Asthma and panic attacks among youth in the community

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Rates of and factors associated with atopy and allergies in posttraumatic stress disorder as compared to controls

OBJECTIVE

Several studies suggest a relationship between atopy and psychiatric disorders, but few have investigated the association between atopic conditions and posttraumatic stress disorder (PTSD). We sought to compare the rates of atopy and allergies in a South African case-control study of 220 patients with PTSD (mean age 41.7 years, SD = 11.7) and 196 trauma exposed controls (TEC, mean age 45.4 years, SD = 14.7) conducted in Cape Town, South Africa from May 2014 to June 2017.

METHODS

Self-reported atopic conditions and allergies were regressed on PTSD, as determined with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), in multivariate logistic regression models, controlling for age, gender, body mass index, physical activity, lifetime and childhood trauma, and time since index trauma.

RESULTS

Rates of lifetime atopy (p = 0.03), current asthma (p = 0.04), lifetime allergic rhinitis (p = 0.002), and current allergic rhinitis (p = 0.004) were significantly higher in patients than TEC on bivariate analysis. On multivariate analysis, rates of current atopy (Cohen's d = 0.26, p = 0.04) and current allergic rhinitis (Cohen's d = 0.34, p = 0.012) were significantly higher in patients with PTSD than in TEC. Current eczema (p = 0.24), current asthma (p = 0.26), and allergies (p = 0.59) were not associated with PTSD.

CONCLUSIONS

Rates of atopy are higher in participants with PTSD than TEC, and this effect is related to higher rates of allergic rhinitis. Further studies are needed to elucidate the pathways linking allergic rhinitis and PTSD.

Asthma and early smoking associated with high risk of panic disorder in adolescents and young adults

PURPOSE

Studies have reported a strong link between asthma and panic disorder. We conducted a 17-year community-based large cohort study to examine the relationship between asthma, early smoking initiation, and panic disorder during adolescence and early adulthood.

METHODS

A total of 162,766 participants aged 11-16 years were categorized into asthma and nonasthma groups at baseline and compared within the observation period. Covariates during late childhood or adolescence included parental education, cigarette smoking by family members of participants, and participant's gender, age, alcohol consumption, smoking, and exercise habits. Data for urbanicity, prednisone use, allergic comorbidity, and Charlson comorbidity index were acquired from the National Health Insurance Research Database. The Cox proportional-hazards model was used to evaluate the association between asthma and panic disorder.

RESULTS

Our findings revealed that asthma increased the risk of panic disorder after adjustment for key confounders in the Cox proportional hazard regression model (adjusted HR: 1.70, 95% CI 1.28-2.26). Hospitalizations or visits to the emergency department for asthma exhibited a dose-response effect on the panic disorder (adjusted HR: 2.07, 95% CI 1.30-3.29). Patients with asthma with onset before 20 years of age who smoked during late childhood or adolescence had the greatest risk for panic disorder (adjusted HR: 4.95, 95% CI 1.23-19.90).

CONCLUSIONS

Patients newly diagnosed with asthma had a 1.7-times higher risk of developing panic disorder. Smoking during late childhood or adolescence increased the risk for developing the panic disorder in patients with asthma.

Further Exploration of Treatment Response in Latinos with Comorbid Asthma and Panic Disorder: A Brief Report of HRV and ETCO2 as Potential Mediators of Treatment Response

Heart rate variability (HRV) and end tidal CO2 (ETCO2) in relation to treatment response have not been studied in Latino populations or in comorbid asthma and panic disorder (PD). An extension of previously published research, the current study explored psychophysiological variables as possible mediators of treatment response. Latino treatment completers (N = 32) in the Bronx with asthma-PD received either Cognitive-Behavioral Psychophysiological Therapy (CBPT) or Music Relaxation Therapy (MRT). CBPT included HRV-biofeedback (HRVB); in-the-moment heart rate data to help an individual learn to influence his/her own heart rate. The sample was primarily female (93.8%) and Puerto Rican (81.25%). Treatment groups did not differ on demographics, except for less education in CBPT. The Panic Disorder Severity Scale (PDSS) and Asthma Control Questionnaire (ACQ) assessed changes in symptoms. HRV and ETCO2 were measured at four of eight therapy sessions. Baseline ETCO2 and changes in HRV from first to last of psychophysiology sessions were investigated as mediators of change on ACQ and PDSS. Mixed model analyses indicated in the CPBT group, changes in both asthma control and PD severity were not mediated by changes in HRV. In the CBPT and MRT groups combined, changes in PD severity were not mediated by baseline ETCO2. These findings may be due to the brevity of HRVB in CBPT, multiple treatment components, ETCO2 not directly targeted, and/or unique physiological pathways in Latinos with asthma-PD.

Inhaled corticosteroids as treatment for adolescent asthma: effects on adult anxiety-related outcomes in a murine model

RATIONALE

Allergic asthma, typically controlled with inhaled corticosteroids (ICS), is the leading chronic health condition for youth under 18 years of age. During this peri-adolescent period, significant brain maturation occurs. Prior studies indicate that both chronic inflammation and corticosteroid medications increase risk for developing an internalizing disorder like anxiety.

OBJECTIVES

To determine if chronic ICS treatments exacerbate or alleviate anxiety symptoms associated with developmental allergic asthma, we used a mouse model to isolate the influence of ICS (fluticasone propionate, FLU) vs. airway inflammation (induced with house dust mite extract, HDM).

METHODS

During development, male and female BALB/cJ mice were repeatedly exposed to HDM or saline plus one of four FLU doses (none/vehicle, low, moderate, or high). In adulthood, we assessed lung inflammation, circulating and excreted corticosteroids, anxiety-like behavior, and gene expression in stress and emotion regulation brain regions.

RESULTS

FLU treatment decreased body weight and anxiety-like behavior and increased fecal corticosterone metabolite concentrations and Crhr2 gene expression in ventral hippocampus. FLU effects were only observed in saline/non-HDM-exposed mice, and the FLU doses used did not significantly decrease HDM-induced airway inflammation. Females had greater serum and fecal corticosterone concentrations, less anxiety-like behavior, and lower Crhr1 gene expression in ventral hippocampus and prefrontal cortex than males.

CONCLUSIONS

These findings suggest that steroid medications for youth with allergic asthma may not exacerbate anxiety-related symptoms, and that they should be avoided in children/adolescents without a health condition. The results are informative to future work on the use of corticosteroid medications during childhood or adolescent development.

Peri-adolescent asthma: Acute impacts on innate immune response, corticosterone, and microglia in mice

Asthma is highly comorbid with anxiety in youth. We investigated the hypothalamic-pituitary-adrenal (HPA) axis and microglia as mechanisms underlying asthma and anxiety comorbidity. We induced asthma symptoms in developing BALB/cJ mice with house dust mite (HDM) for airway inflammation and methacholine (MCH) for bronchoconstriction. On the last day of exposure, we analyzed samples at six timepoints. Lung IL-5 and IL-1β expression peaked 4 h after final HDM exposure. Circulating corticosterone was blunted in a sex- and treatment-specific temporal pattern. Hippocampal IL-1β expression and microglial area were marginally increased 24 h after MCH exposure. These results provide a foundation for further work investigating asthma-anxiety mechanisms.

Internalizing symptoms and sleep outcomes in urban children with and without asthma

STUDY OBJECTIVES

This study examines associations between internalizing symptoms and sleep in a sample of urban children with and without asthma, whether asthma status moderates these associations, and whether associations differ by ethnic group.

METHODS

Participants were Latino, African American (AA), and non-Latino white (NLW) urban 7- to 9-year-olds with (n = 259) and without (n = 122) persistent asthma. Teacher-reported internalizing symptoms (anxiety, depressive, and somatic) were assessed using the Behavioral Assessment System for Children-2. Sleep duration, variability in sleep duration, and sleep onset latency were assessed with actigraphy.

RESULTS

Depressive symptoms were associated with variability in sleep duration and shorter sleep onset latency; somatic symptoms were associated with variability in sleep duration. In Latino children, depressive symptoms were associated with shorter sleep onset latency. In AA children, anxiety, depressive, and somatic symptoms were associated with variability in sleep duration; somatic symptoms were related to variability in sleep duration in NLW children. The association between internalizing symptoms and sleep outcomes did not differ by asthma status. However, asthma status was a significant moderator when examining these associations by ethnic group: among AA children, depressive symptoms were significantly related to variability in sleep duration only in children with asthma, whereas in NLW children, somatic symptoms were related to variability in sleep duration only in children without asthma.

CONCLUSIONS

Targeting specific internalizing symptoms and sleep outcomes may be beneficial in the development of interventions tailored for urban children with and without asthma from specific ethnic groups.

Allergies, asthma, and psychopathology in a nationally-representative US sample

BACKGROUND

Symptoms of depressed mood and anxiety have been associated with immune dysregulation and atopic disorders, however it is unclear whether this relationship spans other forms of psychopathology. The objective of this study was to use a large, population-based sample to examine the association between several common psychiatric conditions and two atopic disorders: seasonal allergies and asthma. This study also examined whether comorbidity between psychiatric disorders confounded the relationship between atopy and each psychiatric disorder.

METHODS

Data come from the Comprehensive Psychiatric Epidemiology Surveys, a nationally-representative sample of US adults (N = 10,309). Lifetime history of major depressive disorder (MDD), generalized anxiety disorder (GAD), panic disorder (PD), and post-traumatic stress disorder (PTSD) was assessed using the Composite International Diagnostic Inventory. History of seasonal allergies and asthma were assessed by self-report. Weighted logistic regression was used to evaluate the association between allergies and asthma and psychopathology. Psychiatric comorbidities were also examined as potential confounders.

RESULTS

Approximately 36.6% had a history of allergies and 11.5% a history of asthma. Seasonal allergies were positively associated with odds of MDD (Odds ratio (OR): 1.24, 95% Confidence Interval (CI): 1.06-1.46), GAD (OR: 1.54 (1.28-1.84)), PD (OR: 1.54 (1.24-1.91)), and PTSD (OR: 1.32 (1.09-1.59)). Asthma was not significantly associated with any psychiatric disorder. All significant associations persisted after adjustment for psychiatric comorbidities.

LIMITATIONS

Limitations include self-reporting of atopic disorder status and of all disorder ages of onset.

CONCLUSIONS

This study confirms the association between MDD and PD and seasonal allergies, and extends this relationship to GAD and PTSD.

Asthma among Household Youth on Racial Minority Operated Farms-United States, 2008

OBJECTIVES

Youth on farms are at risk for injuries and illnesses, including asthma, which continues to disproportionately affect minority groups.

METHODS

For this study, the 2008 Minority Farm Operator Childhood Agricultural Injury Survey (M-CAIS) data were used to estimate the prevalence of asthma among youth aged 0-19 years living on racial minority-operated farms. Youth were considered to have a lifetime diagnosis of asthma based on an affirmative response to the question "Has he/she ever been diagnosed as having asthma by a health professional?"

RESULTS

In 2008, of the estimated 37,400 youth (0-19 years) who lived on racial minority operated farms, 11% had asthma. Asthma prevalence was highest among males (13%) and youth 10-19 years of age (12%). Asthma prevalence among youth varied by race, ranging from 13% among household youth living on Black/African American operated farms to 7% among youth living on Asian/Native Hawaiian/Pacific Islander operated farms. In 2008, nearly half (46%) of household youth (0-19 years) worked on the farm. The odds of having asthma were higher among working youth compared with non-working youth (POR, 1.5; 95% CI: 1.3-1.8).

CONCLUSION

Disparities in asthma among youth living or working on racial minority-operated farms were observed. These findings may assist agricultural safety and health researchers, practitioners, and educators in identifying and designing targeted interventions to reduce asthma burden among youth on racial minority-operated farms.

Toward a personalized therapy for panic disorder: preliminary considerations from a work in progress

Although several treatment options for panic disorder (PD) are available, the best intervention for each individual patient remains uncertain and the use of a more personalized therapeutic approach in PD is required. In clinical practice, clinicians combine general scientific information and personal experience in the decision-making process to choose a tailored treatment for each patient. In this sense, clinicians already use a somehow personalized medicine strategy. However, the influence of their interpretative personal models may lead to bias related to personal convictions, not sufficiently grounded on scientific evidence. Hence, an effort to give some advice based on the science of personalized medicine could have positive effects on clinicians' decisions. Based on a narrative review of meta-analyses, systematic reviews, and experimental studies, we proposed a first-step attempt of evidence-based personalized therapy for PD. We focused on some phenomenological profiles, encompassing symptoms during/outside panic attacks, related patterns of physiological functions, and some aspects of physical health, which might be worth considering when developing treatment plans for patients with PD. We considered respiratory, cardiac, vestibular, and derealization/depersonalization profiles, with related implications for treatment. Given the extensiveness of the topic, we considered only medications and some somatic interventions. Our proposal should be considered neither exhaustive nor conclusive, as it is meant as a very preliminary step toward a future, robust evidence-based personalized therapy for PD. Clearly much more work is needed to achieve this goal, and recent technological advances, such as wearable devices, big data platforms, and the application of machine learning techniques, may help obtain reliable findings. We believe that combining the efforts of different research groups in this work in progress can lead to largely shared conclusions in the near future.

Anxiety disorders in children and adolescents: aetiology, diagnosis and treatment

The presentation of anxiety disorders in children and adolescents shares similarities and differences with that in adults, and may vary significantly, depending on the age of the individual. Assessment must differentiate anxiety disorders from developmentally appropriate fears as well as medical conditions and drugs that can mimic anxiety states. Aetiology of anxiety disorders in this group encompasses complex genetic and environmental influences. Additional insight into causation is provided by neuroimaging and research into temperament. Recommended interventions include both cognitive-behavioural therapy and pharmacology. Although childhood anxiety disorders generally remit, there remains an increased risk for anxiety and depressive disorders to emerge in adulthood, most likely through heterotypical continuity.

Panic attacks and smoking cessation among cancer patients receiving smoking cessation treatment

OBJECTIVE

Little is known about factors associated with smoking cessation in cancer patients. This study examined the impact of panic attacks on smoking abstinence likelihood among cancer patients receiving tobacco cessation treatment.

METHOD

The relationship of panic attacks to 7-day point-prevalence abstinence at mid-treatment, end of treatment, and 6-month post-end of treatment were examined among cancer patients (N=2255 patients; 50.1% female; Mage=54.9, SD=11.0) who received counseling and pharmacotherapy for smoking cessation. Panic attack history indexed by two questions from the Patient Health Questionnaire (PHQ). Point-prevalence abstinence was assessed via the Timeline Follow-Back.

RESULTS

Cancer patients with a history of panic attacks, (n=493, 21.9%) relative to those without, were less likely to be abstinent at mid-treatment (OR=0.79, CI95%=0.64-0.98) and end of treatment (OR=0.72, CI95%=0.58-0.89). After adjusting for significant covariates, panic attack history remained predictive of decreased abstinence likelihood at end of treatment (OR =0.78, CI95%=0.62-0.99).

CONCLUSIONS

Panic attacks may be related to poorer cessation outcome during smoking treatment among cancer patients, and may be usefully assessed and targeted for intervention.

Differences in panic psychopathology between smokers with and without asthma

Cigarette smoking is more common among individuals with asthma compared to those without, resulting in increased risk of morbidity and mortality. However, there has been little exploration of psychological factors that differ between smokers with and without asthma. Thus, the aim of the current study was to examine differences between smokers with and without asthma in terms of anxiety sensitivity, panic symptoms, lifetime history of panic attacks, and lifetime history of panic disorder. Participants were 115 smokers with asthma (55.3% male, M_age = 38.4 years, SD = 11.9) and 120 smokers without asthma (70.6% male, M_age = 37.0 years, SD = 12.8) who were administered a structured diagnostic interview and completed self-report measures. As hypothesized, after controlling for the effects of cigarettes per day, gender, race, and education, smokers with asthma reported higher levels of anxiety sensitivity and panic symptoms and were at an increased risk for having a lifetime history of panic attacks (OR = 3.01) and panic disorder (OR = 2.96) compared to smokers without asthma. Further, group differences in anxiety sensitivity and panic symptoms remained even after removing participants with a lifetime history of panic attacks or panic disorder. These findings suggest that smokers with asthma are a particularly 'at-risk' population for panic psychopathology and likely in need of specialized smoking-related prevention and intervention efforts.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A nationwide assessment of asthma-mental health nexus among veterans

OBJECTIVE

In this study, we evaluated the association between both current and lifetime asthma to that of mental illness among veterans in the USA.

METHODS

We utilized the 2005-2013 National Survey on Drug Use and Health data, a national population-based survey in the USA. Mental illness was defined as past year major depressive episode and doctor diagnosis of depression. Survey-weighted univariate and multivariable regression analyses were utilized. A total of 20,581 veterans were included in the study.

RESULTS

A 4.00% and 7.50% prevalence of current and lifetime asthma were noted among veterans, respectively. A significantly higher prevalence of major depressive episode was noted among veterans with current asthma (8.23%), as compared to those without (4.68%), with a similar trend noted among those with lifetime asthma versus those without (7.84% vs. 4.58%). Doctor diagnosis of depression among veterans was higher among those with current asthma (11.83% vs. 5.86%) and lifetime asthma (10.32% vs. 5.76%), as compared to those without asthma. Upon adjusting for confounders, current asthma was significantly associated with past year major depressive episode [adjusted odds ratio (aOR) = 1.65) and depression diagnosis (aOR = 1.88). Similarly, veterans with lifetime asthma, as compared to those without, had higher odds of past year major depressive episode (aOR = 1.56) and depression diagnosis (aOR = 1.66).

CONCLUSION

The asthma/mental health nexus is significant among the US veterans. Such results warrant the need for integrated care to address mental health burden among veterans with asthma.

Anxiety Sensitivity and Reactivity to Asthma-Like Sensations Among Young Adults With Asthma

Anxiety sensitivity, particularly the physical concerns domain, is associated with more problematic asthma symptoms and greater functional limitations. It has been theorized that anxiety sensitivity fosters greater reactivity to asthma-related physical sensations; however, this theory has yet to be empirically tested. Thus, the present investigation sought to examine the role of anxiety sensitivity-physical concerns in terms of affective and physical reactivity to asthma-like symptoms. Participants were 101 undergraduates with asthma (76.2% female, Mage = 19.69 years, SD = 3.77 years, range = 18-49 years) who completed self-report measures and a straw-breathing task. Results indicated that after controlling for the effects of gender, asthma control (i.e., how well one's asthma symptoms are managed or controlled), and negative affectivity, greater levels of anxiety sensitivity-physical concerns significantly predicted greater anxiety (4.7% unique variance) and asthma symptoms (6.9% unique variance) and lower levels of lung function (4.4% unique variance) after the straw-breathing task. These findings suggest that individuals with asthma who are fearful of physiological arousal are a particularly "at-risk" population for poor asthma outcomes because of this greater reactivity and could benefit from interventions targeting anxiety sensitivity.

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

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

Racial and ethnic differences in asthma and mental health among US adults: results from the National Survey on Drug Use and Health

OBJECTIVE

Evaluate the racial and ethnic differences in asthma and mental health comorbidity.

METHODS

A secondary analysis of 2008-2013 National Survey on Drug Use and Health was conducted, resulting in a total of 206 993 civilian adult respondents to evaluate the association between asthma and mental health (past year serious psychological distress [SPD] and doctor diagnosis of depression). Both survey weighted bivariate (chi-square) and multivariable (binary logistic) regression analyses, after accounting for control variables, were conducted to evaluate the asthma/mental health nexus. A p value of less than 0.05 was used to denote significance.

RESULTS

Current asthma was significantly associated with past year SPD for non-Hispanic Whites (adjusted odds ratio [aOR] = 1.45), Hispanics (aOR = 1.68), and Black/African Americans (aOR = 1.47). A similar association was noted for current asthma and past year doctor diagnosis of depression (non-Hispanic White aOR = 1.74; Hispanics aOR = 1.77; Black/African American aOR = 1.62). Among those with lifetime asthma, higher odds of SPD were reported for non-Hispanic Whites (aOR = 1.42), Hispanics (aOR = 1.64), and Black/African Americans (aOR = 1.50). Lifetime asthma also significantly associated with past year doctor diagnosis of depression for non-Hispanic Whites (aOR = 1.42), Hispanics (aOR = 1.41), and Black/African Americans (aOR = 1.46).

CONCLUSION

Our results demonstrate the significant burden of asthma and mental health comorbidity among diverse racial and ethnic groups. Improved public health efforts through promotion of integrated care for early screening and preventive measures are needed to alleviate the burden for at-risk groups.

Attentional bias to respiratory- and anxiety-related threat in children with asthma

This study investigated attentional biases in children with asthma. The study aimed at testing whether children with asthma are vigilant to asthma and/or anxiety cues. Thirty-six children (18 with asthma and 18 healthy controls) aged 9-12 completed a computerised dot probe task designed to measure attentional bias to three different categories of words: asthma, anxiety symptom and general negative emotion. Main caregiver anxiety was also assessed, as was frequency of inhaler use for those with asthma. Children with asthma showed an attentional bias towards asthma words but not anxiety or general negative emotion words. Children without asthma showed no significant attentional biases to any word categories. Caregiver anxiety was correlated with asthma word attentional bias in the asthma group. The findings indicate that attentional bias is present in children with asthma. Further research is required to ascertain if this exacerbates or maintains health-related problems.

Association between asthma and serious psychological distress among male veterans compared to civilian counterparts

OBJECTIVE

Identify the association between current asthma status and serious psychological distress among males who served in the U.S. Armed Forces as compared to civilians.

METHODS

A secondary analysis was performed utilizing the 2009 and 2011 California Health Interview Survey, including 9993 veteran males and 26,999 civilian males. All analyses used replicate weights to account for complex survey design. Descriptive statistics and chi-square analyses were generated to describe the population. Multivariable logistic regression analyses were utilized to model the effect of asthma and other covariates on past year and past month serious psychological distress, stratified by veteran status.

RESULTS

After model adjustment, current asthma status was significantly associated with past month and year serious psychological distress among veterans only. In addition, while race/ethnicity and risk behaviors of smoking and/or binge drinking were significantly associated with distress among civilians, no such association was noted among veterans.

CONCLUSION

To the authors' knowledge, this was the first study to demonstrate that the relationship between asthma and serious psychological distress varies by veteran status. Several unique correlates among veterans were also noted. Future preventive strategies for mental health disorders should incorporate these reported differences, including that of asthma co-morbidity among veterans.

Association between mental disorders and subsequent adult onset asthma

BACKGROUND AND OBJECTIVES

Associations between asthma and anxiety and mood disorders are well established, but little is known about their temporal sequence. We examined associations between a wide range of DSM-IV mental disorders with adult onset of asthma and whether observed associations remain after mental comorbidity adjustments.

METHODS

During face-to-face household surveys in community-dwelling adults (n = 52,095) of 19 countries, the WHO Composite International Diagnostic Interview retrospectively assessed lifetime prevalence and age at onset of 16 DSM-IV mental disorders. Asthma was assessed by self-report of physician's diagnosis together with age of onset. Survival analyses estimated associations between first onset of mental disorders and subsequent adult onset asthma, without and with comorbidity adjustment.

RESULTS

1860 adult onset (21 years+) asthma cases were identified, representing a total of 2,096,486 person-years of follow up. After adjustment for comorbid mental disorders several mental disorders were associated with subsequent adult asthma onset: bipolar (OR = 1.8; 95%CI 1.3-2.5), panic (OR = 1.4; 95%CI 1.0-2.0), generalized anxiety (OR = 1.3; 95%CI 1.1-1.7), specific phobia (OR = 1.3; 95%CI 1.1-1.6); post-traumatic stress (OR = 1.5; 95%CI 1.1-1.9); binge eating (OR = 1.8; 95%CI 1.2-2.9) and alcohol abuse (OR = 1.5; 95%CI 1.1-2.0). Mental comorbidity linearly increased the association with adult asthma. The association with subsequent asthma was stronger for mental disorders with an early onset (before age 21).

CONCLUSIONS

A wide range of temporally prior mental disorders are significantly associated with subsequent onset of asthma in adulthood. The extent to which asthma can be avoided or improved among those with early mental disorders deserves study.

Anxiety sensitivity as a mediator of the association between asthma and smoking

OBJECTIVE

Despite its negative effects, smoking is more common among individuals with asthma compared to those without. Anxiety sensitivity (fear of arousal-related sensations) is associated with both smoking and asthma; however, no research, to date, has examined the interplay between these three factors. Thus, the purpose of the current study was to evaluate the mediating role of anxiety sensitivity in the association between asthma diagnosis and smoking status.

METHODS

The current study was a secondary analysis of data from three existing datasets of non-smokers and smokers with and without asthma (n = 433; 56.3% female, M(age) = 34.01 years, SD = 13.9). Participants provided information on their asthma diagnosis status and smoking status and completed self-report measures.

RESULTS

As hypothesized, after controlling for gender, race and age, there was a significant indirect effect of asthma diagnosis on smoking status through anxiety sensitivity (95% CI = 0.07-0.48).

CONCLUSIONS

These results indicate that the association between asthma diagnosis and smoking status appears to be driven, in part, by anxiety sensitivity and suggest that anxiety sensitivity may serve as an important target for prevention and intervention efforts for smokers with asthma.

Characteristics of postural control among young adults with asthma

OBJECTIVE

We investigated whether young adults with asthma have impaired balance and whether this impairment is related to altered musculoskeletal function and/or psychological characteristics.

METHODS

21 participants with a self-reported asthma diagnosis but no known postural instability or history of falls, and 18 control participants were recruited from undergraduate psychology courses. Participants performed a postural control task of maintaining the center of pressure (COP) in a fixed position with visual feedback (feedback condition) and while standing as still as possible without visual feedback (no-feedback condition). COP variability, regularity and task performance were used to characterize the quality of balance. To document group differences in musculoskeletal function, we measured neck and lower back angles as well as range of motion (ROM) of the neck in the frontal and sagittal planes. To document group differences in psychological state, we administered self-report questionnaires to assess symptoms of anxiety and depression, anxiety sensitivity and negative effect.

RESULTS

COP variability and task performance were similar between the groups, but participants with asthma exhibited more regular anterior-posterior COP dynamics. Participants with asthma had smaller ROM of neck extension, a more forwardly bent neck, greater thoracic spine angle, and they reported greater levels of the physical concerns facet of anxiety sensitivity. These musculoskeletal and affective variables moderated COP differences between the groups.

CONCLUSIONS

Young adults with asthma showed a different postural control strategy in the absence of any obvious balance impairment. This change in strategy is related to musculoskeletal and affective characteristics of individuals with asthma.

Asthma and mental health among youth in high-risk service settings

OBJECTIVE

To investigate the prevalence of asthma and mental health problems among representative samples of youth in high-risk service settings and the community, and to examine the relationship between asthma and mental health in these groups.

METHODS

Data were drawn from the Alternative Service Use Patterns of Youth with Serious Emotional Disturbance Study (SED) (n = 1181), a combined representative, cross-sectional sample of youth in various clinical settings and the community. Multiple logistic regression analyses were used to examine the association between asthma and mental disorders. Demographic characteristics were investigated as potential confounders.

RESULTS

Asthma was common among 15.2% of youth in service settings and 18.8% of youth in the community. The prevalence of mental disorders was extremely high among youth with and without asthma in all service settings, and asthma was associated with increased prevalence of mental disorders among youth in the community, but not among youth in service settings. The relationship between asthma and internalizing disorders among youth in the community does not appear entirely attributable to confounding by demographics.

CONCLUSIONS

Findings are consistent with and extend previous data by showing that both asthma and mental disorders are disproportionately common among youth in high-risk service settings. Almost half of youth with asthma in service settings meet diagnostic criteria for a mental disorder. Clinicians and policy makers who are responsible for the health care of youth in these high-risk groups should be aware that asthma is common, and that the prevalence of internalizing disorders are especially common among those with asthma.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Severity and persistence of asthma and mental health: a birth cohort study

BACKGROUND

The goal of the current study was to investigate asthma and mental health among youth in the community, and to consider the role of asthma severity and persistence in this link. Method Data were drawn from the Raine Study, a population-based birth cohort study in Western Australia. Logistic regression models and generalized estimating equations were used to examine the relationship between asthma at age 5 years and the range of internalizing and externalizing mental health problems at ages 5-17 years. Analyses were stratified by asthma severity and persistence, and adjusted for a range of potential confounders.

RESULTS

More severe and persistent asthma at age 5 was associated with significantly increased odds of affective, anxiety, somatic, oppositional defiant and conduct problems at ages 5-17. Mild asthma and remitted asthma were not associated with heightened vulnerability to mental disorders.

CONCLUSIONS

Our results suggest that youth with symptomatic asthma are more likely to suffer from a wide range of mental health problems, and that the likelihood of mental health problems appears to increase as a function of asthma severity. Youth with poorly controlled and/or more severe and persistent asthma may be considered a vulnerable group who might benefit from mental health screening in clinical, school and community settings.

Minority caregivers' emotional responses and perceptions of the emotional responses of their children to asthma: comparing boys and girls

Approximately 7.1 million children in the US suffer from asthma. An exploratory qualitative study using a stratified purposive sampling method was conducted. The sample included four Latina and four African American female caregivers of children (ages 6-12) who had asthma. Caregivers were asked open-ended questions about perceptions of their children's emotional responses to asthma. Major themes and subthemes were identified with content analysis. Sons were reported as quiet when experiencing asthma. Daughters were described as being verbal, worried, excited. A question from the study was whether the children's responses were related to caregivers' (a) actions, (b) responses to asthma, and/or(c) race/ethnicity.

Asthma and mental health among youth: etiology, current knowledge and future directions

Asthma and mental health problems, such as depression, anxiety and behavior disorders, are common among youth and are significant sources of morbidity. There is a consistent association between asthma and anxiety/depression and a less consistent association between asthma and behavior disorders. Possible biological and psychological mechanisms may include inflammatory processes as well as the stress of having to live with a life-threatening condition. Future studies are warranted with longitudinal designs to establish temporality as well as measures of potential confounds. Biological and psychological measures would complement the longitudinal design to further establish causality. In addition, more information on the degree to which asthma and mental health have reciprocal influences on each other over time - and the mechanisms of these relationships - are needed in order to develop more effective intervention strategies to improve asthma control and mental health among those with both.

Asthma and suicide behaviors: results from the Third National Health and Nutrition Examination Survey (NHANES III)

Asthma and suicide attempts are leading causes of morbidity and mortality among adults in the United States. The objective of this study was to investigate the relationship between asthma and suicidal ideation and suicide attempt among adults in the United States, and to examine whether timing of asthma, mood disorders, poverty, allergies, cigarette smoking and sex differences confound these relationships. Data were drawn from the Third National Health and Nutrition Examination Survey (NHANES III), a representative sample of adults (N = 6584) in the United States. Logistic regression analyses were used to examine the relationships between current and former asthma and suicidal ideation and suicide attempt, adjusting for demographics, poverty, smoking, allergies and mood disorders. Current asthma is significantly associated with an increased likelihood of suicidal ideation (OR: 1.77, CI: 1.11, 2.84) and suicide attempt (OR: 3.26, CI: 1.97, 5.39), after adjusting for mood disorders, smoking, poverty and demographics. There does not appear to be a significant relationship between former asthma and suicidal ideation or suicide attempt. These findings confirm and extend previous evidence by showing that the link between asthma and suicide-related outcomes is evident among adults in a representative sample and that this relationship persists after adjusting for a range of variables. This study may provide an empiric foundation for including asthma in the clinical assessment of suicide risk.

Factors related to emotional responses in school-aged children who have asthma

A systematic review of the literature was performed to answer the following questions (a) What factors contribute to the emotional responses of school-age children who have asthma? (b) What are the potential gaps in the literature regarding the emotional responses of school-age children (ages 6-12) who have asthma? (c) Are children with a lower socioeconomic status (SES) and those who are minorities represented in the literature proportionate to their prevalence? Two main focus areas regarding emotional responses were identified: (a) factors related to children who have asthma and (b) factors related to caregivers of children who have asthma. Internalizing disorders were reported consistently for children and caregivers of children who have asthma. Negative consequences of asthma for children included panic and asthma attacks, missed school days, and behavioral problems. Issues for caregivers included higher levels of anxiety and depressive symptoms, asthma management deficits, and lower caregiver warmth and involvement. Gaps in the literature included separated studies for children ages 6-12, a lack of a standardized method to define SES, studies that were of a more experimental nature, and a disparate number of studies of minority children and caregivers relative to their asthma prevalence.

Preliminary validation of a screening tool for adolescent panic disorder in pediatric primary care clinics

This study examines the validity of a brief screening tool for adolescent panic disorder (PD) in a primary care setting. A total of 165 participants (ages 12-17 years) seen in two pediatric primary care clinics completed the Autonomic Nervous System Questionnaire (ANS; Stein et al. in Psychosomatic Med 61:359-364, 40). A subset of those screening positive (n = 22) and negative (n = 23) for panic symptoms on the ANS completed follow-up phone interviews assessing fit with DSM-IV criteria for panic disorder, self-reported anxiety and depression symptom severity, anxiety-related correlates, and functional impairment. A two-question version of the ANS demonstrated excellent sensitivity (Se = 1.00), but lower specificity (Sp = 0.47) for PD diagnostic status. Three-question and five-question versions modestly improved specificity (Sp = 0.57 and 0.65, respectively). In addition, screen-positive participants reported higher panic symptoms, anxiety sensitivity, and functional impairment, relative to screen-negative participants. Preliminary results suggest the ANS may be a valid screening tool for PD among adolescents, while simultaneously being brief and easy to score. Replication with larger samples is recommended as one related future research endeavor.

Psychological considerations of the child with asthma

Asthma, the most common chronic disease in children and adolescents in industrialized countries, is typified by airway inflammation and obstruction leading to wheezing, dyspnea, and cough. However, the effect of asthma does not end with pulmonary changes. Research has shown a direct link between asthma and stress and psychiatric illness, which if untreated results in heightened morbidity and effects on society. The link between asthma and psychiatric illness, however, is often underappreciated by many pediatric and child mental health professionals. This article reviews the diagnosis and treatment of asthma as well as the correlation between asthma and psychiatric illness in children in an effort to improve management and treatment strategies for this prevalent disease.

Asthma and major depressive episode in adolescents in France

RATIONALE

The association between asthma and anxiety disorders in teenagers is well documented, but data about the association with mood disorders are scarce.

METHODS

We analyzed data from a cross-sectional study conducted among ninth grade schoolchildren in France in 2003-2004. The teenagers were selected by two-stage sampling and interviewed by school doctors/nurses using a standardized questionnaire including questions about asthma and asthma-like symptoms. They also completed a self-administered questionnaire in which the occurrence of major depressive episodes (MDEs) during the past 12 months was assessed by the Composite International Diagnostic Interview-Short Form.

RESULTS

A total of 7000 teenagers (mean age 15.1 years) were included. The prevalence of wheezing in the past 12 months was 10.0% and that of current asthma (wheezing in the past 12 months in children who had already had asthma attacks, or treatment for wheezing or asthma in the past 12 months) was 8.5%. The prevalence of MDE during the past year was 14.2% in teenagers with current asthma versus 9.2% among the others. The association between current asthma and past-year MDE remained significant after adjustment for age, gender, family structure, and the father's employment status. Asthma was uncontrolled (at least four attacks of wheezing, one awakening per week due to wheezing, one severe wheezing, four unplanned medical visits, or one hospitalization for a wheezing attack in the past year) in more than half (58.3%) of asthmatic teenagers with an MDE in the past year versus 35.3% of those without an MDE.

CONCLUSION

Asthma is associated with a higher prevalence of MDE. Among adolescents with asthma, MDE is associated with poorer asthma control. These findings highlight the need for a comprehensive care management of asthma in France that takes the psychological dimension into account.

Panic attacks as a risk for later psychopathology: results from a nationally representative survey

BACKGROUND

There is a growing body of literature suggesting that panic attacks without panic disorder are associated with increases in a wide range of psychopathology and impairment. However, the majority of the literature to date has been cross-sectional. Some longitudinal research supports the view that panic attacks are a nonspecific risk factor for future psychopathology. Using a large nationally representative longitudinal survey of adults, we sought to determine whether panic attacks predict new onset Axis I disorders.

METHODS

The Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version was used to make diagnoses of psychiatric disorders in the National Epidemiologic Survey on Alcohol and Related Conditions Waves 1 and 2 (n = 34,653, aged 18 and older, response rate = 70.2%). Incident psychiatric disorders at Wave 2 were compared between people with and without panic attacks at Wave 1.

RESULTS

Panic attacks at Wave 1 were significantly associated with increased incidents of generalized anxiety disorder, panic disorder, social phobia, major depression, dysthymia, mania and hypomania, any anxiety disorder, and any mood disorder even after adjusting for sociodemographic variables, Wave 1 Axis I disorders, and Axis II disorders (OR's ranging from 1.62 to 2.77).

CONCLUSIONS

The presence of panic attacks may be an important indicator of overall psychological distress and the risk of more severe psychopathology in the future.

The puzzle of problem-solving efficacy: understanding anxiety among urban children coping with asthma-related and life stress

Children with asthma living in urban environments are at risk for experiencing anxiety by virtue of both social context and health-related stressors. Although the use of active coping strategies is generally associated with more optimal psychosocial functioning, there is evidence that active coping is less helpful in response to uncontrollable or severe stress. Expectations that one can fix a problem that is uncontrollable or insurmountable may create distress. Problem-solving efficacy was examined as a moderator of the association between stress and anxiety among children residing in inner-city neighborhoods. It was hypothesized that children's perceptions of high problem-solving efficacy would exacerbate their vulnerability to stress. Forty-five parent-child dyads were recruited from urban community health centers. Most participants were members of ethnic minority groups. Hierarchical multiple regression analyses revealed main effects of asthma-related stress and life stress on children's anxiety. However, these effects were moderated by problem-solving efficacy. Asthma-related stress and life stress were positively associated with anxiety only for children who had the highest levels of problem-solving efficacy. In other words, positive expectations about the ability to solve problems functioned as a liability for highly stressed children. Implications for psychosocial interventions with at-risk children are discussed.

Psychological considerations of the child with asthma

Asthma, the most common chronic disease in children and adolescents in industrialized countries, is typified by airway inflammation and obstruction leading to wheezing, dyspnea, and cough. However, the effect of asthma does not end with pulmonary changes. Research has shown a direct link between asthma and stress and psychiatric illness, which if untreated results in heightened morbidity and effects on society. The link between asthma and psychiatric illness, however, is often underappreciated by many pediatric and child mental health professionals. This article reviews the diagnosis and treatment of asthma as well as the correlation between asthma and psychiatric illness in children in an effort to improve management and treatment strategies for this prevalent disease.

Panic disorder: a review of DSM-IV panic disorder and proposals for DSM-V

This review covers the literature since the publication of DSM-IV on the diagnostic criteria for panic attacks (PAs) and panic disorder (PD). Specific recommendations are made based on the evidence available. In particular, slight changes are proposed for the wording of the diagnostic criteria for PAs to ease the differentiation between panic and surrounding anxiety; simplification and clarification of the operationalization of types of PAs (expected vs. unexpected) is proposed; and consideration is given to the value of PAs as a specifier for all DSM diagnoses and to the cultural validity of certain symptom profiles. In addition, slight changes are proposed for the wording of the diagnostic criteria to increase clarity and parsimony of the criteria. Finally, based on the available evidence, no changes are proposed with regard to the developmental expression of PAs or PD. This review presents a number of options and preliminary recommendations to be considered for DSM-V.

Family–school connections and internalizing problems among children living with asthma in urban, low-income neighborhoods

Children with asthma living in urban environments are at risk for experiencing internalizing problems and difficulties at school due to social context and health-related stressors. Parent confidence and participation in the school and children's attitudes about school were explored in association with children's depressed mood and school anxiety. Forty-five parent-child dyads were recruited from urban community health centers. Most participants were members of ethnic minority groups. Hierarchical multiple regression analyses revealed that higher levels of parent confidence in the school were associated with fewer symptoms of school anxiety in children. Children's attitudes toward school moderated the relation between parent participation in the school and children's depressed mood. Specifically, lower levels of parent participation were associated with higher levels of depressed mood only for children with the least positive school attitudes. Although preliminary, these results suggest the importance of attending to family-school connections to optimize the school-related psychological functioning of children living with asthma in urban environments.

Panic attacks and their relation to psychological and physical functioning in Canadians: results from a nationally representative sample

OBJECTIVE

US-based studies have suggested that panic attacks (PA) are common and associated with an increased prevalence of mental disorders and poorer quality of life, and may be a marker of severe psychopathology. Using a population-based survey with a greater sample size than has been previously used, we sought to determine the prevalence rates and correlates of PAs among Canadians aged 15 years and older.

METHOD

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition classification was used to determine the past-year prevalence of PAs in the Canadian Community Health Survey: Mental Health and Well-Being (n = 36,984, aged 15 and older, response rate = 77%). Psychological and physical function variables were compared among people with PAs, with panic disorder (PD), and without PAs.

RESULTS

The prevalence of past-year PAs was 6.4%. Compared to people without PAs, those with PAs had poorer overall functioning for disability, mental disorders, suicidal ideation, psychological distress, restriction of activity, chronic physical conditions, psychological well-being, and self-rated physical and mental health. PD was associated with poorer overall functioning than PAs for numerous variables; however, there were no significant differences between these 2 panic groups for several other variables.

CONCLUSIONS

Though associated with less severe impairment than PD in some domains, PAs are associated with mental health problems and reduced overall psychological and physical functioning and may be an indicator of more severe psychopathology.

The impact of medical comorbidity on mental health and functional health outcomes among children with anxiety disorders

OBJECTIVE

Medical comorbidity is common among children with anxiety disorders; however, little is known about the impact of such comorbidity on mental and functional health outcomes. Even less is known about these problems in high-risk samples of youth.

METHOD

Participants in this study were youth with at least one anxiety disorder with a physical illness (N = 77) or without a physical illness (N = 73), as well as youth with at least one physical illness (but no anxiety disorder) (N = 438). These youth were recruited as part of the Patterns of Care study in which the original set of participants (N = 1715) were randomly sampled from one of five public sectors of care (e.g., juvenile justice, child welfare, mental health, alcohol and substance use services, school services for children with serious emotional disturbance) in San Diego County. Psychiatric diagnoses were assessed with a structured interview and three standardized measures were used to assess child health, emotional, and behavior functioning.

RESULTS

At least half of children with anxiety disorders had a comorbid physical illness. Allergies and asthma were the most common comorbid physical illnesses. Children with anxiety disorders who had a comorbid physical illness exhibited greater levels of emotional problems, more somatic complaints, and more functional impairment than anxious children without a physical illness as well as than children with physical illness alone. Parents of children in the comorbid group also reported greater caregiver strain than the other two groups.

CONCLUSIONS

Children with anxiety disorders have high rates of chronic illnesses such as asthma and allergies. These children experience considerable impairment and likely have unique needs that may complicate usual care.

The effect of comorbid anxiety and depressive disorders on health care utilization and costs among adolescents with asthma

OBJECTIVE

To assess whether youth with asthma and comorbid anxiety and depressive disorders have higher health care utilization and costs than youth with asthma alone.

METHODS

A telephone survey was conducted among 767 adolescents (aged 11 to 17 years) with asthma. Diagnostic and Statistical Manual-4th Version (DSM-IV) anxiety and depressive disorders were assessed via the Diagnostic Interview Schedule for Children. Health care utilization and costs in the 12 months pre- and 6 months post-interview were obtained from computerized health plan records. Multivariate analyses were used to determine the impact of comorbid depression and anxiety on medical utilization and costs.

RESULTS

Unadjusted analyses showed that compared to youth with asthma alone, youth with comorbid anxiety/depressive disorders had more primary care visits, emergency department visits, outpatient mental health specialty visits, other outpatient visits and pharmacy fills. After controlling for asthma severity and covariates, total health care costs were approximately 51% higher for youth with depression with or without an anxiety disorder but not for youth with an anxiety disorder alone. Most of the increase in health care costs was attributable to nonasthma and non-mental health-related increases in primary care and laboratory/radiology expenditures.

CONCLUSIONS

Youth with asthma and comorbid depressive disorders have significantly higher health care utilization and costs. Most of these costs are due to increases in non-mental health and nonasthma expenses. Further study is warranted to evaluate whether improved mental health treatment and resulting increases in mental health costs would be balanced by savings in medical costs.

The prevalence of DSM-IV anxiety and depressive disorders in youth with asthma compared with controls

PURPOSE

To determine the prevalence of anxiety and depressive disorders in youth with asthma compared with a control sample of youth and to determine the sociodemographic and clinical characteristics associated with having one or more anxiety/depressive disorders among youth with asthma.

METHODS

A telephone interview was offered to all youth aged 11-17 years with asthma (N = 781) and a random sample of similar aged controls (N = 598) enrolled in a Health Maintenance Organization. The C-DISC-4.0 was used to diagnose anxiety and depressive disorders and reliable and valid questionnaires were used to assess severity of anxiety and depressive symptoms. Automated diagnostic, pharmacy and health use data were used to measure asthma treatment intensity, asthma severity and nonasthmatic medical comorbidity. One parent was interviewed to assess sociodemographic variables, child/adolescent psychiatric symptoms and to confirm the asthma diagnosis.

RESULTS

In all, 16.3% of youth with asthma compared with 8.6% of youth without asthma met DSM-IV criteria for one or more anxiety and depressive disorders (OR = 1.92, 95% CI = 1.13-3.28). Independent factors associated with a significantly higher likelihood of meeting criteria for one or more anxiety or depressive disorders included female gender [OR = 1.96 (95% CI = 1.27, 3.03)], living in a single-parent household, [OR = 1.96 (95% CI = 1.26, 3.07)], more parent-reported externalizing behaviors [OR = 1.03 (95% CI = 1.01, 1.05)], more recent diagnosis of asthma [OR = 0.94 (95% CI = 0.89, 0.98)], and more impairment on the asthma physical health scale [OR = 0.95 (95% CI = 0.94, 0.96)].

CONCLUSIONS

Youth with asthma have an almost twofold higher prevalence of comorbid DSM-IV anxiety and depressive disorders compared with control youth. Clinical factors associated with meeting criteria for one or more anxiety and depressive included more recent asthma diagnosis, more impairment on the asthma physical health scale, and increased externalizing behaviors.

A twin study of post-traumatic stress disorder symptoms and asthma

RATIONALE

Studies have suggested heightened anxiety among adults with asthma; the mechanism of this association is not known.

OBJECTIVES

To determine the association between post-traumatic stress disorder (PTSD) symptoms and asthma among adults, and to examine if this association is due to confounding by environmental and genetic factors.

METHODS

Data were obtained from twins in the Vietnam Era Twin Registry, which includes male veteran twin pairs born between 1939 and 1956 who served during the Vietnam era (1965-1975). Measurements included a symptom scale for PTSD, history of a doctor diagnosis of asthma, and sociodemographic and health confounding factors. Co-twin control analytic methods used mixed-effects logistic regression to account for the paired structure of the twin data and to examine the association between PTSD symptoms and asthma in all twins. Separate analyses were conducted within twin pairs and according to zygosity.

MEASUREMENTS AND MAIN RESULTS

PTSD symptoms were associated with a significantly increased likelihood of asthma (P(trend) < 0.001) even after adjustment for confounding factors. Among all twins, those in the highest quartile of PTSD symptoms were 2.3 times as likely (95% confidence interval, 1.4-3.7) to have asthma compared with those in the lowest quartile. These findings persist when examined within twin pairs and when stratified by zygosity.

CONCLUSIONS

Symptoms of PTSD were associated with an elevated prevalence of asthma. Even after careful adjustment for familial/genetic factors and other potential confounding factors, an association between PTSD symptoms and asthma remains. Efforts to understand this comorbidity may be useful in identifying modifiable environmental risk factors contributing to this pattern and therefore in developing more effective prevention and intervention strategies.

Mental disorders and asthma in the elderly: a population-based study

BACKGROUND

Clinical studies have mostly linked anxiety disorders with asthma in young patients, but the data are inconsistent for depression. Few population-based studies have investigated the co-morbid diagnoses of mental disorders with asthma in older adults.

METHOD

Cross-sectional study of a population sample of older adults aged 60 and above (n = 1092). The diagnoses of recent depression and anxiety were made using the Geriatric Mental State (GMS) Schedule. The presence of asthma was ascertained by self-reports of physician-diagnosed asthma.

RESULTS

Asthma was associated with a higher prevalence of depressive disorders, with odds ratio of 2.45 (95% CI, 1.06-5.69) when compared against non-asthmatic controls; and 2.42 (95% CI, 1.04-5.64) when compared against controls with other chronic illnesses, after adjusting for psychosocial factors, physical co-morbidity and use of depression-causing drugs. Odds ratios were elevated but statistically insignificant for anxiety disorders and dementia.

CONCLUSION

We observed that asthma in the elderly was more evidently associated co-morbidly with depression, rather than anxiety disorder. However, possible associations with anxiety and dementia are not excluded, and should be further investigated.

Asthma symptom burden: relationship to asthma severity and anxiety and depression symptoms

OBJECTIVE

The purpose of this work was to examine the relationship between youth-reported asthma symptoms, presence of anxiety or depressive disorders, and objective measures of asthma severity among a population-based sample of youth with asthma.

METHODS

We conducted a telephone survey of 767 youth with asthma (aged 11-17 years) enrolled in a staff model health maintenance organization. The Diagnostic Interview Schedule for Children was used to diagnose Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, anxiety and depressive disorders; the Child Health Status-Asthma questionnaire (modified) was used to assess asthma symptoms; and automated administrative data were used to measure asthma treatment intensity and severity. Analyses of covariance were performed to determine whether the number of anxiety and depressive symptoms was related to the number of asthma symptoms. Logistic regression analyses were used to evaluate the strength of association between individual symptoms of asthma and the presence of an anxiety or depressive disorder and objective measures of asthma severity.

RESULTS

After adjusting for demographic characteristics, objective measures of asthma severity, medical comorbidity, and asthma treatment intensity, youth with > or = 1 anxiety or depressive disorder (N = 125) reported significantly more days of asthma symptoms over the previous 2 weeks than youth with no anxiety or depressive disorders. The overall number of reported asthma symptoms was significantly associated with the number of anxiety and depressive symptoms endorsed by youth. In logistic regression analyses, having an anxiety or depressive disorder was also strongly associated with each of the 6 asthma-specific symptoms, as well as the 5 related nonspecific somatic symptoms contained in the Child Health Status-Asthma questionnaire.

CONCLUSIONS

The presence of an anxiety or depressive disorder is highly associated with increased asthma symptom burden for youth with asthma.

Assisting teens with asthma to take command

To meet and work with teenagers may be a challenge for caregivers as adolescence is a period when youths try to establish autonomy. Although asthma is an increasing problem worldwide, few studies have addressed professional caregivers' motives and actions. Therefore, the aim of this study was to describe professional caregivers' strategies in their work with teenagers with asthma. Grounded theory, inspired by Glaser, was used to uncover the phenomenon. The informants were seven professional caregivers who worked at an eight-day asthma camp for teenagers in Sweden. Participant observations and interviews were used, and the first author collected the data and participated in the activities. Findings show that professional caregivers' core concern is to assist teenagers with asthma to take command. This core concern gives rise to five strategies: showing respect, being at hand, promoting own responsibility, promoting to exceed boundaries and promoting reflections. In professional caregivers' attempt to assist teenagers to take command some differences are seen in the way they support boys and girls. One conclusion drawn from our study is that the provisional theory of 'Assisting teenagers with asthma to take command' is not only suitable for professional caregivers working at asthma camps; it may, in some degree, also be used as a source of inspiration for professional caregivers in other settings.

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.