Psychological issues in the treatment of asthmatic patients

Impact of Anxiety and Depression on the Level of Asthma Control Among Jordanian Adults with Asthma

Purpose

Recent studies imply that psychological factors may actively contribute to the development of asthma. It is generally known that people with asthma frequently suffer from psychological illnesses. This association can make it challenging to reach asthma control. This study aimed to assess the prevalence of depression and anxiety among Jordanian adults with asthma, in addition to the link between asthma control levels and these psychological disorders.

Patients and Methods

This cross-sectional study included 175 adults with asthma who visited the tertiary asthma clinic in three Jordanian Governmental hospitals. Sociodemographic data was collected directly from the patients who were assessed for their level of depression and anxiety using a self-administered questionnaire, the Hospital Anxiety and Depression Scale (HADS). Also, asthma control was assessed using the Asthma Control Test (ACT). The relation between the different sociodemographic variables and clinical data, particularly depression and anxiety and asthma control level, was assessed.

Results

Among 175 asthmatic patients, 60.57% had poor disease control, 8% had anxiety alone, 11.43% had depression alone, and 53.14% had anxiety plus depression. Poor asthma control was significantly associated with anxiety and depression (p= 0.044) and low levels of education (p=0.001). Further, a lower level of education was also related to higher levels of anxiety and depression.

Conclusion

Most of the assessed Jordanian patients with asthma had their disease poorly controlled. Anxiety and depression are common among the studied sample of adults with asthma, and they appear to affect the level of disease control, suggesting the possibility that addressing these psychological conditions could enhance asthma control levels.

Bronchial asthma control, quality of life, and psychiatric disorders vicious cycle: Asyut society point of view

Background

Poorly controlled bronchial asthma limits patients’ quality of life (QOL), the condition which may potentiate the development of psychiatric disorders. The aim of this study was the assessment of anxiety and depression in bronchial asthma patients, and their interrelation with both level of asthma control and quality of life in our society.

Results

This study included 102 bronchial asthma patients, and 50 healthy control individuals. Patients had poorer QOL, and higher anxiety and depression scores compared to healthy control, moreover these scores were higher in uncontrolled asthma patients compared to controlled group. Poor QOL, frequent hospital admissions, and poor asthma control were the predictors for psychiatric disorders.

Conclusion

Depression and anxiety are frequently encountered in patients with bronchial asthma in our society; poor symptom control, poor QOL, and frequent hospital admissions are the main predictors for these psychiatric disorders.

Anxiety in asthma: a systematic review and meta-analysis

BACKGROUND

Background: Growing evidence from observational studies indicates a high prevalence of anxiety in asthma. However, prevalence rates of coexisting anxiety symptoms and comorbid anxiety disorders vary widely across studies. We aimed to evaluate the associations between anxiety and asthma and provide more precise comorbidity estimates.

METHODS

We systematically reviewed the literature from case-controlled studies and conducted a meta-analysis to evaluate the pooled prevalence estimates and risks of anxiety symptoms and anxiety disorders in asthma individuals. Screening, data extraction, and quality assessment were undertaken following PRISMA guidelines for preferred reporting of systematic reviews and meta-analysis. A random-effects model was used to calculate pooled prevalence rates. Meta-analysis was conducted using Review Manager 5.3. Multiple databases including PubMed, ScienceDirect, PsychINFO, and PsycARTICLES were searched for publications before 1 December 2019. The review protocol was registered on PROSPERO (ref: CRD42020176028).

RESULTS

In total, 19 studies involving 106813 participants were included. The pooled prevalence of anxiety symptoms and anxiety disorders in individuals with asthma was 0.32 (95% CI 0.22-0.43) and 0.24 (95% CI 0.13-0.41), respectively. The risks of coexisting anxiety symptoms and comorbid anxiety disorders were significantly higher in asthma patients than in non-asthma controls indicated by OR 1.89 (95% CI 1.42-2.52; Z = 4.37; p < 0.001) and OR 2.08 (95% CI 1.70-2.56; Z = 6.97; p < 0.001), respectively. Anxiety symptoms and anxiety disorders occur at increased frequency among patients with asthma.

CONCLUSIONS

Our findings highlight the need for appropriate assessments for these comorbid conditions, which may help to identify a subgroup of patients who might benefit from interventions designed to reduce anxiety and enhance the quality of life.

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.

Prevalence of depression and anxiety among otolaryngology outpatients at Jordan University Hospital

PURPOSE

To determine the prevalence of depression and anxiety among otolaryngology outpatients at Jordan University Hospital.

METHODS

A cross-sectional observational study was conducted between January 2017 and February 2018. The sample included 1328 otolaryngology adult outpatients, who completed (PHQ-9) and (GAD-7) questionnaires for depression and anxiety. Sociodemographic and clinical data were recorded.

RESULTS

Depression and anxiety prevalence rates were 36.1% and 22.9%. The significant risk factors found for them were: age range 30 to 50 years, female sex, divorced status, smoking, alcohol drinking, asthma, family history of psychiatric illness, chronic illnesses, negative life events, secondary education, unemployment, low income, globus pharyngeus, tinnitus, and dizziness.

PRACTICE IMPLICATIONS

Healthcare providers should have the vigilance to suspect and treat these disorders to improve patients' symptoms and quality of life.

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.

Avoiding misdiagnosis in patients with dyspnea and wheezing: a case report illustrating the clinical implications of fixation error

Background

Bronchial asthma is a heterogeneous respiratory condition which can be mimicked by a wide range of pathologies including upper airways stenosis. The accurate diagnosis of asthma, as with other conditions, may be influenced by fixation errors, which are common in medicine and occur when a physician concentrates on only one element of a clinical case without considering other relevant aspects. Here we report a challenging case characterized by the contemporaneous presence of a common disease, asthma, together with a rare respiratory disease, idiopathic tracheal stenosis.

Case presentation

The 56-year-old female patient, a former smoker, was referred to our outpatient clinic for exertional dyspnea and persistent wheezing. There were no other respiratory or systemic symptoms over the past three months, and a psychological component was suspected. Spirometry with flow-volume evaluation and bronchoscopy were the key elements to establish the diagnoses and provide treatments. Once the diagnosis of asthma was confirmed, the combination of the anti-inflammatory corticosteroid fluticasone and the rapid-acting bronchodilator formoterol in a single inhaler effectively controlled the patient’s symptoms, confirming the favorable efficacy and safety profile which are reflected in the recommendations of the international guidelines.

Conclusions

In this paper we describe the clinical investigations and interventions that eventually confirmed a diagnosis of asthma complicated by an idiopathic tracheal stenosis and led to effective treatment of the patient. Awareness of fixation error may avoid misdiagnosis in patients with respiratory disease and a complicated history at presentation.

Impact of a history of maternal depression and anxiety on asthma control during pregnancy

OBJECTIVE

To determine the impact of self-reported maternal depression/anxiety on asthma control during pregnancy.

METHOD

Pregnant women with a doctor diagnosis of asthma (n = 189) were prospectively recruited at their antenatal booking visit, and the presence of maternal depression and anxiety was identified using self-report and routine questionnaire assessments. Data on exacerbations and asthma control were collected during gestation. Asthma control was assessed using the Juniper Asthma Control Questionnaire (ACQ) and women were classified as having recurrent uncontrolled asthma if their ACQ score was >1.5 during two or more consecutive study visits. Exacerbations were defined as events that led to increased treatment requirements, and doctor or hospital visits.

RESULTS

There were 85 women with self-reported depression/anxiety and 104 women without self-reported depression/anxiety. The presence of depression/anxiety was associated with an increased likelihood (adjusted hazard ratio (HR) 1.67: 95% confidence interval (CI) 1.03-2.72) and incidence (adjusted incidence rate ratio (IRR) 1.71: 95% CI 1.13-2.58) of uncontrolled asthma during pregnancy, as well as an increased risk of recurrent uncontrolled asthma during 2 or more study visits (adjusted relative risk (RR) 1.98: 95% CI 1.00-3.91). No impact of depression/anxiety was observed with respect to the likelihood (adjusted HR 0.70: 95% CI 0.35-1.41) or incidence of exacerbations during pregnancy (adjusted IRR 0.66: 95% CI 0.35-1.26).

CONCLUSIONS

This study provides evidence that the presence of maternal depression/anxiety is associated with an increased likelihood and incidence of uncontrolled asthma during pregnancy. Given the high prevalence of co-morbid depression/anxiety among asthmatics, further research investigating such associations is urgently required.

Childhood atopy and mental health: a prospective, longitudinal investigation

BACKGROUND

Prior studies have suggested a relationship between atopy and mental health, although methodological barriers have limited the generalizability of these findings. The objective of this study was to investigate the relationship between early-life atopy and vulnerability to mental health problems among youth in the community.

METHOD

Data were drawn from the Raine Study (N = 2868), a population-based birth cohort study in Western Australia. Logistic regression and generalized estimating equations were used to examine the relationship between atopy at ages 1-5 years [using parent report and objective biological confirmation (sera IgE)], and the range of internalizing and externalizing mental health problems at ages 5-17 years.

RESULTS

Atopy appears to be associated with increased vulnerability to affective and anxiety problems, compared to youth without atopy. These associations remained significant after adjusting for a range of potential confounders. No relationship was evident between atopy and attention deficit hyperactivity disorder or externalizing problems.

CONCLUSIONS

Findings are the first linking atopy (measured by both parent report and objective verification) with increased vulnerability to affective and anxiety problems. Therefore, replication is required. If replicated, future research aimed at understanding the possible biological and/or social and environmental pathways underlying these links is needed. Such information could shed light on shared pathways that could lead to more effective treatments for both atopy and internalizing mental health problems.

Depressive symptoms, quality of sleep, and disease control in women with asthma

PURPOSE

A large number of asthmatic patients, particularly females, present inadequate disease control. Depressive symptoms are reportedly common in asthma and have been related to poor disease control, but the mechanism of this association is still unclear. Poor quality sleep, frequently observed in asthmatics, is also a manifestation of depression and has been related to uncontrolled asthma. This study aimed to investigate the relationship between depressive symptoms, sleep quality, and asthma control.

METHODS

This was a cross-sectional study of 123 women with previous diagnosis of asthma from a reference center in Fortaleza, Brazil. Depressive symptoms were assessed by the Beck Depression Inventory (BDI); quality of sleep was evaluated by the Pittsburgh Sleep Quality Index (PSQI), daytime sleepiness by the Epworth Sleepiness Scale (ESS), and asthma control by the Asthma Control Test (ACT).

RESULTS

Inadequate asthma control (ACT <20) was found in 94 (76.4 %) subjects, depressive symptoms in 92 (74.8 %), poor quality sleep (PSQI >5) in 99 (80.49 %), and excessive daytime sleepiness (ESS ≥10) in 34 (27.64 %). Depressive symptoms were associated with both poor quality sleep (R = 0.326) and inadequate asthma control (R = -0.299). Regression analysis showed that depressive symptoms and sleep quality were independent predictors of the level of asthma control.

CONCLUSION

Asthma control in women is independently associated with depressive symptoms and quality of sleep, suggesting that these patients might benefit from simple measures to promote healthy sleep behavior and sleep hygiene and also that routine screening for depression can be relevant, particularly, in poorly controlled cases.

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.

Psychological characteristics of patients with asthma

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Increasing awareness of sex differences in airway diseases

There is growing epidemiologic data demonstrating sex differences with respect to prevalence and progression of airway diseases, including asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF) and non-CF-related bronchiectasis. In asthma, for example, young boys have increased exacerbations and higher morbidity than girls which distinctly reverses after adolescence and into adulthood. In COPD, a disease that was historically considered an illness of men, the number of women dying per year is now greater than in men. Finally, women with CF-related bronchiectasis have a decreased median life expectancy relative to men and a higher risk of respiratory infections despite equal prevalence of the disease. A number of studies now exist demonstrating mechanisms behind these sex differences, including influences of genetic predisposition, sex hormones and comorbidities. The notable sex disparity has potential diagnostic, therapeutic and prognostic implications and for the practicing respiratory or general physician, a familiarity with these distinctions may augment effective management of patients with airway diseases. This review seeks to concisely summarize the data regarding gender-based differences in airway diseases, outline the current understanding of contributing factors and discuss therapeutic implications for clinicians.

Cough variant asthma patients are more depressed and anxious than classic asthma patients

OBJECTIVE

Many recent studies have indicated that depression and anxiety are more common in asthmatic patients than in the general population and psychological stress can lead to asthma exacerbations, but no study specifically targets cough variant asthma (CVA) patients. The purpose of this study was to evaluate depression and anxiety levels in CVA patients compared with classic asthma patients and to identify the psychological features of CVA patients.

METHODS

Fifty-nine outpatients with CVA and 128 outpatients with classic asthma were interviewed about psychosomatic and psychiatric symptoms, and they underwent three psychological tests: Self-rating Depression Scale (SDS), State-Trait Anxiety Inventory (STAI), and Comprehensive Asthma Inventory (CAI). They were ultimately screened for major and minor depression, dysthymia, panic disorder, generalized anxiety disorder, social anxiety disorder, and other anxiety disorders.

RESULTS

CVA patients showed higher SDS and STAI scores than classic asthma patients, and mood disorders and anxiety disorders were more common than in classic asthma outpatients. The psychological factors 'frustration', 'fright into illness', and 'distorted lifestyle' were more prominent in CVA patients than in classic asthma patients.

CONCLUSION

CVA patients are on average more depressed and anxious than classic asthma outpatients. Though CVA appears pathologically to be just an early stage of typical asthma, the psychological stress may often be more serious than in asthma controlled by medication, which may explain why CVA cannot be controlled by a bronchodilator alone and patients often require no less intense therapy than for severe asthma.

Comparison of clinical effectiveness of acupuncture and a Western drug on allergic rhinitis: study protocol for a randomized controlled trial

OBJECTIVE

To compare the efficacy of an acupuncture regimen for persistent allergic rhinitis (PER), aimed at improving a patient's mind or Shen in Traditional Chinese Medicine, to that of a second-generation Hi-receptor antagonist, cetirizine hydrochloride.

METHODS

This multicenter, randomized, controlled clinical trial on PER will be conducted at three institutions in China. The total study period will be 9 weeks. After a 1-week preparatory screening period, 240 eligible participants with PER will be randomized to receive acupuncture or pharmacotherapy (1:1) for 4 weeks with a 4-week follow-up. The primary outcome will be changes in 7-day average total nasal symptom score. Secondary outcome measures include rhinoconjunctivitis quality of life questionnaire score and total non-nasal symptom score.

RESULTS

The presence and seriousness of psychological and emotional impairments should be considered in therapeutic programs for allergic rhinitis. No clinical trial for treating allergic rhinitis via acupuncture regulation of psychological and emotional activities has been reported.

CONCLUSION

The findings of the trial will allow us to determine the effects of the mind (Shen)-regulation treatment approach. We will also be able to confirm if the effects of acupuncture are equivalent to those of the conventional drug cetirizine hydrochloride.

Health status measurement in patients with severe asthma

BACKGROUND

Patients with severe asthma experience problems in different areas of their health status. Identification of these areas will provide insight in the patients needs and perhaps what determines the burden of disease. The Nijmegen Clinical Screening Instrument (NCSI) was recently developed for use in clinical practice in patients with COPD and provides a detailed picture of the patients' physiological functioning, symptoms, functional impairment, and Quality of Life. Main purpose of this study is to evaluate the use of the NCSI as compared to the Asthma Control Questionnaire (ACQ) and Asthma Quality of Life Questionnaire (AQLQ) in patients with severe asthma.

METHODS

The NCSI, AQLQ, and ACQ were measured in 167 patients with severe asthma. Pearson correlations were calculated between NCSI sub-domains and the AQLQ domains and the ACQ.

RESULTS

The NCSI measures more aspects of health status as compared to the ACQ and AQLQ in patients with severe asthma. Beside symptoms, subjective impairment, and emotions the NCSI also measures general Quality of Life, health related Quality of Life, satisfaction with relations, fatigue, and behavioural impairment. On all NCSI sub-domains proportions of patients with normal, mild, and severe problems were found. Heterogeneity was found on the number and on the combination of sub-domains on which patients reported severe problems.

CONCLUSIONS

The NCSI provides a more detailed picture of the individual patient with severe asthma than the ACQ and AQLQ. The use of the NCSI might allow quick identification of the problem areas and possible factors that impair health status.

Improving allergy management in the primary care network--a holistic approach

The incidence, prevalence and costs of allergy have increased substantially in recent decades in many parts of Europe. The dominant model of allergy care within Europe is at the moment specialist-based. This model will become unsustainable and undeliverable with increasing disease prevalence. One solution to increase provision of allergy services is to diversify the providers. A new model for the provision of allergy care in the community with the general practitioner at the forefront is proposed. Pre- and postgraduate allergy education and training, implementation of pathways of care, allergy specialization and political will to generate resources and support are essential to achieve this new model. In parallel the holistic view of allergic diseases should be maintained, including assessment of severity and risk, psychological factors and health-care related costs in the context of the patient-centered decision making process.

Impact of allergy treatment on the association between allergies and mood and anxiety in a population sample

BACKGROUND

Previous studies have suggested an association between allergy and mood and anxiety disorders. Yet, extant work suffers from methodological limitations.

OBJECTIVE

To investigate the association between physician-diagnosed allergy and DSM-IV mood and anxiety disorders in the general population, and to examine the role of allergy treatment in this relationship.

METHODS

Data were drawn from the German National Health Interview and Examination Survey, a population-based, representative sample of 4,181 adults aged 18-65 in Germany. Allergy was diagnosed by physicians during medical examination and mental disorders were diagnosed using the CIDI.

RESULTS

Allergy was associated with an increased prevalence of any anxiety disorder [OR = 1.3 (1.1, 1.6)], panic attacks [OR = 1.6 (1.1, 2.1)], panic disorder [OR = 1.6 (1.01, 2.3)], GAD [OR = 1.8 (1.1, 3.0)], any mood disorder [OR = 1.4 (1.1, 1.7)], depression [OR = 1.4 (1.1, 1.7)] and bipolar disorder [OR = 2.0, (1.0, 3.8)]. After adjusting for desensitization treatment status, these relationships were no longer significant. Those treated for allergy were significantly less likely to have any mood or anxiety disorder [OR = 0.65 (0.4, 0.96)], compared to those untreated. All relationships were adjusted for age, gender and socioeconomic status (SES).

CONCLUSIONS & CLINICAL RELEVANCE

These findings provide the first evidence of a link between physician-diagnosed allergy and DSM-IV mood and anxiety disorders in a representative sample. Treatment for allergy may mitigate much of this relationship.

Adherence in severe asthma

Adherence in asthma is an important cause for concern. Although nearly 50% of asthma patients are considered poorly adherent to therapeutic advices, adherence is still difficult to assess, understand and improve despite major medical consequences. In this review, we revisited the literature of the last 10 years related to adherence in severe asthma. The concepts have changed and "compliance" is usually replaced by "adherence". Assessment of adherence is addressing ethical issues, but provides important insight into difficult-to-treat asthma. Different tools have been used but none is routinely recommended. Health-related outcomes (poor control, exacerbations, hospitalizations, lung function decline), which are clearly associated with severe asthma, are often worsened by non-adherence with consequences also on patient related outcomes (quality of life). The potential behaviour associated with non-adherence and all other related factors including easy-to-recognize psychological traits can help for patient's future management. Therapeutic educational interventions have been recognized with a scientifically proven efficiency even though evolution and improvements are needed. A multidisciplinary approach is required in severe asthma. Therapeutic adherence for a given patient is always a prerequisite to any other aspects when addressing severe asthma phenotypes. Severe asthma should be considered only in those who still experienced poor asthma outcomes despite optimal adherence. At a glance, poor adherence and severe asthma should be considered antinomic. Better understanding of the causes and customised management are potential future directions.

Reliability and validity of shortened state trait anxiety inventory in Spanish patients receiving mechanical ventilation

BACKGROUND

In order to measure anxiety in physically and cognitively debilitated patients, such as patients receiving invasive mechanical ventilation, the use of reliable and valid instruments is recommended; however, these instruments should be short.

OBJECTIVE

To analyze the reliability and validity of a short version of the state subscale from the Spielberger State-Trait Anxiety Inventory, developed by Chlan and colleagues and translated into Spanish (STAI-E6), in patients receiving invasive mechanical ventilation.

METHODS

An instrumental study was conducted of 80 patients receiving invasive mechanical ventilation in the intensive care unit at the Hospital of Alicante (Spain). The patients completed the 6-item STAI-E6 scale. Before the patients completed the scale, the interviewers indicated their impression of each patient's level of anxiety by using a linear scale. Internal consistency, construct validity, and convergent validity of the scale were analyzed.

RESULTS

The scale did not present a floor/ceiling effect, the Cronbach α was 0.79, and the single-factor structure of the original scale was maintained. Scores on the scale correlated positively with the subjective assessment of the health professional. Significant differences were found only between anxiety level and duration of intubation.

CONCLUSIONS

The 6-item version of the state subscale from the STAI-E6 shows satisfactory reliability and validity for Spanish patients receiving invasive mechanical ventilation.

Mental health among adults with asthma and chronic bronchitis. A population-based study in Spain

OBJECTIVES

To analyze the conditions of psychological dysfunction and positive mental health in patients with asthma and chronic bronchitis (CB), as compared to healthy individuals, and to identify the factors associated with these mental health indicators.

METHODS

Cross-sectional study based on data obtained from the European Health Interview Survey for Spain (EHISS, 2009). We identified individuals with asthma and CB using a specific questionnaire. In order to assess mental health, two indicators extracted from questionnaire SF-36 were used: psychological dysfunction and positive mental health status.

RESULTS

Out of 19,598 subjects included in the study, 8.3% were classified as asthmatic and 7.4% as CB. Healthy individuals had significantly higher psychological dysfunction scores than those with asthma and CB. The same occurred with positive mental health. The variables independently associated with lower scores out of these variables were gender female, a greater number of chronic diseases and obesity. On the contrary, alcohol consumption and physical exercise were associated with a higher score in the aforementioned variables.

CONCLUSIONS

Healthy individuals have significantly higher scores in psychological dysfunction and positive mental health than patients with asthma and CB. This suggests that their mental health is much better. The variables related with lower scores out of these variables, and therefore with worse mental health, are: being female, having a greater number of chronic diseases and obesity. On the contrary, alcohol consumption and the practicing of physical exercise are associated with a higher score in the aforementioned variables, thus indicating a greater degree of mental health.

Analysis of the relation between level of asthma control and depression and anxiety

BACKGROUND

Frequent co-existence of bronchial asthma and depression or anxiety is an unquestioned phenomenon. In contrast, little is known about the relationship between the degree of asthma control and the prevalence of depression and anxiety. The aim of this study was to determine the potential relationship between the degree of asthma control and the prevalence of depression and anxiety.

MATERIAL/METHODS

This study included a group of 128 randomly selected asthmatic individuals with various degree of asthma control. The study was based on a questionnaire survey, using the following tools: the Asthma Control Test, Beck Depression Inventory, and State-Trait Anxiety Inventory (STAI) - X-1 and X-2 questionnaires. All the questionnaires were completed during a single follow-up visit at the clinic.

RESULTS

The occurrence of depression and its severity significantly correlated with the degree of asthma control. Individuals with depression were characterized by a significantly lower degree of asthma control compared to depression-free individuals (p<0.001). The degree of asthma control decreased significantly with increasing severity of depression (R=-0.367; p<0.001). No significant correlation was observed between the degree of asthma control and the levels of trait anxiety (R=-0.095; p=0.295) and state anxiety (R=-0.093; p=0.308).

CONCLUSIONS

The prevalence of depression and its severity significantly correlate with the degree of asthma control. Large, standardized multicenter studies of the relationship between the degree of asthma control and the prevalence of depression and other psychopathological symptoms are needed. Furthermore, it seems reasonable to introduce the screening of asthmatics for mental disorders.

Anxiety and depression in asthma patients: impact on asthma control

OBJECTIVE

There is evidence that asthma is associated with an increase in psychiatric symptoms and mental disorders. This association can make it difficult to achieve asthma control. The purpose of this study was to determine whether the level of asthma control is associated with anxiety and depression.

METHODS

A crosssectional study involving 78 patients with confirmed moderate or severe asthma and under regular treatment at the Asthma Outpatient Clinic of the Federal University of São Paulo Hospital São Paulo, in the city of São Paulo, Brazil. The patients were divided into two groups by asthma control status, as assessed by the asthma control test, and were subsequently compared in terms of demographic, clinical, and spirometric data, as well as scores for asthma quality of life and hospital anxiety/depression.

RESULTS

The sample was predominantly female. Of the 78 patients, 49 (63%) were classified as having uncontrolled asthma. The prevalence of anxiety and of anxiety+depression was significantly higher among patients with uncontrolled asthma than among those with controlled asthma (78% and 100%; p = 0.04 and p = 0.02, respectively), whereas there were no differences between the two groups in terms of the prevalence of depression, spirometry results, or quality of life score.

CONCLUSIONS

In this sample, the prevalence of anxiety symptoms was higher in the patients with uncontrolled asthma than in those with controlled asthma.In the evaluation of asthma patients, the negative impact of mood states ought to be taken into consideration when asthma control strategies are being outlined.

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'.

Reliability and validity of a short version of the STAI anxiety measurement scale in respiratory patients

BACKGROUND

There is comorbidity between respiratory disease and anxiety. In order to measure the anxiety of hospitalized patients it is necessary to use reliable and valid, and preferably short questionnaires.

OBJECTIVE

To analyze the reliability and validity of a shortened version of the state subscale of the “State-Trait Anxiety Inventory (STAI)” in respiratory patients.

PATIENTS AND METHODS

A total of 103 respiratory patients admitted to the respiratory ward between February of 2009 and February of 2010 were non-consecutively selected. They answered two questionnaires: the Spanish version of the STAI-state and a short version consisting of 7 items. Sociodemographic and clinical variables of the patients were also obtained. The internal consistency, and convergent and construct validity of the short scale were analyzed.

RESULTS

The short scale did not have floor/ceiling effect, the α-Cronbach was acceptable (0.89), and correlated positively (r = 0.90; P = .01) and also maintained the factorial structure of the original scale (half anxiety-present items and half anxiety-absent items).

CONCLUSIONS

The short version of the state subscale of the STAI has showed good metric properties in hospitalized respiratory patients.

Psychiatric comorbidity in asthma patients. Associated factors

OBJECTIVE

To study the prevalence of anxiety and depression in patients with asthma and to identify associated factors.

MATERIAL AND METHODS

The study was based on individual data of subjects aged ≥18 years drawn from the 2006 Spanish National Health Survey. We identified asthmatic individuals through a specific questionnaire. Presence of depression or anxiety was assessed using the following questions: ( 1 ) "Have you suffered depression or anxiety over the previous 12 months?" ( 2 ) "Has your medical doctor confirmed the diagnosis?" ( 3 ) "Have you consumed antidepressants prescribed by your physician over the last 2 weeks?" ( 4 ) "Have you consumed anxiolytics prescribed by your physician over the last 2 weeks?" Those who answered yes to questions 1, 2, and 3 or to all questions were considered "Depression sufferers," those who answered yes to questions 1, 2, and 4 were considered "Anxiety sufferers." We analyzed sociodemographic characteristics and health-related variables.

RESULTS

Of the 28,966 subjects included in the study, 1650 were classified as asthmatic (5.6%). The prevalence of anxiety was 9.7% among people with asthma and 6.6% among those without the disease (p < .01). After multivariate adjustment the probability of a subject suffering anxiety was 1.27 (95% CI 1.08-1.49) higher among those with asthma than among those without. Independent and significantly associated variables with anxiety among asthmatic patients were older age, concomitant comorbidities, and visits to general practitioner in the last 4 weeks. The prevalence of depression was 9% among asthmatics and 5.5% among those without the disease (p < .05). The multivariate adjustment revealed that suffering depression was associated with suffering asthma (adjusted OR 1.39, 95% CI 1.18-1.64). Variables associated with depression among asthmatic patients were female sex, older age, worse self-related health, concomitant comorbidities, abstemious individuals, and the need for attendance on emergency room in the last year.

CONCLUSIONS

Suffering anxiety or depression is associated with suffering asthma. Associated variables with anxiety or depression among asthmatic patients include older age and concomitant comorbidities.

Scales for evaluating self-perceived anxiety levels in patients admitted to intensive care units: a review

OBJECTIVE

To review studies of anxiety in critically ill patients admitted to an intensive care unit to describe the level of anxiety and synthesize the psychometric properties of the instruments used to measure anxiety.

METHODS

The CUIDEN, IME, ISOC, CINAHL, MEDLINE, and PSYCINFO databases for 1995 to 2005 were searched. The search focused on 3 concepts: anxiety, intensive care, and mechanical ventilation for the English-language databases and ansiedad, cuidados intensivos, and ventilación mecánica for the Spanish-language databases. Information was extracted from 18 selected articles on the level of anxiety experienced by patients and the psychometric properties of the instruments used to measure anxiety.

RESULTS

Moderate levels of anxiety were reported. Levels were higher in women than in men, and higher in patients undergoing positive pressure ventilation regardless of sex. Most multi-item instruments had high coefficients of internal consistency. The reliability of instruments with only a single item was not demonstrated, even though the instruments had moderate-to-high correlations with other measurements.

CONCLUSION

Midlength scales, such the anxiety subscale of the Brief Symptom Inventory or the shortened state version of the State-Trait Anxiety Inventory are best for measuring anxiety in critical care patients.

Close correlation between anxiety, depression, and asthma control

BACKGROUND

We investigated the correlation between patients' characteristics, including anxiety and depression, and the level of asthma control evaluated by asthma control test (ACT), a self-administered validated questionnaire.

METHODS

This is a cross-sectional study on asthmatic outpatients of three Italian hospitals. Demographic data, spirometry, anxiety and depression scores as well as the level of asthma control from 315 patients were collected.

RESULTS

Patients with poorly controlled asthma were more frequently women, older, with a worse pulmonary function, obese, more anxious and/or more depressed. Four different independent factors associated with poor asthma control evaluated by ACT have been found: FEV(1)<60% (odds ratio, OR: 6.52), anxiety (OR: 3.76), age > or =65 years (OR: 2.69), and depression (OR: 2.45). The presence of anxiety and depression was associated with a higher healthcare utilization. Finally, we found a high level of agreement between ACT and multidimensional GINA approach in evaluating asthma control, with a concordance in 239 patients (81% of the population).

CONCLUSION

There is a close correlation between anxiety and depression, and a poor asthma. A better understanding of this association may have major clinical implications, mainly in patients with poor controlled asthma in whom the presence of anxiety and depression should be investigated.

Psychological assessment of patients with Menière's disease

The objective of this study was to evaluate daily stressors, coping, personality, physical and mental health, and quality of life in Menière patients. 110 consecutive patients with definite Menière's disease were assessed using the Dutch Daily Hassles List, Coping Inventory for Stressful Situations (CISS), Symptoms Checklist 90 (SCL-90), NEO Five Factor Inventory (NEO-FFI), General Health Questionnaire (GHQ-12), and the Short Form Health Survey 36 (SF-36). Duration and subjective severity of symptoms were scored using a self-report questionnaire. It was shown that Menière patients had more daily stressors, used certain coping strategies less often, and had more psychopathology (e.g. anxiety and depression), and a worse quality of life compared to healthy reference groups. No abnormalities in personality were found. Patients with more severe symptoms had more psychopathology and a worse quality of life than patients with mild symptoms. The psychological profile of Menière patients seems comparable to patients with other chronic diseases. The outcomes should be used to intensify psychological support in patients with this disabling disease.

Impact of depression and anxiety on quality of life, health behaviors, and asthma control among adults in the United States with asthma, 2006

BACKGROUND

Psychological factors such as anxiety and depression are increasingly being recognized as influencing the onset and course of asthma.

METHODS

We obtained Patient Health Questionnaire 8 depression data from 41 states and territories using the 2006 Behavioral Risk Factor Surveillance System. Heath risk behaviors, social and emotional support, life satisfaction, disability, and four health-related quality-of-life (HRQOL) questions were available for all states and territories (n = 18,856 with asthma). Five additional HRQOL questions were asked in three states (n = 1345 persons with asthma), and questions assessing asthma control were available for nine states (n = 3943 persons with asthma).

RESULTS

Persons with asthma were significantly more likely than those without asthma to have current depression (19.4% vs. 7.7%), a lifetime diagnosis of depression (30.6% vs. 14.4%), and anxiety (23.5% vs. 10.2%). For most domains examined, there was a dose-response relationship between level of depression severity and mean number of days of impaired HRQOL in the past 30 days, as well as an increased prevalence of life dissatisfaction, inadequate social support, disability, and risk behaviors, such as smoking, physical inactivity, and obesity, among those with asthma. Moreover, depression and anxiety were associated with a decreased level of asthma control, including more visits to the doctor or emergency room, inability to do usual activities, and more days of symptoms compared to those without depression or anxiety.

CONCLUSION

This research indicates that a multidimensional, integrative approach to health care should be considered when assessing patients with asthma.

Psychological factors in asthma

Asthma has long been considered a condition in which psychological factors have a role. As in many illnesses, psychological variables may affect outcome in asthma via their effects on treatment adherence and symptom reporting. Emerging evidence suggests that the relation between asthma and psychological factors may be more complex than that, however. Central cognitive processes may influence not only the interpretation of asthma symptoms but also the manifestation of measurable changes in immune and physiologic markers of asthma. Furthermore, asthma and major depressive disorder share several risk factors and have similar patterns of dysregulation in key biologic systems, including the neuroendocrine stress response, cytokines, and neuropeptides. Despite the evidence that depression is common in people with asthma and exerts a negative impact on outcome, few treatment studies have examined whether improving symptoms of depression do, in fact, result in better control of asthma symptoms or improved quality of life in patients with asthma.

[Self-reported history of physician-diagnosed asthma and common mental disorders among civil servants at a public university in Rio de Janeiro, Brazil: the Pró-Saúde study]

This study investigates the association between history of asthma and common mental disorders among employees at a public university in the State of Rio de Janeiro, Brazil. Phase 1 cross-sectional data from a cohort study (the Pró-Saúde Study) were collected from 4,030 employees. Asthma was ascertained by self-reported medical diagnosis, and the occurrence of common mental disorders was based on the General Health Questionnaire (GHQ-12). Generalized linear models were used to calculate prevalence rates. Asthma prevalence was 11% (444), of whom 39.7% (176) presented common mental disorders. History of asthma was associated with higher income (p = 0.01) and female gender (p = 0.01). The analysis adjusted by gender, age, and per capita income revealed an association between asthma and common mental disorders (PR = 1.37; 95%CI: 1.22-1.55). Employees with less than 10 years since their asthma diagnosis showed a higher prevalence of common mental disorders (PR = 1.88; 95%CI: 1.32-2.70). These findings suggest that multidisciplinary teams should consider emotional aspects of asthma patients, especially those recently diagnosed.

Female sexual and hormonal status in patients with bronchial asthma: relationship with respiratory function tests and psychological and somatic status

OBJECTIVES

To assess the relationship among the sexual, hormonal, physical, and psychological status of women with bronchial asthma (BA) compared with that of healthy volunteers.

METHODS

Thirty-eight women with BA were enrolled in the study. The patients were asked to complete the Female Sexual Function Index, General Health Questionnaire, and Medical Outcomes Study Short Form 36-item Health Survey (SF-36). Using the answers on the SF-36, the mental and physical component summary scores were calculated. A total of 20 healthy women were enrolled in the study as the control group. The same questionnaires were given to this group as well. Statistical analysis was performed using the Mann-Whitney U test and Pearson correlation tests.

RESULTS

At the end of the study, statistically significant differences were observed for all questionnaire scores (P <0.05). The most common female sexual dysfunction was diminished arousal (n = 30, 78.9%) in women with BA. In the correlation analysis, the total Female Sexual Function Index score had a statistically significant and positive correlation with the mental component summary score (r = 0.503, P = 0.001) and a negative correlation with the General Health Questionnaire score (r = -0.380, P = 0.020).

CONCLUSIONS

The results of our study have shown that BA, as a chronic medical condition, can be a cause of female sexual dysfunction with mental and psychiatric mechanisms.

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

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

Women with asthma: a review of potential variables and preferred medical management

OBJECTIVES

To summarize the potential variables that contribute to the increased risk of asthma in women, outline therapeutic strategies that address these variables, and review current treatment recommendations for both pregnant and nonpregnant women with asthma.

DATA SOURCES

Literature searches (MEDLINE and cross-references) were performed using the keywords asthma and women in combination with the terms compliance, depression, emergency department, hormones, menstruation, mortality, National Asthma Education and Prevention Program, osteoporosis, pregnancy, prevalence, smoking, and treatment. Searches were limited to human studies with data published before 2005.

STUDY SELECTION

The author selected relevant articles for inclusion in this review.

RESULTS

Fluctuations in sex hormones, menstruation, pregnancy, obesity, depression, medication nonadherence, and smoking may contribute to increased asthma symptoms or severity in women. Asthma control may be improved if physicians address conditions and behaviors associated with asthma variability and severity in women. Notably, asthma must be managed aggressively in pregnant women, because uncontrolled asthma can lead to perinatal complications. Asthma treatment in women is optimized through patient and physician adherence to national guideline recommendations, including provision of patient education and asthma action plans.

CONCLUSIONS

Multiple variables throughout the female life cycle may influence asthma control. Successful asthma management requires an ongoing partnership between the patient and her physician to address physiologic (eg, sex hormones, pregnancy, obesity, depression) and nonphysiologic (eg, smoking, medication nonadherence) factors that may contribute to decreased asthma control.

Negative mood and quality of life in patients with asthma

The aim of this study was to evaluate the effect of negative mood states at the moment of questionnaire, and other patient and disease characteristics on quality of life (QoL) in patients with asthma. The study groups were composed of 116 stable adult asthmatic patients and 116 age and sex matched healthy subjects. We used Short-Form Health Survey-36 (SF-36) for the assessment of general QoL in all participants, and the Asthma Quality of Life Questionnaire (AQLQ) for the assessment of disease specific QoL in patients with asthma. We evaluated negative mood in all subjects with a questionnaire including six mood subscales in three categories (nervous-anxious, hostile-angry and fearful-panicky). Negative mood scores were not different between asthmatic and comparison groups (p=0.4), but both SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were significantly lower in asthmatic group (p=0.003 and p=0.001, respectively). Multiple linear regression analysis in all study population indicated that both reduced PCS and MCS scores of SF-36 were associated with negative mood score (beta=-0.28, p<0.001 and beta=-0.37, p<0.001, respectively) and with FEV(1)% (beta=0.19, p=0.001 and beta=0.25, p<0.001, respectively) after adjusting for age, female sex, and the presence of asthma. On the other hand, multiple linear regression analysis in patients with asthma revealed that negative mood score and disease severity score were significant predictors for overall score of AQLQ after adjusting for other patient and disease characteristics (beta=-0.17, p=0.008 and beta=-0.64, p<0.001, respectively). The level of negative mood and disease severity in asthmatics significantly impair QoL. Thus, considering that one of the main objectives of health care should be preserving a satisfactory QoL in asthmatics, the presence and seriousness of negative mood and their effects on QoL should be taken into account as part of the clinical evaluation in asthmatics.

Anxiety and depression in COPD patients: The roles of gender and disease severity

BACKGROUND

The aim of our study was to assess the prevalence of anxiety and depression in the whole chronic obstructive pulmonary disease (COPD) population and in subgroups according to sex and severity classification. A secondary objective was to evaluate the possible differences between patients with and without a significant high level of anxiety, depression, or both, and finally to find out a correlation between psychological aspects, symptoms, functional parameters, and quality of life (QoL).

METHODS

Two hundred and two COPD patients were enrolled. Their levels of anxiety, depression, dyspnea, and QoL were assessed using specific questionnaires. One hundred and fourteen sex- and age-matched healthy subjects were used as the control population.

RESULTS

The prevalences of anxiety and depression were high (28.2% and 18.8%) in COPD even when it was of mild degree, compared to the control group, in which the prevalence of anxiety and depression were 6.1% and 3.5%, respectively. Female patients had higher levels of anxiety and depression and worse symptom-related QoL. Female patients reported a higher level of dyspnea than males for the same level of ventilatory impairment. Dyspnea was more strongly correlated with depression in women than in men.

CONCLUSIONS

Anxiety and depressive symptoms are common in patients affected by COPD, even when their disease is mild in terms of FEV1 and respiratory symptoms. Female patients appear to be more exposed to psychological impairment, which correlates well with some specific symptomatic aspects of the disease, such as dyspnea. Psychological aspects need to be carefully assessed in COPD patients, particularly in females.

Personality characteristics of asthma patients

INTRODUCTION

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Asthma and depression: a pragmatic review of the literature and recommendations for future research

BACKGROUND

Although the association between asthma and psychosocial factors has long been recognised, it is only in the last decade that the impact of coexisting asthma and depression has become the focus of considerable research interest. However, the findings so far have been confusing and often contradictory. This paper sets out a methodical review and appraisal of the literature to date, including suggestions for future research.

METHOD

PubMed and PsycINFO databases were used to search for English-language articles relating to asthma and depression research. The resulting articles were then reviewed and summarised, creating a report that was used to develop research recommendations.

RESULTS

The main findings from this review included: (a) results are mixed as to whether persons with asthma are more likely to be depressed than those without asthma; (b) asthma and depression may have an 'additive' adverse effect on the normal asthma-related quality of life reductions; (c) subjective measures of asthma severity may be more strongly related to depression than objective measures; (d) specific asthma symptoms appear to be linked to depression; (e) sadness and depression can produce respiratory effects consistent with asthma exacerbations; (f) depression appears to be negatively related to asthma treatment compliance; (g) corticosteroid use in asthma treatment has been associated with depression, though it is unclear how common this problem is in real life; (h) interventions that address the physical, psychological, and social consequences of asthma are likely to lead to the most successful treatment outcomes; (i) treating the depression of individuals with asthma is likely to minimise the negative effects of the coexistence; and (j) a number of common methodological problems were observed in the literature.

RECOMMENDATIONS

There is a large amount of research yet to be undertaken to clarify issues around asthma and depression, with the overdue next step being to design integrated treatment approaches, and carry out large-scale prospective studies to determine the impact of using such approaches to treat individuals with depression and asthma. Such studies will be the only way in which some fundamental questions about the development and coexistence of these two conditions will be answered.

High risk of schizophrenia and other mental disorders associated with chlamydial infections: hypothesis to combine drug treatment and adoptive immunotherapy

Many microbial factors have been implicated as pathogenic factors in mental disorders. Occurrence of such microbial factors also in the mentally unaffected population raised skepticism against such findings, although each microbial factor may cause mental problems only in some individuals, depending on the individual's immunogenetic disposition. Skepticism against the role of infection in schizophrenia was also fostered by the low impact of antiinfections treatment on the course of disease progression in schizophrenia. We discovered previously that neurotrophins like neurotrophin3 (NT-3) and brain-derived neurotrophic factor (BDNF), involved in processes of neuroplasticity, are also secreted by immune cells, but only by subpopulations of immune cells. Therefore, infection of the immune cell subpopulation, specialized in secreting BDNF, or of another subpopulation, specialized in secreting NT-3, could distort communication of immune cells with the central nervous system (CNS). Chlamydiaceae could cause disbalancement of immune cell sub-populations and, in some individuals with a vulnerable disposition, symptoms of mental illness. Based on previous observations of persisting IgA titers in some patients with mental illness we hypothesize that the intracellular parasites Chlamydiaceae are main pathogenic factors in schizophrenia. We hypothesize furthermore that antiinfectious treatment has to be accompanied by adoptive immunotherapy because antibiotics alone will not restore the balance of immune subpopulations. Our hypothesis is supported by examination of patients with schizophrenia and other mental disorders. Using nested PCR we found a significant prevalence of the intracellular parasites Chlamydophila psittaci, C. pneumoniae and Chlamydia trachomatis (9/18, 50%), as compared to controls (8/115, 6.97%) (chi(2)=25.86, Fisher's exact p two-tailed=5x10(-5)). Treatment with in vitro-activated immune cells together with antibiotic modalities showed sustained mental improvements in patients that did not depend on treatment with antipsychotic drugs. Future controlled studies including sham treatment of patients have to be carried out to prove our hypotheses.

Major depression and the use of electroconvulsive therapy (ECT) in lung transplant recipients

The purpose of this study is to describe the potential risks and benefits of electroconvulsive therapy (ECT) for treatment of depression in lung transplant recipients. The authors performed a record review of depressed patients who underwent lung transplantation at Johns Hopkins Hospital and evaluated their treatment, including ECT. In 9 years, 131 lung transplants were performed, and four patients had been diagnosed with major depression. Of those, two were candidates for ECT, and one received it. This patient's depression did abate with ECT. ECT, an effective treatment for depression, remains a treatment method of choice for depression in the posttransplant population.

Psychological status and quality of life in elderly patients with asthma

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Managing asthma in the real world

Asthma treatment is suboptimal in many patients, with impacts on morbidity and mortality, healthcare resource utilisation and patients' quality of life. The reasons for this include the inherent variability of asthma and the unpredictability of exacerbations, which can range from mild to fatal. In addition, asthma can be difficult to diagnose, particularly in the very young and old. Although treatment guidelines are widely available and well publicised, surveys have identified a significant gap between treatment aims and current levels of asthma control. Patient adherence to inhaled corticosteroids is poor, and many patients rely on short-acting beta2-agonists. The reasons for this are complex but are believed to include poor perception by patients of their asthma severity, concerns about the safety and efficacy of medication and low treatment expectations. Patients appear to be unaware of the extent to which airway inflammation can be controlled and are therefore satisfied with poor asthma control, accepting a high level of symptoms. Increasing patient understanding of asthma and its treatment, allowing patients greater involvement in treatment decisions, increasing the role of asthma nurses and improved communication between physicians and patients may improve outcomes in patients with asthma.

Lung disease and internalizing disorders. Is childhood abuse a shared etiologic factor?

OBJECTIVE

To investigate the role of childhood abuse in the relationship between panic attack, depression and lung disease among adults in the population.

METHODS

Data were drawn from the National Comorbidity Survey (n=5877), a representative sample of adults age 15-54 in the United States. Multiple logistic regression analyses were used to determine the association between childhood abuse and lung disease, and to determine whether childhood abuse is an independent predictor of the co-occurrence of lung disease, panic attack and depression.

RESULTS

Childhood abuse was associated with significantly increased odds of panic attacks (OR=2.2 (1.5, 3.1)) and depression (OR=1.6 (1.1, 2.3)). Childhood abuse increased likelihood of lung disease (OR=1.5 (1.1, 2.2)). Childhood abuse independently predicted the co-occurrence of lung disease, panic attack and depression (OR=10.7 (2.2, 51.5)).

CONCLUSION

These data are preliminary, but if replicated, suggest that childhood abuse may be associated with increased risk of lung disease during adulthood, and further may reflect a shared vulnerability for the co-occurrence of lung disease, panic attack and depression in the community. Future studies are needed to further explore the mechanism of this association.

Atopy and depression: results from the Northern Finland 1966 Birth Cohort Study

Several studies have suggested an association between IgE-mediated atopic allergies and depression. The present study extends our understanding about putative gender differences of this association and provides further epidemiological evidence for our previous finding that the association between atopy and depression may be characteristic for females only. In order to clearly determine the presence of atopic disorders and depression, we used more valid tools than had been employed earlier and we had access to a database (the Northern Finland 1966 Birth Cohort), in which individuals were followed up prospectively until the age of 31 years. The information on allergic symptoms, verified by skin-prick tests and comprising data of 5518 individuals, was used to ascertain the presence of atopy. Depression was assessed with the help of Hopkins' Symptom Checklist-25 and self-reported doctor-diagnosed depression. After adjusting for a father's social class, mother's parity, and place of residence, logistic regression analyses showed that the risk of developing depression increased in parallel with the increasing severity of depression and, when compared with nonatopic subjects, was 3.0 to 4.7-fold up in atopic females and statistically significant. In atopic males, the association between atopy and depression was statistically significant only in the highest depression scores, the odds ratio being 6.3-fold. The results indicate that females suffering from atopic diseases might possess an elevated risk of developing depression already during early adulthood. In males, the association between these two disorders is evident only among the most severe manifestations of depression. Possible background theories, that is, genetic abnormalities in serotonin metabolism, HPA-axis dysfunction, and histamine theory are discussed.

Prevalence and correlates of DSM-IV major depression in an Australian national survey

BACKGROUND

Community surveys have reported prevalence of depressive disorders in adult populations since the 1970s. Until recently, no epidemiological studies of the same magnitude have been conducted to provide a profile of the adult population in Australia. This study examines the current (30-day) prevalence and correlates of major depression in the adult Australian population using data from the National Survey of Mental Health and Well-being, and compares the results with other national studies.

METHODS

Data were derived from a national sample of 10,641 people 18-75+ years of age surveyed using the computerised version of the Composite International Diagnostic Interview Version 2.1.

RESULTS

The overall weighted prevalence of current (30-day) major depression was 3.2% with the highest rate (5.2%) being found in females in mid life. This rate is between those of the USA National Comorbidity Survey and the Epidemiological Catchment Area study, and similar to the British Psychiatric Morbidity Survey. The strongest correlates for reported current major depression include being unemployed, smoking, having a medical condition, followed by being in mid life, previously married, and female. Living with a partner and drinking 1 to 2 glasses of alcohol per day were least correlated. Some correlates of major depression relate to social disadvantage and lifestyle issues.

LIMITATIONS

The study design does not allow definition of direction of causality.

CONCLUSION

Lowering the prevalence rate of major depression will require close attention to public health approaches to address the relationships between smoking, social isolation, poor health, mood and physical well-being. The best focus for this approach may be primary care settings.