 1.13 and 1.09; allergic rhinitis with obesity, 1.18 and 1.10; bronchial asthma with obesity, 1.18 and 1.21).

CONCLUSIONS

Allergic disease and obesity negatively and additively influence mental health in adolescents.

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.

Severe Asthma-Perspectives From Adult and Pediatric Pulmonology

Both adults and children with severe asthma represent a small proportion of the asthma population; however, they consume disproportionate resources. For both groups it is important to confirm the diagnosis of severe asthma and ensure that modifiable factors such as adherence have, as far as possible, been addressed. Most children can be controlled on inhaled corticosteroids and long term oral corticosteroid use is rare, in contrast to adults where steroid related morbidity accounts for a large proportion of the costs of severe asthma. Atopic sensitization is very common in children with severe asthma as are other atopic conditions such as allergic rhinitis and hay fever which can impact on asthma control. In adults, the role of allergic driven disease, even in those with co-existent evidence of sensitization, is unclear. There is currently an exciting pipeline of novel biologicals, particularly directed at Type 2 inflammation, which afford the possibility of improved asthma control and reduced treatment side effects for people with asthma. However, not all drugs will work for all patients and accurate phenotyping is essential. In adults the terms T2 high and T2 low asthma have been coined to describe groups of patients based on the presence/absence of eosinophilic inflammation and T-helper 2 (TH₂) cytokines. Bronchoscopic studies in children with severe asthma have demonstrated that these children are predominantly eosinophilic but the cytokine patterns do not fit the T2 high paradigm suggesting other steroid resistant pathways are driving the eosinophilic inflammation. It remains to be seen whether treatments developed for adult severe asthma will be effective in children and which biomarkers will predict response.

The association of psychological factors and healthcare use with the discrepancy between subjective and objective respiratory-health complaints in the general population

BACKGROUND

We examined the prevalence of self-perceived respiratory symptoms (SRS) in the absence of any objective findings of respiratory pathology, and the association of such prevalence with psychological factors and healthcare use in the general population.

METHODS

The study was conducted among a nationally representative sample of Finnish adults (BRIF8901). Respiratory functioning was measured by a spirometry test. Structured questionnaires were used to measure SRS, physician visits and psychological factors of alexithymia, sense of coherence, illness worry and common mental disorders. Individuals with a diagnosed respiratory disease or a severe psychiatric disorder, determined in a diagnostic interview, were excluded, giving a sample comprising 4544 participants.

RESULTS

Twenty-six per cent of the general population and 36% of those with no diagnosed severe psychiatric disorder or respiratory disease experienced SRS despite a normal spirometry result. Psychological factors were associated with SRS (0.0001 &lt; p &lt; 0.032), and on the number of physician visit explaining 42.7% of the difference in visits between individuals with and without SRS, respectively. Illness worry was associated most strongly with SRS [odds ratio (OR) 1.29, 95% confidence interval (CI) 1.19-1.41, p &lt; 0.0001] and higher numbers of physician visits (OR 1.35, CI 1.32-1.38, p &lt; 0.00001), even after several adjustments.

CONCLUSIONS

Respiratory symptoms without objective findings are common in the general population. The study results underline the role of psychological factors in the reporting of respiratory symptoms and the associated medical burden, thereby indicating the functional nature of the symptomatology.

Estimating causal associations of atopic dermatitis with depression using the propensity score method: an analysis of Korea Community Health Survey data, 2010-2013

OBJECTIVES

Numerous studies have reported associations between atopic dermatitis (AD) and depression, but the causal relationship between the 2 diseases has not been established. Therefore, this study used the propensity score method to investigate whether there was a positive causal effect of AD on depression in 16 regions (cities and provinces) in Korea.

METHODS

The study analyzed 16 regions (cities and provinces) in Korea, using data obtained from the Korea Community Health Survey for the years 2010-2013. Propensity score matching was used to estimate the causal influence of AD on depression in Korea.

RESULTS

After propensity score matching, the standardized difference for each covariate among the 16 regions (cities and provinces) was less than 1, indicating a balance between the case and control groups. At the national level, those diagnosed with AD had a 2.31 times higher risk for being diagnosed with depression than those who had not been diagnosed with AD. In particular, the risk was highest in North Jeolla Province (odds ratio [OR], 4.87; 95% confidence interval [CI], 2.28 to 10.43) and lowest in Gwangju (OR, 1.82; 95% CI, 0.87 to 3.79), and the OR for Seoul was 2.23 (95% CI, 1.66 to 2.99).

CONCLUSIONS

This study provides insights into how causal inferences can be derived from observational studies, through an analysis of Korea Community Health Survey data. Furthermore, the study results have implications for region-specific guidelines for preventive health policies targeting depression.

Associations between distress tolerance and asthma symptoms and quality of life

Objective: Given the robust associations between anxiety and asthma, the purpose of the current study was to explore associations between asthma outcomes and tolerance for negative affective states (i.e. distress tolerance) as well as tolerance for the specific negative emotional states of anxiety and fear. Methods: Participants were 61 nonsmoking adults with asthma (61.9% female, 54.8% African-American, M_age = 34.72, SD = 13.58) who underwent spirometry and completed self-report measures. Results: After controlling for the effects of age, race and the physical concerns domain of anxiety sensitivity, poorer global distress tolerance and tolerance for fear and anxiety each significantly predicted poorer lung function (8.7-13.8% variance), asthma control (4.9-8.8% variance) and asthma-related quality of life (6.7-8.9%). Conclusions: These findings suggest that targeting distress tolerance, specifically tolerance of fear and anxiety, may be helpful in improving asthma outcomes.

Evaluating the role of mindfulness in terms of asthma-related outcomes and depression and anxiety symptoms among individuals with asthma

The aim of the current study was to examine the unique role of mindfulness skills in terms of: (1) asthma-related outcomes (i.e., asthma control, asthma quality of life); (2) depression symptoms; and (3) anxiety symptomatology (i.e., anxiety sensitivity, panic symptoms, global anxiety) among non-smoking adults with current asthma. Participants were 61 (61.9% female; M_age = 34.72 years, SD = 13.58, range = 18-65) non-smoking adults with current asthma who completed a battery of self-report measures. Results indicated that, after controlling for the effects of race and age, greater ability to describe present moment experiences was significantly associated with better asthma-related quality of life and lower levels of anxiety symptoms. Though mindfulness skills together were associated with lower levels of panic symptoms, there were no significant individual associations between specific skills and panic symptoms. Greater nonjudgment of present moment experiences was associated with lower levels of anxiety and anxiety sensitivity. Greater nonreactivity was significantly associated with lower levels of depression symptoms and anxiety sensitivity. Lastly, a greater ability to observe present moment experiences was associated with lower levels of anxiety sensitivity. Mindfulness was not significantly associated with asthma control. These findings suggest that it may be useful to target the mindfulness skills of describing, nonjudgment, and nonreactivity among individuals with asthma, particularly those with elevated levels of anxiety and depression, in order to improve psychological and asthma-related outcomes.

Epidemiology of Depression and Associated Factors among Asthma Patients in Addis Ababa, Ethiopia

BACKGROUND

Depression in asthma patients can cause worsening of respiratory symptoms. Addressing mental illness in those with asthma improves asthma outcomes. This study aimed to assess the epidemiology of depression and associated factors among asthma patients attending government hospitals in Ethiopia.

METHODS

Institutional based cross-sectional study was conducted on patients with asthma at three governmental hospitals of Addis Ababa from June to July 2017. Patient health questionnaire (PHQ-9) depression scale was used to assess prevalence of depression among asthmatic patients. The data were entered and analyzed using SPSS version 20 statistical software. Binary logistic regression analysis was conducted to identify associated factors for depression. To indicate the strength of association, odds ratios (OR) and 95% confidence intervals (95% CI) were used.

RESULT

A total of 405 participants were enrolled in the study giving an overall response rate of 96%. The respondents had mean age of 54.46 and standard deviation (SD) of 10.01 years. About 273 (67.4%) were females. The prevalence of depression among asthma patients was 85 (21%). The odds of developing depression among single asthma patients were increased by 1.63 with 95% CI [1. 8, 3.493]. Depression among asthma patients who had comorbid cardiac illness was 6.2 times higher than those who do not have at CI [1.145, 24.109]. The prevalence of depression among uncontrolled asthma patients was 8 times higher than those with well-controlled asthma at CI [1.114, 19.025].

CONCLUSION

One-fifth of asthmatic patients were experiencing depression. Uncontrolled asthma, comorbid cardiac illness, and single patients were important predictors of depression among asthmatic patients. Proper control of asthmatic attack and cardiac illnesses is very important to reduce the burden of depression.

Associations between asthma trigger reports, mental health conditions, and asthma morbidity among world trade center rescue and recovery workers

Aim: There is limited information regarding asthma triggers in World Trade Center (WTC) rescue and recovery workers (RRW) or how mental health conditions affect the perception of triggers. Methods: We included 372 WTC workers with asthma. The Asthma Trigger Inventory (ATI) assessed triggers along five domains: psychological, allergens, physical activity, infection, and pollution. We administered the Structured Clinical Interview to diagnose post-traumatic stress disorder (PTSD), major depression and panic disorder (PD). The Asthma Control Questionnaire (ACQ) and Mini Asthma Quality of Life Questionnaire (AQLQ) measured asthma control and quality of life, respectively. Linear regression models were fitted to examine the association of ATI total and subdomain scores with mental health conditions as well as the percent of ACQ and AQLQ variance explained by ATI subscales. Results: The most common triggers were air pollution (75%) and general allergens (68%). PTSD was significantly associated with psychological triggers (partial r²=0.05, p < 0.01), physical activity (partial r²=0.03, p < 0.01) and air pollution (partial r²=0.02, p = 0.04) subscales while PD was significantly associated with air pollution (partial r²=0.03, p = 0.03) and general allergens (partial r²=0.02, p = 0.03). ATI subscales explained a large percentage of variance in asthma control (r²=0.37, p < 0.01) and quality of life scores (r²=0.40, p < 0.01). Psychological subscale scores explained the largest portion of the total variability in ACQ (partial r²= 0.11, p = 0.72) and AQLQ (partial r²=0.14, p = 0.64) scores. Conclusion: RRW with mental health conditions reported more asthma triggers and these triggers were associated with asthma morbidity. These data can help support interventions in RRW with asthma.

Comorbid "treatable traits" in difficult asthma: Current evidence and clinical evaluation

The care of patients with difficult-to-control asthma ("difficult asthma") is challenging and costly. Despite high-intensity asthma treatment, these patients experience poor asthma control and face the greatest risk of asthma morbidity and mortality. Poor asthma control is often driven by severe asthma biology, which has appropriately been the focus of intense research and phenotype-driven therapies. However, it is increasingly apparent that extra-pulmonary comorbidities also contribute substantially to poor asthma control and a heightened disease burden. These comorbidities have been proposed as "treatable traits" in chronic airways disease, adding impetus to their evaluation and management in difficult asthma. In this review, eight major asthma-related comorbidities are discussed: rhinitis, chronic rhinosinusitis, gastroesophageal reflux, obstructive sleep apnoea, vocal cord dysfunction, obesity, dysfunctional breathing and anxiety/depression. We describe the prevalence, impact and treatment effects of these comorbidities in the difficult asthma population, emphasizing gaps in the current literature. We examine the associations between individual comorbidities and highlight the potential for comorbidity clusters to exert combined effects on asthma outcomes. We conclude by outlining a pragmatic clinical approach to assess comorbidities in difficult asthma.

Prospective Impact of Psychiatric Disorders on Employment Status and Health Care Use in Patients Investigated for Occupational Asthma

OBJECTIVE

We previously reported high rates (34%) of psychiatric disorders (PSY) in patients evaluated for occupational asthma (OA). We determined the impact of PSY on employment status and health care use 12 to 18 months later.

METHODS

One hundred ninety-six patients underwent clinical and psychiatric interviews on the day of their OA evaluation. Patients were re-contacted 12to 18 months later to assess employment status and health care use.

RESULTS

Results indicated that patients with a PSY at baseline were less likely to be employed (adjusted odds ratio = 2.88; 95% confidence interval = 1.29 to 6.44) irrespective of final medical diagnosis (including OA), and had higher rates of emergency visits (35% vs 19%, P = 0.04).

CONCLUSION

Psychiatric morbidity is common in this population and associated with lower employment rates and greater use of emergency services. Greater efforts should be made to assess and treat PSY in this population.

Chronic respiratory disease and high altitude are associated with depressive symptoms in four diverse settings

SETTING

Depression is a prevalent comorbidity of chronic respiratory disease (CRD), and may indicate worse clinical outcomes. The relationship between depression and living with chronic hypoxia due to CRD or residence at altitude has received little attention in resource-poor settings.

OBJECTIVE

To investigate the association between CRD conditions and depressive symptoms in four settings in Peru.

DESIGN

We collected data on CRD and depressive symptoms in adults aged ⩾35 years. Depressive symptoms were measured according to the Center for Epidemiologic Studies Depression scale. Multivariable ordinal logistic regression was used to assess the adjusted odds of being in a higher category of depressive symptoms as a function of CRD.

RESULTS

We analyzed data from 2953 participants (mean age 55.3 years, 49% male). The prevalence of major depressive symptoms was 19%, with significant variation according to setting. Participants with at least one CRD (OR 1.34, 95%CI 1.06-1.69) and those living at altitude (OR 1.64, 95%CI 1.10-2.43) had an increased adjusted odds of being in a higher category of depressive symptoms.

CONCLUSION

We found a high prevalence of depressive symptoms, and a positive association between depressive symptoms with CRD and with living at altitude, both of which cause chronic hypoxia.

Factors associated with depressive symptoms in uncontrolled asthmatics

RATIONALE

Recent epidemiological data indicate that approximately 6.7% of US adults suffer from depression in any given year. The purpose of the study is to identify factors associated with depressive symptoms in a large diverse group of patients with poorly controlled asthma. The factors include quality of life (QOL), lung function, asthma knowledge, attitudes, self-efficacy, symptoms and control of disease.

METHODS

Baseline characteristics of a cohort of 599 subjects with asthma recruited from twenty Asthma Clinical Research Centers across the United States were examined. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to stratify subjects into those with depressive symptoms (CES-D score ≥ 16) and those without depressive symptoms (CES-D < 16). Bivariate statistics were used to compare the two groups; additionally, logistic regression was used to determine factors that have the greatest association with depressive symptoms.

RESULTS

Subjects with depressive symptoms had significantly lower QOL scores and less knowledge about their disease than subjects with no depression; however, lung function (FEV1%) and asthma control were not significantly associated with depressive symptoms in the logistic regression analysis. Subjects who were non-white had lower household income, high school diploma or less, and those who were unemployed or disabled had significantly higher scores for depressive symptoms.

CONCLUSION

Subjects with depressive symptoms have significantly less knowledge of their disease and poorer QOL compared to those without depressive symptoms. Evaluating depressive symptoms in subjects with asthma will provide a more complete picture of their overall condition. The role of asthma education on depressive symptoms in this population needs to be further investigated. The effect of QOL on treating depression in asthma patients also needs to be studied.

Indicators of Non-adherence to Asthma Treatment in Pediatric Primary Care

PURPOSE

Chronic disease management represents an ongoing challenge, as many childhood illnesses require complex medical management by primary care providers. Asthma is one such illness, and today there is evidence to support primary care-based management strategies that will benefit patients with asthma throughout a lifetime. This study seeks to find significant indicators of asthma non-adherence in pediatric primary care, with potential for utilization in the medical home model.

DESIGN AND METHODS

Potential indicators included in a chart review process of one large Southeastern U.S. primary care pediatric practice were reviewed from the previous calendar year for asthma patients. The study retroactively looks at the incidence of six indicators in relation to asthma-related emergency department visits and hospitalizations, and number of missed appointments for clinically relevant associations.

RESULTS

Strong associations were found between emergency department visits and hospitalizations and many of the indicators of non-adherence with high statistical significance. No associations were found between number of missed appointments and the selected indicators.

CONCLUSIONS

The data analysis performed from the collected patient information can be helpful to guide practices in further discussions on the topic. Results were analyzed and reported to the practice in review as recommendations for a new medical home asthma documentation protocol that is in development.

PRACTICAL IMPLICATIONS

The indicators of non-adherence to asthma treatments identified may be useful in developing markers of disease severity in primary care pediatrics. Medical home access to knowledge of target populations can lead to better patient outcomes with lower cost to stakeholders.

Comorbidities in adults with asthma: Population-based cross-sectional analysis of 1.4 million adults in Scotland

BACKGROUND

Comorbidity in people with asthma can significantly increase asthma morbidity and lower adherence to asthma guidelines.

OBJECTIVE

The objective of this study was to comprehensively measure the prevalence of physical and mental health comorbidities in adults with asthma using a large nationally representative population.

METHODS

Cross-sectional analysis of routine primary care electronic medical records for 1 424 378 adults in the UK, examining the prevalence of 39 comorbidities in people with and without asthma, before and after adjustment for age, sex, social deprivation and smoking status using logistic regression.

RESULTS

Of 39 comorbidities measured, 36 (92%) were significantly more common in adults with asthma; 62.6% of adults with asthma had ≥1 comorbidity vs 46.2% of those without, and 16.3% had ≥4 comorbidities vs 8.7% of those without. Comorbidities with the largest absolute increase in prevalence in adults with asthma were as follows: chronic obstructive pulmonary disease (COPD) (13.4% vs 3.1%), depression (17.3% vs 9.1%), painful conditions (15.4% vs 8.4%) and dyspepsia (10.9% vs 5.2%). Comorbidities with the largest relative difference in adults with asthma compared to those without were as follows: COPD (adjusted odds ratio [aOR] 5.65, 95% CI 5.52-5.79), bronchiectasis (aOR 4.65, 95% CI 4.26-5.08), eczema/psoriasis (aOR 3.30, 95% CI 3.14-3.48), dyspepsia (aOR 2.20, 95% CI 2.15-2.25) and chronic sinusitis (aOR 2.12, 95% CI 1.99-2.26). Depression and anxiety were more common in adults with asthma (aOR 1.60, 95% CI 1.57-1.63, and aOR 1.53, 95% CI 1.48-1.57, respectively).

CONCLUSIONS AND CLINICAL RELEVANCE

Physical and mental health comorbidities are the norm in adults with asthma. Appropriate recognition and management should form part of routine asthma care.

CHOICE: Choosing Health Options In Chronic Care Emergencies

Background

Over 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.

Objectives

The aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).

Design

A three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.

Setting

Primary care. Manchester and London.

Participants

People aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.

Results

Evidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.

Limitations

The findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.

Conclusions

Prior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.

Future work

The potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

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.

Medical and Social Determinants of Health Associated with Intensive Care Admission for Asthma in Children

RATIONALE

Risk factors for severe asthma exacerbations in children requiring admission to the intensive care unit (ICU) may occur in variety of medical, environmental, economic, and socioeconomic domains.

OBJECTIVES

We sought to characterize medical and sociodemographic risk factors among children who required admission to the intensive care unit for asthma.

METHODS

Data were obtained from the Greater Cincinnati Asthma Risk Study, a population-based, prospective, observational cohort of children admitted for treatment of acute asthma or bronchodilator-responsive wheezing. Data collected on 774 children included race, socioeconomic status, allergen sensitization, environmental exposures, psychosocial strain, and financial hardship. Analyses compared children admitted to the ICU to those admitted to a medical inpatient unit.

MEASUREMENTS AND MAIN RESULTS

One hundred sixty-one (20.9%) children required admission to intensive care. There was no difference in sex, race, insurance status, caregiver educational level, income, financial strain, psychological distress, or marital status between the ICU and non-ICU cohorts. Risk for medication nonadherence assessed by parent report was not different between groups. Although previous hospital admission or emergency department visit history did not differ between the groups, prior ICU admission was more common among those admitted to the ICU at the index admission (27 vs. 16%, P = 0.002). Children requiring intensive care admission were more likely to be sensitized to multiple aeroallergens. Exposure to cigarette smoke (measured as salivary cotinine), although a risk factor for hospital admission, was negatively associated with risk of ICU admission.

CONCLUSIONS

Social and economic risk factors typically predictive of increased asthma morbidity, including exposure to tobacco smoke, were not associated with ICU admission among a population of children admitted to the hospital for treatment of acute asthma. Intrinsic disease factors, including allergic sensitization, may be more important predictors of ICU admission.

Co-morbid psychological dysfunction is associated with a higher risk of asthma exacerbations: a systematic review and meta-analysis

BACKGROUND

The longitudinal associations between psychological dysfunction (PD) and asthma exacerbations (AE) have not been adequately addressed. This study aimed to systematically assess the influence of PD on AE, and to determine whether different PD affects AE differentially.

METHODS

Electronic databases (PubMed, Cochrane library, Web of Science, Embase, and Ovid) were searched for prospective cohort studies on the influence of PD on AE in individuals with asthma. Relative risk (RR) and adjusted RR (RRadj) were pooled across studies. Subgroup analyses assessed the effects of different types of PD and the time-dependent response to the duration of PD exposure.

RESULTS

Ten articles that involved 31,432 adults with asthma with follow-up of 6.0-86.4 months were included. PD significantly increased the risk of AE [RRadj =1.06, 95% confidence interval (95%CI): 1.04-1.09, P<0.001], presenting as hospitalizations (RRadj =1.22, 95% CI: 1.12-1.34, P<0.001), unscheduled doctor visits (RR =4.26, 95% CI: 2.52-7.19), and emergency department (ED) visits (RRadj =1.06, 95% CI: 1.01-1.10, P=0.009) because of asthma. Depression significantly increased the risk of AE (RRadj =1.07, 95% CI: 1.04-1.11, P<0.001), presenting as hospitalizations (RRadj =1.26, 95% CI: 1.07-1.49, P=0.007) and ED visits (RRadj =1.06, 95% CI: 1.02-1.11, P=0.007) because of asthma. Anxiety was only associated with an increased risk of AE in pregnant women (RR =1.05, 95% CI: 1.01-1.08), possibly due to the small amount of data available on anxiety. The influence of PD on AE was only significant when the PD exposure time exceeded one year.

CONCLUSIONS

Co-morbid PD adversely affects AE, and there are differential effects of depression and anxiety. Asthmatic subjects with PD may benefit from more attention when establishing a treatment regimen in clinical practice.

Optimizing screening for depression among adults with asthma

OBJECTIVE

The Beck Depression Inventory II (BDI-II) is one of the most frequently used tools to screen for depression in patients with chronic diseases such as cardiovascular disease and asthma. However, its original cut-off score has not been validated in adult asthmatics. The present study aimed to determine the optimal BDI-II cut-off score and to verify the impact of various patient sociodemographic and clinical characteristics on performance accuracy of the BDI-II.

METHODS

A total of 801 adult asthmatic outpatients (mean ± SD, age 49 ± 14 years, 60% female) completed the BDI-II and a structured psychiatric interview (used as the standard referent to determine presence of major depressive disorder [MDD]). The sensitivity and specificity of the BDI-II were computed to determine the optimal cut-off score for identifying MDD. The optimal cut-off scores were also verified across covariate subgroups (e.g., sex, age, smoking status, asthma control levels).

RESULTS

According to the structured psychiatric interview, 108 (13%) patients had current MDD. The overall optimal BDI-II cut-off score was 12 (sensitivity = 85%, specificity = 79%). However, subgroup analyses revealed that this score could range from 11 to 15 depending on the characteristics of the individual.

CONCLUSIONS

Results suggest that the BDI-II is an appropriate screening tool for MDD in asthma populations. However, the cut-off score is influenced by the sociodemographic and clinical characteristics of patients. These findings highlight the importance of validating generic questionnaires for depression in specific populations in order to improve the accuracy of their usage.

Depression, Asthma, and Bronchodilator Response in a Nationwide Study of US Adults

BACKGROUND

Little is known about the relation between 2 common comorbidities (depression and anxiety) and asthma or bronchodilator response (BDR).

OBJECTIVE

To examine the association between depressive symptoms and asthma or BDR in US adults.

METHODS

Cross-sectional study of 20,272 adults aged 20 to 79 years from the 2007-2012 National Health and Nutrition Examination Survey. Depressive symptoms were measured using the 9-item Patient Health Questionnaire, and classified as none to minimal, mild, moderate, moderately severe, and severe. Major depression (comprising moderately severe to severe symptoms) was defined as a 9-item Patient Health Questionnaire score of 15 or more. Anxiety was defined as 5 or more days feeling anxious in the previous month. Current asthma was defined as having been diagnosed with asthma by a doctor or health professional and 1 or more asthma attack in the previous year. BDR (as percentage of baseline FEV1) was measured in 1356 participants with FEV1/forced vital capacity of less than 0.70 and/or FEV1 less than 70% of predicted. Logistic or linear regression was used for the multivariable analysis.

RESULTS

Depressive symptoms were significantly and linearly associated with asthma, independently of anxiety symptoms. Subjects with major depression had 3.4 times higher odds of asthma than did those with minimal or no depressive symptoms (95% CI, 2.6-4.5; P < .01). Among adults with asthma, major depression was associated with a 4.2% reduction in BDR (95% CI, -7.5% to -0.8%; P = .02). Major depression was not associated with BDR among adults without asthma. Anxiety was not associated with asthma or BDR.

CONCLUSIONS

Depressive symptoms are associated with asthma in adults, independently of anxiety symptoms. Major depression is associated with reduced BDR in adults with asthma.

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

Objectives

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

Methods

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

Key findings

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

Conclusions

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

Are asthma patients at increased risk of clinical depression? A longitudinal cohort study

OBJECTIVE

In this study, we assessed whether adult patients with asthma are more likely to be diagnosed with depression than diabetes patients or "healthy" controls during follow-up in primary care.

METHODS

Data from the Nijmegen Continuous Morbidity Registration were used to assess the risk for a first depression. Patients with asthma were compared with patients with diabetes and with two healthy controls matched on age, gender, socioeconomic status and attending general practice. With Cox proportional hazard analysis, we compared the risk of depression between these groups. These analyses were corrected for relevant covariates including a time-depending variable for multimorbidity. Explorative subgroup analyses were done for age, gender, socioeconomic status and multimorbidity.

RESULTS

Cumulative incidence of depression in asthma patients was 5.2%, in DM patients 4.1% and in control subjects 3.3%. The hazard ratios for a first episode of depression in the asthma patients (n = 795) compared to DM patients (n = 1033) and control subjects after correction for covariates were 1.11 (95% CI 0.60-2.04) and 1.18 (95% CI 0.78-1.79), respectively. Exploratory analyses showed that asthma patients without multimorbidity were at higher risk for a depression compared to reference groups, while asthma patients with multimorbidity were at lower risk for depression.

CONCLUSION

Asthma patients were not more likely to be diagnosed with a first depression compared to "healthy" control subjects or diabetes patients. The influence of multimorbidity on depression risk in asthma patients warrants further study.

Decreased work ability associated to indoor air problems--An intervention (RCT) to promote health behavior

INTRODUCTION

Indoor air problems may induce respiratory irritation and inflammation. In occupational settings, long-lasting non-specific building-related symptomatology, not fully medically explained, is encountered. The symptomatology may lead to illness, avoidance behavior and decreased work ability. In Finland, investigations of workers suspected of occupational asthma have revealed excess disability. There are no well-established clinical practices for the condition.

OBJECTIVE

The aim was to develop a clinical intervention for patients with non-specific indoor air-related symptoms and decreased work ability.

METHODS

A randomized controlled trial including psychoeducation and promotion of health behavior was carried out in 55 patients investigated for causal relationship between work-related respiratory symptoms and moisture damaged workplaces. Inclusion criteria for disability was the work ability score (WAS)≤7 (scale 0-10) and indoor air-related sick leave ≥14 days the preceding year. After medical evaluation and the 3-session counseling intervention, follow-up at 6-months was assessed using self-evaluated work-ability, sick leave days, quality of life, and illness worries as outcome measures.

RESULTS

The mean symptom history was 55.5 months. 82% (45 out of 55) had asthma with normal lung function tests in most cases, although reporting abundant asthma symptoms. 81% of patients (39/48) had symptomatology from multiple organ systems without biomedical explanation, despite environmental improvements at work place. At the psychological counseling sessions, 15 (60%) patients of the intervention (INT, n=25) group showed concerns of a serious disease and in 5 (20%), concerns and fears had led to avoidance and restricted personal life. In the 6-month follow-up, the outcomes in the INT group did not differ from the treatment as usual group.

CONCLUSION

No intervention effects were found. Patients shared features with medically unexplained symptoms and sick building syndrome or idiopathic environmental intolerance. Long environment-attributed non-specific symptom history and disability may require more intensive interventions. There is a need for improved recognition and early measures to prevent indoor-associated disability.

TRIAL REGISTRATION NUMBER

Single-center randomized controlled trial (ISRCTN33165676).

Multiple chronic conditions and asthma: implications for practice and research

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

An examination of adverse asthma outcomes in U.S. Adults with multiple morbidities

RATIONALE

More Americans are managing multiple chronic conditions. Little is known regarding combinations of multiple chronic conditions with asthma.

OBJECTIVES

To examine the prevalence and demographic distribution of five common chronic conditions (arthritis, heart disease, cancer, diabetes, and hypertension) in adults with and without asthma and the adverse asthma outcomes associated with multiple chronic conditions.

METHODS

Cross-sectional interview data from the National Health and Nutrition Examination Survey were analyzed (n = 22,172) between 2003 and 2010. Bivariate analysis methods and multivariate generalized linear regression were used to examine associations.

MEASUREMENTS AND MAIN RESULTS

Of the 10% of subjects with asthma, 54% had one or more coexisting health condition(s). The prevalence of two or three or more other chronic conditions was greater among those with asthma compared with those without (P < 0.001). Common comorbidities with asthma were hypertension (34%) and arthritis (31%). For every additional comorbid chronic condition, there was an increase in the prevalence of reported asthma symptom episodes (prevalence ratio [PR], 1.06; 95% confidence interval [CI], 1.00-1.13), frequent activity limitation (PR, 1.14; 95% CI, 1.04-1.25), sleep disturbances (PR, 1.22; 95% CI, 1.04-1.43), and emergency department visit for asthma (PR, 1.45; 95% CI, 1.19-1.76) when adjusted for socioeconomic and demographic factors and body mass index. The population-attributable risk for emergency department visits for asthma among individuals with asthma who have other chronic comorbidities was 19.5%.

CONCLUSIONS

Half of the adult population with asthma in the United States suffers from comorbid conditions, which are associated with adverse asthma-related outcomes and account for up to 20% of emergency room visits for asthma.

Mental health and asthma in China: the Guangzhou Biobank Cohort Study

BACKGROUND

There is consistent evidence of the co-occurrence of poor mental health and asthma in Western populations. Since the experience and expression of mental health is partly culturally determined, it is of interest to examine if similar associations are found in other cultural settings. In that regard, very little is known about the association between mental health and asthma in Asian countries, such as China.

PURPOSE

The aim of this study was to investigate the relationship between mental health and asthma in a large sample from China.

METHOD

We used data from the Guangzhou Biobank Cohort Study phase 3 (n = 9,280). Participants reported physician-diagnosed asthma. Mental health measures included the 15-item Chinese version of the Geriatric Depression Scale (GDS-C) and the SF-12 Mental Component Summary (MCS) score. We compared the prevalence of asthma by GDS-C and MCS scores by estimating prevalence ratios (PRs) and their corresponding 95% confidence intervals (95% CI), using Poisson regression.

RESULTS

Compared to those without depression, the prevalence of asthma was higher in those with moderate or severe depression levels (PR = 2.63, 95% CI = 1.58–4.40 and PR = 4.43, 95% CI = 1.62–12.09, p for trend ≤0.0001). The prevalence of asthma increased by 46% with every 1 standard deviation increase of the GDS-C score (PR = 1.46, 95% CI = 1.24–1.73). The MCS score was not associated with asthma.

CONCLUSION

Depressive symptoms were associated with asthma prevalence in a Chinese population. Further research into the mechanism and potential directions of causality is warranted.

Asthma and depression: the Cooper Center Longitudinal Study

BACKGROUND

Prior research suggests a possible association between asthma and depression.

OBJECTIVE

To examine the association between asthma and depressive symptoms, controlling for asthma medications, lung function, and overall health.

METHODS

We conducted a cross-sectional study of 12,944 adults who completed physician-based preventive health examinations at the Cooper Clinic from 2000 to 2012. Information on medical histories, including asthma and depression, and medications were collected. Participants reported overall health status, completed spirometry testing, and underwent depression screening using the 10-item Center for Epidemiologic Studies Depression Scale (CES-D). Dependent variables of current depressive symptoms (CES-D scores ≥10) and lifetime history of depression were separately modeled using logistic regression with independent variables, including demographics, spirometry, asthma controller medications, and patient-reported health status.

RESULTS

The sample was predominantly white and well educated. The prevalence of asthma was 9.0%. Asthma was associated with an odds ratio (OR) of 1.41 (95% CI, 1.16-1.70; P < .001) of current depressive symptoms based on CES-D score. Asthma was also associated with lifetime history of depression (OR, 1.66; 95% CI, 1.40-1.95; P < .001). Neither lung function nor asthma controller medications were significantly associated with depression.

CONCLUSION

Asthma was associated with increased prevalence of current depressive symptoms and lifetime depression in a large sample of relatively healthy adults. These findings suggest that the increased likelihood of depression among patients with asthma does not appear to be exclusively related to severe or poorly controlled asthma. People with asthma, regardless of severity, may benefit from depression screening in clinical settings.

The influence of hospitalizations due to exacerbations or spontaneous pneumothoraxes on the quality of life, mental function and symptoms of depression and anxiety in patients with COPD or asthma

BACKGROUND

Patients with bronchial asthma or chronic obstructive pulmonary disease (COPD) frequently have a low quality of life (QoL) in addition to depression symptoms. The aim of this study was to compare the QoL, depression symptoms, mental function and anxiety in patients with asthma or COPD exacerbations or spontaneous pneumothoraxes (SP) to patients with stable disease.

MATERIALS AND METHODS

Patients with a confirmed diagnosis of severe (III degree) bronchial asthma or COPD were included in this study. Prospective observations of asthma or COPD exacerbations or SP were performed over a three-year period. QoL was assessed using St. George's Respiratory Questionnaire (SGRQ). In addition, the AQ20 questionnaire (AQ20), the Hospital Anxiety and Depression Scale (HADS) and the Mini-Mental State Examination (MMSE) were administered.

RESULTS

A total of 233 patients (112 with asthma and 121 with COPD; mean age 57.9 ± 11.9 years) were included in the study. Patients with COPD or asthma had a low QoL as estimated by the SGRQ (mean ± SD: 27.5 ± 12.9 and 25.1 ± 10.2 for asthma and COPD, respectively). Asthma exacerbations, COPD exacerbations or SP requiring hospitalization were associated with lower SGRQ scores over the three-year observation period (41.5 ± 11.7, 57.9 ± 14.3 and 65.3 ± 11.4, respectively). The mean MMSE score significantly decreased after an asthma exacerbation compared to the baseline (29.9 ± 2.1 versus 27.2 ± 3.1; p < 0.05). The mean MMSE score decreased after COPD exacerbations (28.5 ± 0.9 versus 26.9 ± 1.2; p < 0.05) and after COPD with an SP event (28.8 ± 1.2 versus 24.1 ± 2.2; p < 0.05).

CONCLUSION

Low QoL and mental impairment were observed in patients with asthma and COPD. In addition, the QoL significantly decreased following hospitalizations due to exacerbations or SP.

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.

Patterns of health care utilization for asthma treatment in adults with substance use disorders

OBJECTIVES

: National goals for improving asthma outcomes include decreasing emergency room utilization and increasing adherence to outpatient treatment guidelines. Few studies have examined the impact of substance use disorders on asthma treatment. The objective of this study was to describe correlations between substance use disorders and patterns of healthcare utilization for asthma care.

METHODS

: We performed a retrospective analysis of 1999 Medicaid claims for adults with asthma from 5 states. Adjusted odds of receiving asthma treatment in outpatient, inpatient, and emergency settings were calculated for patients with substance use disorder (SUD).

RESULTS

: Consistent patterns emerge demonstrating significantly lower odds of utilization of outpatient services for asthma in patients with SUD. A trend toward increased utilization of acute care resources was observed, with odds of emergency care for asthma significantly increased in New Jersey (odds ratio [OR], 1.14; 95% confidence interval [CI], 1-1.31) and Georgia (OR, 1.24; 95% CI, 1.04-1.48), and odds of inpatient care for asthma significantly increased in Georgia (OR, 1.42; 95% CI, 1.03-1.95).

CONCLUSIONS

: Substance use disorders are associated with decreased odds of receiving outpatient care and equivalent or increased odds of receiving emergency and inpatient care for asthma. Consequently, outpatient-based strategies to improve asthma care may have a very limited impact for this population. Identifying asthma patients with SUD in acute care settings and enhancing the care they receive in these settings may be necessary to improve adherence to treatment guidelines and decrease utilization in this population.