Patient-reported and physician-reported depressive conditions in relation to asthma severity and control

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.

Assessment of the Current Practice of Managing Depression in Patients with Asthma in Saudi Arabia: Physicians' Views

Objective

Depression is a common comorbidity in patients with asthma with a significant impact on clinical management. However, little information is available about physicians' perceptions and current practices in identifying and managing depression in individuals with asthma in Saudi Arabia. Thus, this study aims to assess physicians' views and current practices of identifying and managing depression in patients with asthma in Saudi Arabia.

Methods

A cross-sectional study was employed. Between September 2022 and February 2023, an online survey was distributed to physicians (general practitioners and family, internal and pulmonary medicine specialists) in Saudi Arabia. Descriptive statistics were performed to analyze the collected responses.

Results

Out of 1800 invited participants, a total of 1162 physicians completed the online survey. Nearly 40% of the respondents received adequate training for managing depression. More than 60% of physicians reported that depression interferes with self-management and worsens asthma symptoms, while 50% viewed the importance of regular screening for depression. Less than 40% (n=443) aim to identify depression during patients' visits. Of those, only 20% always screen for depression in asthma patients. Physicians show a low level of confidence when asking patients about their feelings (30%), being able to recognize depression (23%), and knowing if patients have depression (23%). The most common barriers linked to recognizing depression are high workload (50%), lack of time to screen for depression (46%), limited knowledge about depression (42%), and poor training (41%).

Conclusion

The rate of recognizing and confidently managing depression in asthmatic patients is significantly low. This is attributed to high workload, poor training, and limited knowledge about depression. There is a need to support psychiatric training and implement a systematic approach to depression detection in clinical settings.

[The psychological burden of asthma]

The experience of living with asthma varies between patients. In some cases, the psychological experience can take a central place and determine the course of asthma. Asthmatic disease can be complicated by adaption disorders that hamper the treatment, or genuine anxiety and depressive disorders that require the intervention of mental health specialists. Even more, the psychological experience can influence the intensity and frequency of the physical symptoms themselves, for example when asthma is associated with a hyperventilation syndrome worsening the functional impact and complicating the treatment. In this article, we underline the significance of the psychological experience through several clinical vignettes of patients suffering from asthma. In particular, we discuss the role of denial, or conversely identification with the status of being a patient, and the importance of the emotional experience associated with the symptoms of asthma. We highlight the relevance of therapeutic education programs as well as cognitive-behavioral therapies and psycho-corporal techniques, such as relaxation, for the psychological care of asthmatic disease. Finally, we detail how to better recognize a hyperventilation syndrome associated with asthma, how it can be approached with the patient and the treatment options. Through these examples, we illustrate the relevance of a comprehensive approach that integrates the psychological experience into the care of asthmatic disease.

Patient perspectives on living with severe asthma in Denmark and Sweden

Background: Severe asthma has an acknowledged impact on health-related quality of life (HRQOL) and is associated with substantial health care costs. This study aimed to investigate the patients' own experiences of the disease, perceptions of HRQOL, and awareness of disease management. Methods: This study included severe asthma patients in Sweden and Denmark. A quantitative Web-based survey and qualitative in-depth interviews (IDIs) were conducted. The survey included St. George's Respiratory Questionnaire (SGRQ), Asthma Control Test (ACT), Work Productivity and Activity Impairment (WPAI), and a study-specific questionnaire on quality of care and disease awareness. Telephone-based IDIs were conducted by medical interviewers following a semi-structured interview guide. Results: A total of 93 patients participated in the Web survey, and 33 participated in the IDIs. In the survey, the vast majority (77%; 72/93) had uncontrolled asthma (ACT<20). Mean total SGRQ score was 47.4 (59.7 symptom, 53.7 activity, 39.9 impact scores). Nearly 60% were treated in primary care. The IDIs revealed a long path to diagnosis, substantial and constant need for adaptations because of disease limitations, high burden on family members, social restrictions, and sick leaves and income losses. Patient awareness about guidelines, treatment goals, and available therapies was poor, and a low level of satisfaction by primary health care was seen. Conclusions: The vast majority of this severe asthma population had uncontrolled asthma and poor access to lung expert physicians. Impaired HRQOL despite patients' adaptations was indicated. These findings highlight the need for structured patient education and greater access to units with disease-specific knowledge.

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.

[Role of non pharmacological Interventions for asthma]

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

Severe Asthma-Perspectives From Adult and Pediatric Pulmonology

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

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.

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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Psychological aspects in asthma: do psychological factors affect asthma management?

Despite the regular treatment with inhaled corticosteroids (ICS) or ICS plus long-acting beta2-agonists, permits to control de majority of asthmatics, a significant proportion of patients does not respond to this treatment.

This review was aimed to explore the role of psychological factors associated to the unsuccessful fulfilment of optimal levels of asthma control, especially in patients suffering from severe asthma. The results of a Medline search were 5510 articles addressed to different psychological key concepts, constructs and variables. This review will highlight how some selected psychological factors may have a burden on asthma management. Evidences are now available about the link between asthma (in terms of severity and control), some psychological aspects (subjective perception, alexithymia, coping style) and mental health (anxiety, depression). Taking into account this most probably bidirectional influence, a screening of mental symptoms and psychological aspects related to asthma, could lead to plan appropriate interventions to better control asthma and to improve the patient’s well-being.

Risk of developing major depressive disorder and anxiety disorders among adolescents and adults with atopic dermatitis: a nationwide longitudinal study

BACKGROUND

Previous cross-sectional studies have suggested a comorbid association between atopic dermatitis (AD) and depressive disorder as well as anxiety disorders, but the temporal relationship was not determined.

METHODS

Using the Taiwan National Health Insurance Research Database, 8208 AD patients aged 12 and older without psychiatric history and age-/sex-matched (1:1) controls between 1998 and 2008 were enrolled in our study and followed to the end of 2011. Subjects who developed major depression, any depressive disorder, and anxiety disorders during the follow-up were identified.

RESULTS

The Cox regression analysis after adjusting for demographic data and atopic comorbidities demonstrated that patients with AD had an elevated risk of developing major depression (hazard ratio [HR]: 6.56, 95% confidence interval [CI]: 3.64-11.84), any depressive disorder (HR: 5.44, 95% CI: 3.99-7.44), and anxiety disorders (HR: 3.57, 95% CI: 2.55-4.98). Stratified by age group, both adolescents and adults with AD were prone to developing major depression (HR: 4.26, 95% CI: 1.39-13.13; HR: 7.56, 95% CI: 3.75-15.23), any depressive disorder (HR: 4.38, 95% CI: 2.09-9.18; HR: 5.66, 95% CI: 4.01-7.99), and anxiety disorders (HR: 5.40, 95% CI: 2.02-14.39; HR: 3.36, 95% CI: 2.38-4.80).

CONCLUSIONS

AD in both adolescence and adulthood increased the risk of developing major depression, any depressive disorder, and anxiety disorders in later life. Further studies would be required to clarify the possible underlying mechanism between AD and depression as well as anxiety disorders.

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

BACKGROUND

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Mediators and moderators of behavior change in patients with chronic cardiopulmonary disease: the impact of positive affect and self-affirmation

Among patients with chronic cardiopulmonary disease, increasing healthy behaviors improves outcomes, but such behavior changes are difficult for patients to make and sustain over time. This study aims to demonstrate how positive affect and self-affirmation improve health behaviors compared with a patient education control group. The patient education (PE control) patients completed a behavioral contract, promising to increase their physical activity or their medication adherence and received an educational guide. In addition to the contract and guide, the positive affect/self-affirmation intervention (PA intervention) patients also learned to use positive affect and self-affirmation to facilitate behavior change. Follow-up was identical. In 756 patients, enrolled in three randomized trials, the PA intervention resulted in increased positive affect and more success in behavior change than the PE control (p < .01). Behavior-specific self-efficacy also predicted success (p < .01). Induction of positive affect played a critical role in buffering against the adverse behavioral consequences of stress. Patients who experienced either negative psychosocial changes (p < .05) or interval negative life events (p < .05) fared better with the PA intervention than without it. The PA intervention increased self-efficacy and promoted success in behavior change by buffering stress.

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.

Depressive symptomatology, quality of life and disease control among individuals with well-characterized severe asthma

OBJECTIVES

A thorough examination of the relationship of asthma severity and control with symptoms of depression is needed to identify groups of asthmatics at high risk for poor disease control outcomes. This study examines the relationship of symptoms of depression with severity and control in a well-characterized cohort of asthmatics and healthy controls.

METHODS

Depressive symptoms and quality of life were assessed using the Beck Depression Inventory. Disease control was measured by a composite index incorporating symptoms, activity limitation and rescue medication use.

RESULTS

Individuals with asthma (n = 91) reported more symptoms of depression than controls (n = 36; p < 0.001). Those with severe asthma (n = 49) reported more symptoms of depression (p = 0.002) and poorer asthma control (p < 0.0001) than those with not severe asthma. Worse asthma control was associated with more depressive symptoms in severe (r = 0.46, p = 0.002) but not in not severe (r = 0.13, p = 0.40) asthmatics. The relationship of symptoms of depression among severe asthmatics was attenuated by disease control. Exploratory analyses identified specific disease symptom characteristics, as opposed to exacerbations, as associated with symptoms of depression.

CONCLUSIONS

Among individuals with severe asthma, increased symptom burden is positively associated with risk for co-morbid depression. These findings point to a need for regular mood disorder screenings and treatment referrals among this group. Further research is warranted to examine whether treatment of comorbid depression improves treatment adherence and asthma-related quality of life.

Frequency of non-asthma GP visits predicts asthma exacerbations: an observational study in general practice

BACKGROUND

Being able to identify patients at risk of exacerbations is useful as it enables resources to be targeted at these patients.

AIMS

To test the theoretically-derived prediction that the frequency of non-asthma related visits to the general practitioner (GP) predicts exacerbations.

METHODS

Clinical and demographic data and both self-report and prescription-based adherence data were obtained from 166 patients diagnosed with asthma attending a GP clinic, all of whom were prescribed inhaled corticosteroids (ICS). Asthma exacerbations (treated by the GP or in hospital) and non-asthma visits and symptoms were assessed from notes for the subsequent 5 years.

RESULTS

Exacerbations correlated with non-asthma visits (0.35), severity as measured by BTS step (0.28), and with prescription-based adherence (0.28). Asthma severity correlated with non-asthma visits (0.35). Receiver operating curves showed that ≥2 non-asthma visits per year provided 79% sensitivity and 58% specificity for detecting ≥3 exacerbations over 5 years. Poor adherence predicted outcomes only for patients with high levels of non-asthma visits (≥3) and only for those reporting regular-but-less ICS use but not symptom-directed ICS use.

CONCLUSIONS

Non-asthma visits are a good predictor of asthma exacerbations, particular in non-adherent patients. These results are consistent with a mechanism where exacerbations result from a combination of random oscillating specific and non-specific inflammatory processes. It is important to consider the total patient rather than just the lung when managing patients with asthma.

Severe asthma: an expanding and mounting clinical challenge

Although all patients with asthma have variable airflow obstruction, airway inflammation, and bronchial hyperresponsiveness, some have disease that is severe in many aspects: persistent airflow obstruction, ongoing symptoms, increased frequency of exacerbations, and, most importantly, a diminished response to medications. A number of definitions have emerged to characterize the clinical features of severe asthma, but a central feature of this phenotype is the need for high doses of medications, especially corticosteroids, in attempts to achieve disease control. The prevalence of severe asthma is also undergoing reevaluation from the usual estimate of 10% to larger numbers on the basis of medication needs and the lack of disease control achieved. At present, the underlying mechanisms of severe asthma are not established but likely reflect a heterogeneous pattern, rather than a single unifying process. Guideline-directed treatment for severe asthma has limits with usual approaches centered on high doses of inhaled corticosteroids, long-acting β-agonists, and trials with omalizumab, the monoclonal antibody to IgE. With the development of approaches to recognize asthma phenotypes with distinct pathogenesis and hence unique therapeutic targets, it is hoped that a personalized strategy in treatment directed toward disease-specific features will improve outcomes for this high-risk, severely affected population of patients.

Depressive symptoms, low adherence, and poor asthma outcomes in the elderly

OBJECTIVE

To examine the impact of depressive symptoms on asthma outcomes and medication adherence in inner-city elderly patients with asthma.

METHODS

Cohort study of elderly asthmatics receiving primary care at three clinics in New York City and Chicago from 1 January 2010 to 1 January 2012. Depressive symptoms were ascertained with the Patient Health Questionnaire (PHQ-9). Outcomes included asthma control (Asthma Control Questionnaire, ACQ), asthma-related quality of life (Asthma Quality of Life Questionnaire, AQLQ), and acute resource utilization (inpatient and outpatient visits). Asthma medication adherence was evaluated using the Medication Adherence Reporting Scale (MARS).

RESULTS

Three hundred and seventeen participants ≥60 years were included in the study (83% women, 30% Hispanic, and 31% Black). In unadjusted analyses, participants with depressive symptoms were more likely to report poor asthma control (p < .001), worse AQLQ scores (p < .001), and higher rates of inpatient asthma-related visits (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.04-3.99). Those with depressive symptoms also reported lower medication adherence (OR: 0.23, 95%CI: 0.10-0.54). Similar results were obtained in analyses adjusting for age, sex, race/ethnicity, income, asthma medication prescription, years with asthma, intubation history, comorbidities, and health literacy.

CONCLUSION

In this cohort of elderly inner-city participants, depressive symptoms were associated with poorer asthma control and quality of life, as well as with lower rates of adherence to controller medications. Future work exploring possible mediators, including adherence, might elucidate the relationship between depression and poorer asthma outcomes in this population.

Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma

BACKGROUND

Asthma guidelines advise addressing adherence at every visit, but no simple tools exist to assist clinicians in identifying key adherence-related beliefs or behaviours for individual patients.

AIMS

To identify potentially modifiable beliefs and behaviours that predict electronically recorded adherence with controller therapy.

METHODS

Patients aged ≥ 14 years with doctor-diagnosed asthma who were prescribed inhaled corticosteroid/long-acting β(2)-agonist (ICS/LABA) completed questionnaires on medication beliefs/behaviours, side-effects, Morisky adherence behaviour score and Asthma Control Test (ACT), and recorded spirometry. Adherence with ICS/LABA was measured electronically over 8 weeks. Predictors of adherence were identified by univariate and multivariate analyses.

RESULTS

99/100 patients completed the study (57 female; forced expiratory volume in 1 s mean ± standard deviation 83 ± 23% predicted; ACT 19.9 ± 3.8). Mean electronically recorded adherence (n= 85) was 75% ± 25, and mean self-reported adherence was 85% ± 26%. Factor analysis of questionnaire items significantly associated with poor adherence identified seven themes: perceived necessity, safety concerns, acceptance of asthma chronicity/medication effectiveness, advice from friends/family, motivation/routine, ease of use and satisfaction with asthma management. Morisky score was moderately associated with actual adherence (r=-0.45, P < 0.0001). In regression analysis, 10 items independently predicted adherence (adjusted R(2) = 0.67; P < 0.001). Opinions of friends/family about the patient's medication use were strongly associated with poor adherence. Global concerns about ICS/LABA therapy were more predictive of poor adherence than were specific side-effects; the one-third of patients who reported experiencing side-effects from their steroid inhaler had lower adherence than others (mean 62% vs 81%; P= 0.015).

CONCLUSIONS

This study identified several specific beliefs and behaviours which clinicians could use for initiating patient-centred conversations about medication adherence in asthma.

Improving quality of depression care using organized systems of care: a review of the literature

OBJECTIVE

To establish the need for a chronic disease management strategy for major depressive disorder (MDD), discuss the challenges involved in implementing guideline-level treatment for MDD, and provide examples of successful implementation of collaborative care programs.

DATA SOURCES

A systematic literature search of MEDLINE and the US National Library of Medicine was performed.

STUDY SELECTION

We reviewed clinical studies evaluating the effectiveness of collaborative care interventions for the treatment of depression in the primary care setting using the keywords collaborative care, depression, and MDD. This review includes 45 articles relevant to MDD and collaborative care published through May 2010 and excludes all non-English-language articles.

RESULTS

Collaborative care interventions include a greater role for nonmedical specialists and a supervising psychiatrist with the major goal of improving quality of depression care in primary care systems. Collaborative care programs restructure clinical practice to include a patient care strategy with specific goals and an implementation plan, support for self-management training, sustained patient follow-up, and decision support for medication changes. Key components associated with the most effective collaborative care programs were improvement in antidepressant adherence, use of depression case managers, and regular case load supervision by a psychiatrist. Across studies, primary care patients randomized to collaborative care interventions experienced enhanced treatment outcomes compared with those randomized to usual care, with overall outcome differences approaching 30%.

CONCLUSIONS

Collaborative care interventions may help to achieve successful, guideline-level treatment outcomes for primary care patients with MDD. Potential benefits of collaborative care strategies include reduced financial burden of illness, increased treatment adherence, and long-term improvement in depression symptoms and functional outcomes.

The association of asthma and wheezing with major depressive episodes: an analysis of 245 727 women and men from 57 countries

BACKGROUND

Epidemiological studies have shown that asthma is positively associated with depression. Most of this evidence stems from individual studies conducted in Western populations (e.g. Europe, North America and Australia). It is still unclear whether such findings generalize to non-Western countries. To address this question, the present study investigated the association of asthma and wheezing with depression in a large multi-national sample.

METHODS

We used data from the 2002 World Health Survey. Participants reported physician-diagnosed asthma and attacks of wheezing within the past 12 months. Questions on depressive symptoms, their duration and persistence were used to define presence of a major depressive episode (MDE) within the past 12 months. ORs and 95% CIs were estimated by logistic regression for the entire sample, by continent (Australia, Europe, South America, Asia and Africa) and by country. Complete information was available for 57 countries.

RESULTS

Both asthma and wheezing were associated with MDE in the entire sample (OR=2.37, 95% CI=2.10-2.66 and OR=3.06, 95% CI=2.75-3.40, respectively). Similar associations were found for all continents with generally stronger ORs in South America, Asia and Africa for both asthma (ORs ≥ 1.8) and wheezing (ORs  ≥ 2.8). On the country level, wheezing showed a consistent pattern of association with MDE. Similar patterns were found for asthma.

CONCLUSIONS

Despite a range of country differences that could affect the association of asthma with depression, such as access to health care, the results of this study indicate that the co-occurrence of asthma and depression is a universal phenomenon.

Comparison of asthma control criteria: importance of spirometry

AIMS

To compare the measurements of asthma control using Canadian Thoracic Society (CTS) Asthma Management Consensus Summary and Global Initiative for Asthma (GINA) guidelines composite indices with and without spirometry.

METHODS

Asthma control parameters were extracted from electronic medical records (EMRs) of patients ≥6 years old at two primary care sites. Asthma control ratings calculated according to CTS and GINA criteria were compared.

RESULTS

Data were available from 113 visits by 93 patients, aged 6-85 years (38.7 ± 24.8; mean ± SD). The proportion of visits at which individuals' asthma was completely controlled was 22.1% for CTS symptoms only and 9.7% for CTS with spirometry (p < .01); and 17.7% versus 14.1% for GINA symptoms only versus symptoms with spirometry (p = .125).

CONCLUSIONS

Asthma control ratings using GINA and CTS criteria are discordant in more than half of the patients deemed "in control" by at least one scale. Differences in the spirometry criterion threshold are primarily responsible for this discordance. Failure to include spirometry as part of the control index consistently overestimates asthma control and may underestimate future risk of exacerbations.

Specificity in the association of anxiety, depression, and atopic disorders in a community sample of adolescents

The specificity of relationships between anxiety and depressive symptoms, with each of the major atopic disorders of asthma, allergic rhinitis (AR), and atopic dermatitis (AD) was systematically investigated within a single study sample. Participants included 367 adolescents who participated in a community, longitudinal study investigating risk factors for the development of psychiatric and physical health problems. Mental health symptoms were assessed at 7, 9, 11, and 13 years of age. Lifetime history of atopic disorders was assessed by parent report at age 13. Analysis of variance was used to investigate the specificity of the associations between anxiety and depression, and each of the atopic disorders. Results indicated that anxiety was associated with a lifetime history of atopic disorders as a group. The association was significantly strengthened when controlling for depression and externalizing psychiatric symptoms. Among atopic disorders, "pure" anxiety was associated with asthma and AR, and having both asthma and AR strengthened the association compared to having either disorder alone. The association of "pure" anxiety with asthma and AR is consistent with existing data suggesting a relationship between anxiety and respiratory disorders. Having both asthma and AR appeared to confer an additive "dose effect" on the strength of the association. The lack of an association with depression suggests that other factors may contribute to the differential expression of anxiety and depression with atopic disorders. Findings demonstrate the importance of assessing the impact of co-morbid psychiatric symptoms and atopic disorders within individual studies to determine the specificity of underlying relationships between these conditions.

Knowledge, attitude, and self-efficacy in asthma self-management and quality of life

BACKGROUND

Cognitive variables such as knowledge, attitude, and self-efficacy affect asthma patients' abilities to be effective self-managers.

OBJECTIVE

The objective of this cross-sectional analysis was to determine what patient and clinical factors were associated with these cognitive variables and to assess the contributions of these cognitive variables to clinical status.

METHODS

Primary care asthma patients were interviewed using the three domains of the Knowledge, Attitude, and Self-Efficacy Asthma Questionnaire (KASE), as well as established scales to measure social support, depressive symptoms, and ratings of asthma care. Clinical asthma status was measured with the Asthma Quality of Life Questionnaire (AQLQ).

RESULTS

In total, 180 patients were enrolled, with a mean age of 43 years and 84% were women. Knowledge was low, with only 50% of patients answering half or more questions correctly (mean score = 52, possible range 0-100, higher is more knowledge). Attitude toward asthma was generally positive (mean score = 82, possible range 20-100, higher is more positive attitude) and self-efficacy was moderate (mean score = 76, possible range 20-100, higher is more self-efficacy). In separate multivariate analyses, younger age and higher education level were associated with more knowledge (p ≤ .005); more social support, fewer depressive symptoms, and more favorable prior results of asthma care were associated with more positive attitude (p ≤ .05); and favorable prior results, more satisfaction with asthma status, not having stress-related triggers, and not having had a recent emergency department visit for asthma were associated with more self-efficacy (p ≤ .07 for all variables). In additional multivariate analyses, more knowledge (p = .0005), more positive attitude (p = .02), and more self-efficacy (p = .01) were associated with better AQLQ scores.

CONCLUSIONS

Different patient and clinical characteristics were associated with cognitive variables pertinent to self-management. These variables, in turn, were independently associated with asthma status. Thus, although fostering improvement in all three variables would be desirable, interventions that improve any of these variables potentially could be beneficial.

The improvement of cognitive functions in patients with bronchial asthma after therapy

BACKGROUND

The severity of asthma in older people is frequently underestimated because of underdiagnosis and undertreatment. There are a number of reasons for this. In elderly patients, chronic diseases can be related to declining cognitive function. This situation could influence diagnosis and treatment. The objective of this study was to evaluate the influence of appropriate asthma therapy on cognitive function.

METHODS

A total of 359 participants diagnosed with bronchial asthma, 219 women and 140 men with a mean age of 69 ± 4.03 years, were included in this study. Cognitive function was assessed with the Mini-Mental State Examination (MMSE) at the beginning of this study and after 1 year. Patients were divided into three subgroups based on their initial MMSE scores dementia, mild cognitive impairment (MCI), and good cognition.

RESULTS

At the beginning of this study, 31.2% of patients presented uncontrolled asthma, 46.2% exhibited partly controlled asthma, and 25.1% had well-controlled asthma. A significant improvement in control over the patients' asthma was observed over the course of this study. After 1 year of treatment, the mean MMSE score significantly increased in initially demented patients, from 18.2 ± 3.1 (mean ± SD) to 21.9 ± 2.1 (p < .01); in subjects with MCI, from 25.4 ± 0.9 to 27.2 ± 1.2; and in patients with good cognition, from 27.4 ± 0.7 to 29.7 ± 0.4 (chi-square test, p < .01).

CONCLUSION

Proper control of asthma in patients with cognitive impairments can improve some cognitive functions.

Illness perceptions: impact on self-management and control in asthma

PURPOSE OF REVIEW

Outcome in asthma is determined not only by pulmonary function or other biomedical characteristics. An important determinant of asthma outcome is illness perceptions: patients' subjective beliefs and emotional responses to their illness. Illness perceptions influence patients' coping and self-management behavior, and thereby outcome.

RECENT FINDINGS

We review recent studies on associations between illness perceptions and outcome in patients with asthma, with a range of respondents and caregivers, with varying degree of asthma severity, and in different settings of medical care. Most studies pertain to substantial numbers of patients, and have been performed in different countries, adding to the external validity of the findings. All studies report substantial effects of illness perceptions on various categories of outcome: illness perceptions reflecting personal control over the illness are associated with a positive outcome, that is, asthma control. Findings point at the importance and clinical relevance of addressing patients' illness perceptions, and suggest that this may improve outcome in asthma care. Well conducted intervention studies on this topic are called for in order to improve outcomes and quality of life in asthma patients.

SUMMARY

Illness perceptions influence the way in which patients with asthma cope and their self-management of the illness. Illness perceptions can be assessed quite easily and directly, they inform healthcare providers about the psychosocial responses of patients towards their asthma, they are responsive to change in the clinical encounter or via self-management intervention training. Exploring patient's illness perceptions, therefore, is a crucial component of good clinical care.

Adherence to asthma therapy in elderly patients

OBJECTIVES

To assess the adherence to antiasthmatic therapy by the use of questionnaire and objective methods in elderly people, as well as to evaluate the association between cognition, depressive symptoms, functional status, and compliance.

METHODS

Patients aged 65 to 102 with chronic asthma under therapy were analyzed retrospectively to evaluate adherence using the Modified Morisky (MM) scale and a visual analog scale (VAS). In the second part of the study, a 1-year monitoring of asthma based on electronic diary and assessment of drug usage was performed. The MM scale and VAS as well as the estimation of cognition, depression symptoms, and functional status were carried out at the beginning and at the end of the observations.

RESULTS

Among 117 participants at the beginning of the study, only 9% and 21% had high adherence to therapy according to the MM scale and VAS, respectively. After 1 year of monitoring, the compliance assessed by the MM scale increased from 3.08 +/- 0.97 to 3.85 +/- 1.01 and by the VAS from 44% +/- 7.8% to 90% +/- 5.9%. Adherence by electronic diary and drug packages was lower than in both MM scale and VAS. Cognition status correlated with the results of MM and VAS tests but did not influence other methods of assessment. There was a statistical correlation between depression symptoms, cognition, and adherence (p >.01) in contrast to functional status. Compliance correlated with asthma control tests and PEFR.

CONCLUSION

Low adherence to antiasthmatic treatment is common in elderly people. Proper monitoring of asthma by the use of diary or assessment of drugs packages with estimation of depression symptoms and cognition status could increase the compliance and asthma control in this group of patients.

Depressive symptoms, social support, and risk of adult asthma in a population-based cohort study

OBJECTIVE

To investigate the association between depressive symptoms, social support, and prevalent as well as incident asthma. Depressive symptoms and social support may affect the development of asthma. This relationship could be mediated by health behaviors and/or inflammatory processes. Evidence from prospective cohort studies on depressive symptoms and social support in relation to asthma risk in adults remains sparse.

METHODS

Between 1992 and 1995, a population-based sample of 5114 middle-aged adults completed questionnaires covering depressive symptoms, social support, self-reported asthma, and potential confounders. Among those alive in 2002/2003, 4010 (83%) were followed-up by questionnaires. Associations with prevalent and incident asthma were estimated by prevalence ratios (PR) and risk ratios (RR) along with corresponding 95% confidence intervals (CIs), using Poisson regression. PRs and RRs were adjusted for demographics, family history of asthma, smoking, alcohol consumption, body mass index, and physical exercise.

RESULTS

Cross-sectional analyses indicated that the prevalence of asthma was positively associated with depressive symptoms and inversely related to social support. Prospective analysis suggested a 24% increased risk of asthma with each 1-standard deviation increase in depressive symptoms (RR, 1.24; 95% CI, 1.02, 1.50), whereas the social support z score showed an inverse association with asthma incidence (RR, 0.71; 95% CI, 0.58, 0.88). Analyses with tertiles suggested similar, but nonsignificant, associations. Omitting health-related life-style variables from the multivariable models did not substantially alter these associations.

CONCLUSIONS

Risk of adult asthma was found to increase with depressive symptoms and to decrease with social support. These associations do not seem to be explained by health-related life-style factors.

Does higher body mass index contribute to worse asthma control in an urban population?

BACKGROUND

Epidemiologic findings support a positive association between asthma and obesity.

OBJECTIVE

Determine whether obesity or increasing level of body mass index (BMI) are associated with worse asthma control in an ethnically diverse urban population.

METHODS

Cross-sectional assessment of asthma control was performed in patients with asthma recruited from primary care offices by using 4 different validated asthma control questionnaires: the Asthma Control and Communication Instrument (ACCI), the Asthma Control Test (ACT), the Asthma Control Questionnaire (ACQ), and the Asthma Therapy Assessment Questionnaire (ATAQ). Multiple linear regression analysis was performed to evaluate the association between obesity and increasing BMI level and asthma control.

RESULTS

Of 292 subjects with a mean age of 47 years, the majority were women (82%) and African American (67%). There was a high prevalence of obesity with 63%, with only 15% normal weight. The mean score from all 4 questionnaires showed an average suboptimal asthma control (mean score/maximum possible score): ACCI (8.3/19), ACT (15.4/25), ACQ (2.1/6), and ATAQ (1.3/4). Regression analysis showed no association between obesity or increasing BMI level and asthma control using all 4 questionnaires. This finding persisted even after adjusting for FEV(1), smoking status, race, sex, selected comorbid illnesses, and long-term asthma controller use.

CONCLUSION

Using 4 validated asthma control questionnaires, we failed to find an association between obesity and asthma control in an urban population with asthma. Weight loss may not be an appropriate strategy to improve asthma control in this population.