Psychiatric diagnoses in inner city outpatients with moderate to severe asthma

Systemic Inflammation in Asthma: What Are the Risks and Impacts Outside the Airway?

Airway inflammation in asthma has been well recognized for several decades, with general agreement on its role in asthma pathogenesis, symptoms, propensity toward exacerbation, and decline in lung function. This has led to universal recommendation in asthma management guidelines to incorporate the use of inhaled corticosteroid as an anti-inflammatory therapy for all patients with persistent asthma symptoms. However, there has been limited attention paid to the presence and potential impact of systemic inflammation in asthma. Accumulating evidence from epidemiological observations and cohort studies points to a host of downstream organ dysfunction in asthma especially among patients with longstanding or more severe disease, frequent exacerbations, and underlying risk factors for organ dysfunction. Most studies to date have focused on cognitive impairment, depression/anxiety, metabolic syndrome, and cardiovascular abnormalities. In this review, we summarize some of the evidence demonstrating these abnormalities and highlight the proposed mechanisms and potential benefits of treatment in limiting these extrapulmonary abnormalities in patients with asthma. The goal of this commentary is to raise awareness of the importance of recognizing potential extrapulmonary conditions associated with systemic inflammation of asthma. This area of treatment of patients with asthma is a large unmet need.

The efficacy of citalopram or escitalopram in patients with asthma and major depressive disorder

BACKGROUND

Major depressive disorder is common in people with asthma. Yet, few studies have evaluated depression treatment in those with asthma.

OBJECTIVE

To explore the relationship between antidepressant use, depressive symptoms, and asthma control, pooled data from 3 randomized trials of either citalopram or escitalopram were assessed.

METHODS

Linear fixed effects and binary logistic regression analyses were conducted with between-subject covariates including treatment group, (original) study, and demographics. The within-subject effect of visit, and a treatment group-visit (between-within) interaction effect, were also evaluated. Analyses were repeated in a high asthma exacerbation subgroup having at least 3 oral corticosteroid bursts in the previous 12 months. Outcomes included the Hamilton rating scale for depression (HAM-D17), the 7-item asthma control questionnaire (ACQ), and oral corticosteroid use (yes or no).

RESULTS

In the pooled sample (n = 255), the antidepressant treatment group exhibited lower HAM-D17 overall (P ≤ .001) and a lower likelihood for oral corticosteroid use (P ≤ .001) relative to the placebo group. In the high-exacerbation subgroup (n = 96), treatment group participants had lower overall asthma control questionnaire (P = .004) and HAM-D17 scores (P ≤ .001), and a lower likelihood of oral corticosteroid use (P = .003), relative to placebo participants. All treatment group interaction effects were not significant.

CONCLUSION

Citalopram or escitalopram exhibited efficacy in reducing depressive symptoms and the need for rescue oral corticosteroids in patients with asthma and major depressive disorder. Future work should determine whether selective serotonin reuptake inhibitors are effective at improving asthma outcomes in those with asthma who are not depressed.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT00621946 and NCT01324700 (one study was conducted before ClinicalTrials.gov requirements).

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Depression symptoms and quality of life among individuals with aspirin-exacerbated respiratory disease

OBJECTIVE

Patients with aspirin-exacerbated respiratory disease (AERD) have high disease burden due to the severity of asthma and sinonasal symptoms. There is limited research on the psychological well-being and subjective experiences of patients with AERD. This study examined levels of depression symptoms, asthma-related quality of life and asthma control among AERD patients.

METHODS

Thirty-two adults with AERD and 39 patients without AERD (asthma-only) were recruited from outpatient asthma/allergy clinics. The sample was largely comprised of ethnic minority, inner-city patients who ranged in age from 19 to 84 years old. Participants completed the Beck Depression Inventory (BDI), the Mini Asthma Quality of Life Questionnaire (Mini AQLQ), a self-report rating of asthma severity and spirometry testing. Asthma control and severity were determined following national guidelines.

RESULTS

AERD patients reported lower levels of depression symptoms (p = 0.049), better overall asthma-related quality of life (p < 0.001), and perceived their asthma to be less severe (p = 0.01) compared to asthma-only patients. However, clinician ratings of asthma severity were more severe for AERD than asthma-only patients (p = 0.006). No significant differences were found between the groups on asthma controller medications or oral corticosteroid bursts for asthma.

CONCLUSIONS

AERD patients may be resilient given their low levels of depression symptoms and positive views of asthma-related impairment despite higher clinician-rated asthma severity. The adult onset nature of asthma in AERD might be a protective factor on mental health. Future studies should explore mechanisms linking AERD and positive psychological health outcomes and subjective perception of asthma.

A Randomized, Double-Blind, Placebo-Controlled Trial of Escitalopram in Patients with Asthma and Major Depressive Disorder

BACKGROUND

Depression is common in asthma and is associated with poor outcomes. However, antidepressant therapy in depressed patients with asthma has been the topic of little research.

OBJECTIVE

This study examined the impact of antidepressant treatment with escitalopram versus placebo on the Hamilton Rating Scale for Depression (HRSD), Inventory of Depressive Symptomatology-Self Report (IDS-SR), Asthma Control Questionnaire (ACQ), and oral corticosteroid use in patients with asthma and major depressive disorder (MDD).

METHODS

Single-site 12-week, randomized, double-blind, placebo-controlled, parallel-group trial of escitalopram (10 mg/d) was conducted in 139 outpatients with asthma and MDD. Randomization was stratified by oral corticosteroid use (≥3 bursts in past 12 months, yes or no) and baseline depressive symptom severity (HRSD score ≥ 20) (higher severity, n = 42) versus less than 3 bursts, HRSD score less than 20, or both (lower severity, n = 97). The primary data analysis was conducted using hierarchical linear modeling Version 7.01 on the higher and lower severity samples and post hoc was conducted on the combined sample.

RESULTS

Among the higher severity completers (n = 21), a significant reduction in the ACQ score (P = .04) and oral corticosteroid use (P = .04) was observed with escitalopram. In the combined sample, no significant differences were observed, but a trend toward greater reduction in the IDS-SR score was observed with escitalopram (P = .07). Side effects were comparable across groups.

CONCLUSIONS

The findings suggest that patients with more severe asthma and depression symptomatology may have a positive response, in terms of both asthma and depressive symptom reduction, to antidepressant treatment.

Psychological characteristics of patients with asthma

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of psychiatric illness upon asthma patients' health care utilization and illness control. Are all psychiatric comorbidities created equal?

The impact of psychiatric illnesses upon asthma patients' functioning is not well understood. This study examined the impact of psychiatric comorbidity upon illness management in asthma patients using empirically-derived psychiatric comorbidity groups. Participants were a clinic sample of Greek-speaking asthma patients (N = 212) assessed using the Patient Health Questionnaire (PHQ) Somatoform, Depression, Panic Disorder (PD), Other Anxiety Disorder, Eating Disorder (ED) and Alcohol sub-scales. The associations between sub-scales were examined using multiway frequency analysis. The following groups were derived: Somatoform disorder and/or Any Depressive disorder (n = 63), Somatoform disorder and/or Other Anxiety disorder (n = 51), Somatoform disorder and/or Any ED (n = 60), and Any Anxiety group including PD and/or Other Anxiety disorder (n = 24). Across all groups, psychiatric illness was associated with significantly worse asthma control (p < .01). Participants in Any Anxiety group, OR = 4.61, 95% CI [1.90, 11.15], Somatoform and/or Any Depressive disorder, OR = 2.06, 95% CI [1.04, 4.09] and Somatoform and/or Other Anxiety disorder, OR = 2.75, 95% CI [1.35, 5.60] were at higher risk for asthma-related Emergency Room (ER) visits compared to controls. However only Somatoform and/or Any Depressive disorder, OR = 3.67, 95% CI [1.60, 8.72], Somatoform and/or Other Anxiety disorder, OR = 5.50, 95% CI [2.34, 12.74], and Somatoform and/or Any ED, OR = 4.98, 95% CI [2.14, 11.60] group membership were risk factors for asthma-related hospitalizations. Results suggest that while comorbid psychiatric disorders generally negatively impact asthma illness management, different psychiatric comorbidities appear to have disparate effects upon illness management outcomes.

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.

Complex interventions reduce use of urgent healthcare in adults with asthma: systematic review with meta-regression

INTRODUCTION

Asthma accounts for considerable healthcare expenditure, a large proportion of which is attributable to use of expensive urgent healthcare. This review examines the characteristics of complex interventions that reduce urgent healthcare use in adults with asthma.

METHOD

Electronic searches of MEDLINE, EMBASE, PSYCINFO, CINAHL, the British Nursing Library and the Cochrane library, from inception to January 2013 were conducted. Studies were eligible for inclusion if they: i) included adults with asthma ii) assessed the efficacy of a complex intervention using randomised controlled trial design, and iii) included a measure of urgent healthcare utilisation at follow-up. Data on participants recruited, methods, characteristics of complex interventions and the effects of the intervention on urgent healthcare use were extracted.

RESULTS

33 independent studies were identified resulting in 39 comparisons altogether. Pooled effects indicated that interventions were associated with a reduction in urgent healthcare use (OR = 0.79, 95% CI = 0.67, 0.94). When study effects were grouped according to the components of the interventions used, significant effects were seen for interventions that included general education (OR = 0.77, 95% CI = 0.64, 0.91), skills training (OR = 0.64, 95% CI = 0.48, 0.86) and relapse prevention (OR = 0.75, 95% CI = 0.57, 0.98). In multivariate meta-regression analysis, only skills training remained significant.

CONCLUSIONS

Complex interventions reduced the use of urgent healthcare in adults with asthma by 21%. Those complex interventions including skills training, education and relapse prevention may be particularly effective in reducing the use of urgent healthcare in adults with asthma.

Global health benefits of being raised in a rural setting: results from the National Comorbidity Survey

AIM

The aim of this study was to examine the association between being raised in a rural setting and physical and mental health among adults in the USA.

METHODS

Data were drawn from the National Comorbidity Survey (n = 8098), a household probability sample representative of adults aged 15-54 years in the USA. Multiple logistic regression analyses were used to determine the association between being raised in a rural area and the likelihood of mental disorders, physical disorders, suicide behavior, and parental mental health. Odds ratios (OR) with 95% confidence intervals were calculated, adjusting for differences in demographic characteristics.

RESULTS

Being raised in a rural setting was associated with decreased odds of ulcer (OR = 0.56 [0.34, 0.91]). Mental disorders (any lifetime) (OR = 0.74 [0.64, 0.85]), any anxiety disorder (OR = 0.75 [0.6, 0.92]) and any substance use disorder (OR = 0.79 [0.65, 0.94]) were significantly less likely among adults who were raised in a rural setting. Maternal psychopathology and exposure to trauma were significantly lower among those raised in a rural setting, compared with those who were not. These relations were not explained by sociodemographic differences.

CONCLUSIONS

These data provide preliminary evidence that being raised in a rural environment lowers the risk of mental and physical health problems in adulthood. Being raised in a rural community also appears to be associated with significantly lower likelihood of exposure to trauma and maternal psychopathology. Future studies that can identify potential protective factors and mechanisms underlying these pathways are needed next.

Asthma and depression: the Cooper Center Longitudinal Study

BACKGROUND

Prior research suggests a possible association between asthma and depression.

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A comparison of clinician-rated neuropsychological and self-rated cognitive assessments in patients with asthma and rheumatologic disorders

Although data are mixed, asthma and rheumatologic conditions may be associated with cognitive impairment. Medications may play a role because corticosteroids are associated with memory impairment. Therefore, an easily administered assessment of cognition would be useful in these patients. We assessed relationships between self-rated and clinician-rated cognitive performance and mood in patients with asthma and rheumatologic diseases. Participants included 31adults treated for asthma or rheumatologic disorders (17 receiving chronic prednisone therapy, and 14 not receiving prednisone). An objective assessment of a variety of cognitive domains was administered through clinician and patient-rated assessments of cognition. Composite scores for the objective (Global Clinical Rating [GCR]) and subjective (Neuropsychological Impairment Scale: Global Measure of Impairment [GMI]) measures of cognition were derived. Depression was assessed with the 17-item Hamilton Rating Scale for Depression (HRSD-17). A linear regression was conducted with GMI scores as dependent variable and GCR, HRSD-17 scores, and prednisone-use status, as independent variables. Significant differences between prednisone-treated patients and other patients were observed on the GCR, GMI, and HRSD-17. In the regression analysis, HRSD-17 scores, but not GCR scores, significantly predicted GMI scores. Prednisone-treated patients had higher levels of depressive symptoms and subjective and objective cognitive deficits than those not taking prednisone. In the combined patient groups, subjective cognitive assessment was more strongly related to depressive symptoms than objective cognition. Findings suggest physicians should be aware of the potential for cognitive deficits in patients taking corticosteroids and, when appropriate, should consider the use of objective neurocognitive tests or neuropsychology consultation to better characterize its presence and severity.

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.

Escitalopram for severe asthma and major depressive disorder: a randomized, double-blind, placebo-controlled proof-of-concept study

BACKGROUND

Depression is common in asthma and may be a risk factor for asthma-related morbidity and mortality. However, minimal data are available on depression treatment in asthma. Previously, we reported greater sustained depression remission and less oral corticosteroid use in asthma patients treated with citalopram.

METHOD

A 12-week randomized, double-blind, placebo-controlled, proof-of-concept trial of escitalopram was conducted in 26 outpatients with asthma requiring at least one course of oral corticosteroids in the prior 12 months and major depressive disorder (MDD) with baseline Hamilton Rating Scale for Depression (HAM-D) scores of ≥ 20.

RESULTS

Total evaluable sample (n = 25) showed significant baseline to exit reduction in HAM-D and Inventory of Depressive Symptomatology-Self Report (IDS-SR) scores, with no significant between-group differences, although the findings favored escitalopram. Depression remission on the HAM-D, from week 1 to exit, showed a trend (P = 0.06) favoring escitalopram. Relative risk for remission at week 12 was 6.5 with an estimated remission rate of 39.1% with escitalopram and 6.0% with placebo. Between-group differences in oral corticosteroid use were not significant. Changes in Asthma Control Questionnaire (ACQ) correlated significantly with changes in IDS-SR in the escitalopram, placebo, and combined sample groups (τ = 0.49-0.60, P < 0.05) and with changes in HAM-D only in placebo and combined groups (τ = 0.38-0.58, P < 0.05).

CONCLUSIONS

Medium effect sizes and a remission trend were observed favoring escitalopram over placebo on depression measures. Changes in self-reported depressive symptoms correlated with changes in asthma symptoms. A larger trial is needed to confirm the findings from this pilot study.

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.

Suicide ideation, plans, and attempts among general practice patients with chronic health conditions in Puerto Rico

Background:

Little is known about suicidal ideation among general practice patients in Puerto Rico. In this study we examined the rates, severity, and correlates of suicidal ideation, plans, and attempts among general practice patients with chronic illnesses. This is important in targeting appropriate interventions and management approaches to minimize and prevent suicide.

Methods:

We screened patients with chronic physical conditions at general practices. Suicidal ideation was assessed with the suicidality module of the Mini International Neuropsychiatric Interview. Major depression was assessed with the Patient Health Questionnaire depression module. The relationship between sociodemographic factors, depression and suicidal ideation was examined with multiple logistic regression analysis. Among the subgroup that acknowledged suicidal ideation, we used multinomial logistic regression analysis to estimate simultaneously the multivariate associations of depression and sociodemographic factors with suicidality risk levels.

Results:

Of the 2068 patients screened, 15.4% acknowledged recent suicidal ideation. Among this group, 8.6% reported passive ideation, 3.7% active ideation without a plan, and 3.1% active ideation with a plan or attempt. According to multivariate logistic regression, suicidal ideation was higher among patients with moderately severe depression and severe depression than for those with milder symptoms. Patients aged 64 years or younger were over one and a half times more likely to acknowledge suicidal ideation than those aged 65 years and older. Compared with patients having a college degree, those with lower education had a twofold higher risk of suicidal ideation. Multinomial logistic regression analysis indicated that severe depression was associated with a higher likelihood of having a suicide plan or attempt.

Conclusion:

The findings of this study suggest that public health strategies focusing on the systematic identification of patients with increased depression severity and the implementation of evidence-based depression treatments are relevant for minimizing and preventing suicidal behavior among general practice patients with chronic health conditions.

Association of psychiatric disorders, asthma and lung function in early adulthood

OBJECTIVE

To examine the association between psychiatric disorders, asthma, and lung function in young adults.

STUDY DESIGN

Data were from the Mater-University of Queensland Study of Pregnancy (MUSP). The study was based on 2443 young adults (1193 male and 1250 female) for whom data were available on psychiatric disorders, asthma, and respiratory function. Life time and last 12 months' generalized anxiety, panic, posttraumatic stress disorder (PTSD), and depressive disorders were assessed using a computerised version of the Composite International Diagnostic Interview (CIDI-Auto). A Spirobank G spirometer system was used to measure forced vital capacity (FVC), forced expiratory volume in one second (FEV(1)), and forced expiratory flow between 25% and 75% of forced vital capacity (FEF(25-75%)).

RESULTS

Participants with mental health disorders were more likely to have experienced asthma before or to use asthma medication at 21 years. However, for both males and females, life time and last 12 months' experience of generalized anxiety, panic, PTSD, and depressive disorders were not statistically significantly associated with FVC, FEV(1), and FEF(25-75%), except a modest association with major depressive disorders for males.

CONCLUSION

There is an association between mental health and asthma, but the relationship between mental health and lung function appeared to be confounded by the respondent's gender. More narrowly based prospective studies are required to determine the causal pathway between mental disorders and asthma.

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.

The impact of psychological distress on functional disability in asthma: results from the Canadian community health survey

BACKGROUND

Asthma is associated with decreased health-related quality of life and increased physical comorbidity and mortality, high rates of clinic visits and hospitalizations, and loss of productivity in the workplace.

OBJECTIVE

The objective of the present study was to determine the joint effect of psychological distress and asthma on functional disability in a community sample.

METHOD

The authors used data from The Canadian Community and Health Survey (N=62,274). Psychological distress was measured by the 10-item Kessler (K-10) instrument. Asthma, disability days, self-assessed health status, and long-term reduction in activities were assessed by personal interview.

RESULTS

The prevalence of functional disability was higher in subjects with asthma and comorbid psychological distress than in individuals with either asthma or psychological distress alone.

CONCLUSION

Detecting and managing psychological problems might be particularly beneficial for persons with asthma.

Symptom perception in children with asthma: cognitive and psychological factors

OBJECTIVE

This study tested the differential effects of several cognitive and psychological variables on children's perception of asthma symptoms by use of an Asthma Risk Grid. Children's subjective and objective assessments of PEFR (peak expiratory flow rate) were characterized as representing perceptual accuracy, symptom magnification, and/or underestimation of asthma symptoms.

DESIGN

The study included 270 children with asthma (ages 7-17) and their primary caregivers who completed measures assessing cognitive and psychological factors and a 5 to 6 week symptom perception assessment.

MAIN OUTCOME MEASURES

Children's symptom perception scores by use of the Asthma Risk Grid.

RESULTS

Children's attentional abilities had more of a bearing on their symptom monitoring abilities than their IQ estimates and psychological symptoms. The more time children took on Trails and Cancellation Tasks and the fewer errors they made on these tasks, the more likely they were to perceive their asthma symptoms accurately. More time on these tasks was associated with more symptom magnification scores, and fewer errors were related to fewer symptom magnification scores. More errors and higher total scores on the Continuous Performance Task were associated with a greater proportion of scores in the danger zone.

CONCLUSION

Statistical support was provided for the utility of attentional-based instruments for identifying children who may have problems with perceptual accuracy, and who are at risk for asthma morbidity.

The role of panic-fear in comorbid asthma and panic disorder

We examined mediational models of panic-fear, panic disorder (PD), and asthma outcomes among adult asthma patients. PD was assessed by the Anxiety Disorders Interview Schedule. Twenty-one asthma-PD patients and 27 asthma-only patients completed spirometry and questionnaires. Asthma-PD patients reported greater illness-specific and generalized panic-fear than asthma-only patients, despite no differences in asthma severity or physical symptoms during asthma attacks. Illness-specific panic-fear mediated the relationship between PD and poorer health-related quality of life, including emotional disturbance due to asthma. Illness-specific panic-fear was associated with more primary care office visits for asthma. Asthma-PD patients reported greater irritability during asthma attacks than asthma-only patients. Generalized panic-fear was directly associated with restriction of activities due to asthma and use of rescue medication for asthma. Neither measure of panic-fear was associated with asthma severity. Panic-fear experienced during asthma attacks may be an important area to target for improving health-related quality of life among asthma-PD patients.

Childhood adversity, early-onset depressive/anxiety disorders, and adult-onset asthma

OBJECTIVES

To investigate a) whether childhood adversity predicts adult-onset asthma; b) whether early-onset depressive/anxiety disorders predict adult-onset asthma; and c) whether childhood adversity and early-onset depressive/anxiety disorders predict adult-onset asthma independently of each other. Previous research has suggested, but not established, that childhood adversity may predict adult-onset asthma and, moreover, that the association between mental disorders and asthma may be a function of shared risk factors, such as childhood adversity.

METHODS

Ten cross-sectional population surveys of household-residing adults (>18 years, n = 18,303) assessed mental disorders with the Composite International Diagnostic Interview (CIDI 3.0) as part of the World Mental Health surveys. Assessment of a range of childhood family adversities was included. Asthma was ascertained by self-report of lifetime diagnosis and age of diagnosis. Survival analyses calculated hazard ratios (HRs) for risk of adult-onset (>age 20 years) asthma as a function of number and type of childhood adversities and early-onset (<age 21 years) depressive and anxiety disorders, adjusting for current age, sex, country, education, and current smoking.

RESULTS

Childhood adversities predicted adult-onset asthma with risk increasing with the number of adversities experienced (HRs = 1.49-1.71). Early-onset depressive and anxiety disorders also predicted adult-onset asthma (HRs = 1.67-2.11). Childhood adversities and early-onset depressive and anxiety disorders both predicted adult-onset asthma after mutual adjustment (HRs = 1.43-1.91).

CONCLUSIONS

Childhood adversities and early-onset depressive/anxiety disorders independently predict adult-onset asthma, suggesting that the mental disorder-asthma relationship is not a function of a shared background of childhood adversity.

The Quick Inventory of Depressive Symptomatology-Self-report: a psychometric evaluation in patients with asthma and major depressive disorder

BACKGROUND

Despite the high co-occurrence between depression and asthma, few studies have addressed methods assessing the severity of depressive symptoms among patients with asthma.

OBJECTIVE

To evaluate the psychometric properties of the Quick Inventory of Depressive Symptomatology-Self-report (QIDS-SR16), a 16-item measure of depressive symptom severity, in patients with asthma.

METHODS

The psychometric properties of the QIDS-SR16 were compared at treatment exit with those of the 30-item self-report Inventory of Depressive Symptomatology (IDS-SR30) and the 17-item clinician-rated Hamilton Rating Scale for Depression (HRSD17) in 73 outpatients with asthma who were treated with citalopram or placebo for nonpsychotic major depressive disorder. Correlations between the depression rating scales and the Mini Asthma Quality of Life Questionnaire were calculated.

RESULTS

Internal consistency at exit was strong for the QIDS-SR16 (Cronbach alpha values are .87 for the QIDS-SR16, .95 for the IDS-SR30, and .87 for the HRSD17). The QIDS-SR16 and HRSD17 total scores were highly correlated (r = 0.85), as were the QIDS-SR16 and IDS-SR30 total scores (r = 0.97). All QIDS-SR16 item total score correlations were significant (P < .001). The QIDS-SR16, IDS-SR30, and HRSD17 showed comparable sensitivity to symptom change, indicating high concurrent validity for all 3 scales. The total QIDS-SR16 baseline to exit change score demonstrated a significant negative correlation (r = -0.49, P < .001) with the Mini Asthma Quality of Life Questionnaire. Thus, greater depressive symptom severity was associated with lower asthma-related quality of life.

CONCLUSIONS

The QIDS-SR16 showed good reliability and impressive construct validity. Strong psychometric properties of this brief self-report format and its sensitivity to treatment change suggest that the QIDS-SR16 is a valuable clinical tool.

Perceived triggers of asthma: evaluation of a German version of the Asthma Trigger Inventory

BACKGROUND AND OBJECTIVE

Patients' perception of asthma triggers has been explored in a largely unstructured fashion in the past. Therefore, we developed the Asthma Trigger Inventory (ATI), a questionnaire that allows for a psychometrically valid measurement of patients' perceived asthma triggers. Here we evaluate a German language version of the ATI and studied the relationship of subscales with self-reported health status, health care use, psychopathology, and results of allergy skin testing.

METHOD

Data were obtained from 370 asthma patients recruited from the community, primary care, and in-patient asthma treatment and education.

RESULTS

Analysis revealed a five-factor structure that largely confirmed results with the English original. Reliability was good to satisfactory (Cronbach's alpha=0.77-0.89) for allergy, exercise, air pollution/irritants, infection, and psychological trigger subscales. In hierarchical regression analysis adjusting for demographics and asthma severity, asthma patients with stronger non-allergic triggers showed less physical and mental well-being and more asthma-related health care use. Psychological triggers showed unique associations with anxious and depressed mood. Pollen and animal allergen scores of the ATI were significantly related to skin test results for relevant allergens. Non-allergic but not allergic triggers showed substantial associations with asthma control.

CONCLUSION

The German version of the ATI reliably measures asthma patients' trigger perceptions. Non-specific asthma triggers exert a greater burden on patients' well-being and primary health care use.

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.

Anti-inflammatory properties of desipramine and fluoxetine

Background

Antidepressants are heavily prescribed drugs and have been shown to affect inflammatory signals. We examined whether these have anti-inflammatory properties in animal models of septic shock and allergic asthma. We also analysed whether antidepressants act directly on peripheral cell types that participate in the inflammatory response in these diseases.

Methods

The antidepressants desipramine and fluoxetine were compared in vivo to the glucocorticoid prednisolone, an anti-inflammatory drug of reference. In a murine model of lipopolysaccharides (LPS)-induced septic shock, animals received the drugs either before or after injection of LPS. Circulating levels of tumour necrosis factor (TNF)-α and mortality rate were measured. In ovalbumin-sensitized rats, the effect of drug treatment on lung inflammation was assessed by counting leukocytes in bronchoalveolar lavages. Bronchial hyperreactivity was measured using barometric plethysmography. In vitro production of TNF-α and Regulated upon Activation, Normal T cell Expressed and presumably Secreted (RANTES) from activated monocytes and lung epithelial cells, respectively, was analysed by immunoassays. Reporter gene assays were used to measure the effect of antidepressants on the activity of nuclear factor-κB and activator protein-1 which are involved in the control of TNF-α and RANTES expression.

Results

In the septic shock model, all three drugs given preventively markedly decreased circulating levels of TNF-α and mortality (50% mortality in fluoxetine treated group, 30% in desipramine and prednisolone treated groups versus 90% in controls). In the curative trial, antidepressants had no statistically significant effect, while prednisolone still decreased mortality (60% mortality versus 95% in controls). In ovalbumin-sensitized rats, the three drugs decreased lung inflammation, albeit to different degrees. Prednisolone and fluoxetine reduced the number of macrophages, lymphocytes, neutrophils and eosinophils, while desipramine diminished only the number of macrophages and lymphocytes. However, antidepressants as opposed to prednisolone did not attenuate bronchial hyperreactivity. In vitro, desipramine and fluoxetine dose-dependently inhibited the release of TNF-α from LPS-treated monocytes. In lung epithelial cells, these compounds decreased TNF-α-induced RANTES expression as well as the activity of nuclear factor-κB and activator protein-1.

Conclusion

Desipramine and fluoxetine reduce the inflammatory reaction in two animal models of human diseases. These antidepressants act directly on relevant peripheral cell types to decrease expression of inflammatory mediators probably by affecting their gene transcription. Clinical implications of these observations are discussed.

Prevalence and correlates of asthma in children with internalizing psychopathology

Our objective was to determine the prevalence rate of parent-reported asthma in children with internalizing disorders seeking psychological treatment, and to study the level of internalizing and externalizing problems in these patients compared to patients without asthma. Participants were 367 children (ages 5-18 years) with internalizing disorders seeking psychological treatment. Children's psychiatric diagnosis was established with the Anxiety Disorders Interview Schedule for DSM-IV-Child and Parent versions. Parents reported on their child's asthma diagnosis, medical history, and medication usage. Child psychopathology was assessed with the Child Behavior Checklist and by child self-report with the Multidimensional Anxiety Scale for Children and the Children's Depression Inventory. We assessed internalizing psychopathology of the mothers with the Depression Anxiety and Stress Scale. An additional diagnosis of parent-reported asthma was established for 15% of the children diagnosed with an Axis I internalizing disorder, a prevalence rate markedly higher than reported for current parent-reported childhood asthma in the U.S. population. Patients with asthma showed higher levels of internalizing problems than their nonasthmatic counterparts. Internalizing psychopathology was not higher for mothers of patients with asthma. Asthma is a significant problem within the population of patients with childhood internalizing disorders. It can be accompanied by a greater severity of internalizing problems and may require specific precautions in the treatment protocol. Though parent report of asthma diagnosis is commonly used in surveys of childhood asthma, our findings have to be viewed in the light of its limitations.

Mood, anxiety, and physical illness: body and mind, or mind and body?

This research review examines the recent articles that have investigated the relationship between mood, anxiety, and physical illness (e.g., asthma, autoimmune disorders, cancer, cardiovascular disease, obesity, and sexual dysfunction). There is growing evidence of an overall negative impact of depression and other mood states, and anxiety on numerous physical illnesses and conditions, and their outcome.

Mental disorders among adults with asthma: results from the World Mental Health Survey

OBJECTIVE

Our objectives were (a) to determine which common mental disorders are associated with asthma in the general population after controlling for age and sex, and (b) to assess whether the associations of mental disorders with asthma are consistent across diverse countries.

METHOD

Eighteen population surveys of household-residing adults were carried out in 17 countries (N=85,088). Mental disorders were assessed with the Composite International Diagnostic Interview 3.0, a fully structured diagnostic interview. The disorders considered here are 12-month anxiety disorders (generalized anxiety disorder, panic disorder/agoraphobia, posttraumatic stress disorder and social phobia), depressive disorders (dysthymia and major depressive disorder) and alcohol use disorders (abuse and dependence). Asthma was ascertained by self-reports of lifetime diagnosis among a subsample (n=42,697).

RESULTS

Pooled estimates of age-adjusted and sex-adjusted odds of mental disorders among persons with asthma relative to those without asthma were 1.6 [95% confidence interval (95% CI)=1.4, 1.8] for depressive disorders, 1.5 (95% CI=1.4, 1.7) for anxiety disorders and 1.7 (95% CI=1.4, 2.1) for alcohol use disorders.

CONCLUSION

This first cross-national study of the relationship between asthma and mental disorders confirms that a range of common mental disorders occurs with greater frequency among persons with asthma. These results attest to the importance of clinicians in diverse settings being alert to the co-occurrence of these conditions.

Age at onset of major depression in inner-city adults with asthma

Depression generally begins before Type II diabetes and coronary artery disease; however, no data are available on whether asthma or major depressive disorder (MDD) have an earlier onset. The age at onset of asthma and depression were collected from 85 adult asthma patients with current MDD. The mean ages at onset of asthma and MDD were 21.0 years and 28.8 years, respectively. Asthma preceded MDD in 62% of cases; MDD preceded asthma onset in 24% of cases; and asthma and MDD had a concurrent onset in 14% of the cases. In asthma patients, unlike patients with Type II diabetes and coronary artery disease, depression appears generally to occur after the onset of asthma.

Association of depressive symptoms and disease activity in children with asthma: methodological and clinical implications

OBJECTIVE

This study was designed to assess the prevalence of depressive symptoms in children with asthma and the association between depression and asthma activity.

METHOD

Children ages 7 to 17 (n = 129) were recruited from a hospital emergency department after presenting for asthma symptoms. The majority of subjects were from disadvantaged, inner city families. Subjects' asthma disease activity was assessed using the revised National Heart, Lung, and Blood Institute guidelines, and subjects' emotional status was assessed by a combination of self-, parent-, and clinician-reported measures. Parental emotional status was assessed by self-report.

RESULTS

Depressive symptoms within the clinical range were reported in 26% of subjects and 43% of mothers, although symptom severity varied across scales. Self-reported depressive symptoms were more strongly correlated with asthma activity (r = 0.25) than clinician-reported (r = 0.14) or parent-reported symptoms (r = 0.12/0.18). Depressive symptoms in parents were correlated with child's depression scores but not with their asthma activity.

CONCLUSIONS

Depressive symptoms were common and associated with asthma activity in this inner city population of asthmatic children. Self-reported depressive symptoms were more strongly associated with child's asthma activity than either parental depression or parental/clinician ratings of the child's depression.

Allergy to drugs: is there an association with mental ill-health?

Objectives. Hypersensitivity reactions to drugs are not infrequent. A certain of anxiety, aggression or depression should be expected in patients with drug allergies, as they could experience symptoms ranging from mild to life-threatening reactions following consumption of drug. However, a literature search resulted in very limited data. This study was designed to evaluate the psychological status of patients with drug allergy and to assess the relationships between psychological evaluations of the patients and, duration of drug allergy, type of allergic reaction, hypersensitivity reaction of the type of drug involved. Methods. The study group comprised 61 patients (43 F, 18 M), age ranging from 16 to 75 years, with reliable history of drug allergy. A total of 55 healthy subjects (39F, 16M) age ranging from 17 to 70 years served as control group. Assessment tools consisted of Beck Depression Inventory (BDI), and Speilberger's State-Trait Anxiety Inventory (STAI Tx-2). Results. The prevalence of depression and anxiety among patients with drug allergies was not greater than that of the controls. There were no associations between the scores of these psychological assessments and duration of drug allergy, type of allergic reaction, type of drug. Conclusions. Our data suggest that follow-up studies including high numbers of patients and patients with specific and potentially life-threatening clinical pictures of drug allergies are needed to detect clinically relevant associations.

Major depression and allergy: does neuroticism explain the relationship?

OBJECTIVE

To determine the association between major depression, neuroticism, and self-reported allergy among adults in the community.

METHODS

Data were drawn from the Midlife Development in the United States Survey, a nationally representative sample of 3,032 adults age 25 to 74. ANOVA and multiple logistic regression analyses were used to determine the association between depression and allergy and the role of neuroticism in these relationships. These links were also examined by gender.

RESULTS

Among adults in the community, major depression was associated with a significantly increased likelihood of allergy (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.14-1.98). Higher levels of neuroticism were also significantly associated with increased likelihood of allergy (OR, 1.22; 95% CI, 1.04-1.43). Among women, major depression was associated with a significantly increased likelihood of allergy (OR, 1.67; 95% CI, 1.15-2.41), and this relationship persisted after adjusting for demographic characteristics and neuroticism. Among men, there was no significant relationship between allergy and depression, yet neuroticism was related to allergy (OR, 1.42; 95% CI, 1.42-1.82), which persisted after adjustment for depression.

CONCLUSION

These data are consistent with results of previous studies showing an association between major depression and allergy among adults and extend these data by providing preliminary evidence suggesting that this association is specific to women and independent of the effects of neuroticism among women. In addition, the data provide preliminary evidence that neuroticism may be related to allergy among men, though no link between depression and allergy was found among men. Future research with prospective, longitudinal studies is needed next to understand the possible biological underpinnings of these associations.

A randomized trial of citalopram versus placebo in outpatients with asthma and major depressive disorder: a proof of concept study

BACKGROUND

The prevalence of asthma has increased in recent years and depression is common in this population. Minimal data are available on the treatment of depressed asthma patients.

METHODS

Ninety adults with asthma and current major depressive disorder were randomized to receive citalopram or placebo for 12 weeks. At each visit, the Hamilton Rating Scale for Depression (HRSD), Inventory of Depressive Symptomatology - Self-Report, Asthma Control Questionnaire, and Asthma Quality of Life Questionnaire were administered, and oral corticosteroid use assessed.

RESULTS

In the evaluable sample (n = 82), the primary outcome, a random regression analysis of HRSD scores, revealed no significant between-group differences. Bonferroni corrected secondary outcomes revealed HRSD scores decreased significantly in both groups with a significantly greater decrease in the citalopram group at week 6. Changes in asthma symptoms were similar between groups. The groups had similar rates of oral corticosteroid use at baseline, but the citalopram group had less corticosteroid use during the study. Changes in asthma symptom severity correlated with changes in depressive symptom severity.

CONCLUSIONS

A reduction in depressive symptoms was associated with improvement in asthma. Corticosteroid use, an important measure of severe asthma exacerbations, was lower in the citalopram group. Larger clinical trials in this population are warranted.

Psychiatric disorders and asthma outcomes among high-risk inner-city patients

OBJECTIVE

The purpose of this study was to examine the rate of psychiatric disorders among patients attending an ethnically diverse, inner-city asthma clinic for an initial visit and assess the association between psychiatric disorders and asthma morbidity.

METHODS

A semistructured psychological interview was conducted to assess for psychiatric diagnoses. A pulmonary physician, who was blind to psychiatric disorder, established diagnosis of asthma based on national guidelines.

RESULTS

Sixty-four percent of 85 participants received at least 1 psychiatric diagnosis. The pulmonary physician rated patients with a psychiatric disorder as achieving fewer goals (M = 2.3 +/- 1.3) for asthma control than patients without a psychiatric disorder (M = 3.6 +/- 1.5, p = .0002). Patients with a psychiatric diagnosis more frequently reported an emergency room visit for asthma during the past 6 months (OR = 4.89; 95% CI, 1.76-13.39) and greater use of short-acting beta2-agonist medication (M = 1.5 +/- 0.9 canisters per month) than patients without a psychiatric diagnosis (M = 0.9 +/- 0.8, p = .003). These findings were independent of demographics, health insurance, and asthma severity. No differences emerged between patients with and without a mental disorder on percent predicted FEV1. Patients with a psychiatric disorder reported a higher severity level for asthma symptoms than the severity level indicated by their pulmonary function in comparison to patients without a psychiatric diagnosis (OR = 3.52; 95% CI, 1.23-10.10). Health insurance appeared to be a confounding factor in this relationship.

CONCLUSION

A high rate of psychiatric disorders was found among inner-city asthma patients. Psychiatric diagnoses were associated with greater perceived impairment from asthma but not objective measurement of pulmonary function.

Incidence of asthma and mortality in a cohort of young adults: a 7-year prospective study

Background

Few longitudinal data exist on the incidence of asthma in young adults and on the overall mortality risk due to asthma. A 7-year follow-up prospective study was performed to assess the incidence of asthma and mortality from all causes in a cohort of young adults.

Methods

The life status of a cohort of 6031 subjects, aged 20–44 years, who replied to a respiratory screening questionnaire between 1991 and 1992, was ascertained in 1999. A new questionnaire investigating the history of asthma was subsequently sent to the 5236 subjects who were still alive and residents in the areas of the study. 3880 subjects (74%) replied to the second questionnaire.

Results

The incidence of adult-onset asthma was 15.3/10,000/year (95%CI:11.2–20.8). The presence of asthma-like symptoms (IRR:4.17; 95%CI:2.20–7.87) and allergic rhinitis (IRR:3.30; 95%CI:1.71–6.36) at baseline were independent predictors of the onset of asthma, which was more frequent in women (IRR:2.32; 95%CI:1.16–4.67) and increased in the younger generations.

The subjects who reported asthma attacks or nocturnal asthma symptoms at baseline had an excess mortality risk from all causes (SMR = 2.05; 95%CI:1.06–3.58) in the subsequent seven years. The excess mortality was mainly due to causes not related to respiratory diseases.

Conclusion

Asthma occurrence is a relevant public health problem even in young adults. The likelihood of developing adult onset asthma is significantly higher in people suffering from allergic rhinitis, in women and in more recent generations. The presence of asthma attacks and nocturnal symptoms seems to be associated with a potential excess risk of all causes mortality.

Impact of depressive symptoms on adult asthma outcomes

BACKGROUND

Psychological disorders, including depression, are common in adults with asthma. Although depression is treatable, its impact on longitudinal asthma outcomes is not clear.

OBJECTIVE

To elucidate the impact of depressive symptoms on patient-centered outcomes and emergency health care use in adults with asthma.

METHODS

We conducted a prospective cohort study of 743 adults with asthma who were recruited after hospitalization for asthma. Depressive symptoms were defined as having a score of 16 or more on the Center for Epidemiologic Studies Depression Scale. We examined the impact of depressive symptoms on patient-centered outcomes (validated severity-of-asthma score, Marks Asthma Quality of Life Questionnaire, and 12-Item Short-Form Health Survey physical component summary score) and on future emergency health care use for asthma ascertained from computerized databases.

RESULTS

The prevalence of depressive symptoms was 18% (95% confidence interval [CI], 15%-21%) among adults with asthma. Depressive symptoms were associated with greater severity-of-asthma scores after controlling for age, sex, race/ ethnicity, educational attainment, and cigarette smoking (mean score increment, 2.6 points; 95% CI, 1.8-3.4 points). Furthermore, depressive symptoms were associated with poorer asthma-specific quality of life (mean score increment, 19.9 points; 95% CI, 17.7-22.1 points) and poorer physical health status (mean score decrement, 3.7 points; 95% CI, 1.5-5.8 points). Depressive symptoms were associated with a greater longitudinal risk of hospitalization for asthma (hazard ratio, 1.34; 95% CI, 0.98-1.84). After controlling for differences in preventive care for asthma, the relationship was stronger (hazard ratio, 1.45; 95% CI, 1.05-2.0).

CONCLUSION

Depressive symptoms are common in adults with asthma and are associated with poorer health outcomes, including greater asthma severity and risk of hospitalization for asthma.

Asthma, suicidal ideation, and suicide attempts: findings from the Baltimore epidemiologic catchment area follow-up

OBJECTIVES

We examined cross-sectional and longitudinal associations between asthma, suicidal ideation, and suicide attempt among adults in the community.

METHODS

Data were drawn from 3 waves (1981,1982,1993-1996) of the Baltimore follow-up of the Epidemiologic Catchment Area study. Multiple logistic regression analyses were used to examine associations between asthma, asthma treatment, suicidal ideation, suicide attempt, and suicide completion.

RESULTS

Asthma at wave 1 was associated with a significantly increased odds of suicidal ideation (odds ratio [OR] = 2.33; confidence interval [CI] = 1.03, 5.25) and suicide attempt (OR=3.54; CI=1.4, 8.99), which persisted independent of lifetime National Institute of Mental Health Diagnostic Interview Schedule/Diagnostic and Statistical Manual of Mental Disorders, Third Edition major depression and treatment for asthma at wave 2.

CONCLUSIONS

These findings provide preliminary evidence suggestive of an association between asthma and an increased likelihood of suicidal ideation and suicide attempt among adults in the community. Neither lifetime major depression nor treatment for asthma explained this relation. These results provide important directions for future research, and if replicated these data may have clinical and public health implications.

Psychological status and quality of life in elderly patients with asthma

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

Psychiatric Comorbidity Associated with Atopic Disorders in Children and Adolescents

This article examines evidence of an association between psychiatric disorders and atopic disorders in children and adolescents. Findings are discussed within a developmental framework and compared with adult studies, when available, to illustrate similarities and differences between youth and adults. Finally, the article discusses the clinical relevance of comorbid psychiatric and atopic disorders.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Risk behaviors and health-related quality of life among adults with asthma: the role of mental health status

BACKGROUND

Previous research indicates that asthma is strongly associated with depressive disorders. Depression among persons with asthma is associated with poor adherence to medication regimens, more severe asthma, and poorer disease outcomes. The objective of our study was to examine the association of frequent mental distress (FMD) [ie, > or = 14 days in the past 30 days in which respondents reported that their mental health was not good] with modifiable risk behaviors (ie, smoking, physical inactivity, and obesity) and health-related quality of life among adults with asthma.

METHODS

The Behavioral Risk Factor Surveillance System is an ongoing, state-based survey that is conducted by random-digit dialing of noninstitutionalized US adults aged > or = 18 years. In 2001, all 50 states administered the asthma and risk behavior questionnaires (15,080 questionnaires). A total of 12 states administered the health-related quality-of-life questionnaire (3,226 questionnaires). We estimated prevalences, 95% confidence intervals, odds ratios, and adjusted odds ratios (AORs) using a statistical software program to account for the complex survey design.

RESULTS

The prevalence of FMD among adults with asthma was 18.8%. After adjusting for sociodemographic characteristics, the overall associations between smoking and FMD (AOR, 1.9), and between physical inactivity and FMD (AOR, 1.7) were statistically significant. In addition, among those with asthma, persons with FMD were significantly more likely than those without FMD to report fair/poor general health, frequent physical distress, frequent activity limitations, frequent anxiety, and frequent sleeplessness.

CONCLUSIONS

FMD is highly prevalent among persons with asthma, suggesting an apparent synergistic effect of these two conditions. The assessment of the mental health status of persons with asthma by health-care providers appears to be warranted and may prevent the emergence of risk behaviors yielding deleterious effects on the management of this disease.

Comorbidity of asthma and anxiety and depression in Puerto Rican children

Studies have reported that childhood asthma is associated with internalizing disorders, but most of these studies have used global measures of depressive and anxiety symptoms. The Diagnostic Interview Schedule for Children was administered to a group of 1891 youth ages 4 to 17 and their caregivers in Puerto Rico to determine DSM-IV symptoms and diagnoses. Asthma diagnosis and having had an asthma attack were assessed by parental report. A diagnosis of asthma was associated with having any depressive disorder and one symptom of separation anxiety. An asthma attack was associated with any depressive disorder and any anxiety disorder and, more specifically, with separation anxiety disorder, major depressive disorder, and symptoms of depression, separation anxiety, and generalized anxiety. Possible explanations for the findings are discussed.

Presence of atopy in first-degree relatives as a predictor of a female proband's depression: results from the Northern Finland 1966 Birth Cohort

BACKGROUND

Recent investigations suggest a common genetic rather than environmental cause to explain the association between IgE-mediated atopic allergies and depression.

OBJECTIVE

Taking into account psychosocial confounding factors, we investigated separately and at the epidemiologic level the effects of maternal, paternal, and sibling atopy on the cumulative incidence of a child's depression.

METHODS

We used an unselected, genetically homogenous, general population birth cohort of 12,058 live-born children in Finland. The 31-year prospective follow-up included questionnaire information on atopic disorders of the cohort members' parents and siblings. The probands' own atopic conditions were evaluated by means of skin prick tests, and information on lifetime depression diagnoses was gleaned from postal questionnaires and national hospital discharge registers. Potential confounders were mother's parity, father's social class, maternal smoking during pregnancy, proband's regular daily smoking, and proband's dwelling place. Total variable information was available from 4068 cohort members.

RESULTS

Among female probands, the presence of atopy in parents was the strongest predictor for lifetime depression (P <.001), and sibling atopy and parental atopy were the strongest predictors for hospital-treated depression (P =.018 and P =.036, respectively). After controlling for confounders, it was noticed that maternal atopy increased a female proband's risk of lifetime depression up to 1.9-fold (odds ratio, 1.9; 95% CI, 1.1-3.0). The corresponding risk increased over 4-fold if parental-maternal atopy was combined with proband's own atopy.

CONCLUSIONS

Our findings suggest that maternal inheritance could be a significant causative factor in the association between atopy and depression of female probands.

Novel Uses of Selective Serotonin Reuptake Inhibitors in Women

Selective serotonin reuptake inhibitors (SSRIs) are commonly used as first-line therapy to treat mood disorders due to their demonstrated efficacy, safety, and tolerability profiles. SSRIs may play an intricate role in treating hormone-mediated disorders that disturb the quality of life for women. Selected uses of SSRIs, specifically in the treatment of hot flashes, premenstrual dysphoric disorder, and postpartum depression, are explored in this article. Data from several studies support the use of SSRIs in these conditions, and therefore, these agents have the potential to significantly improve mood, cognitive function, physical symptoms, and social functioning in patients with these disorders. In addition, SSRIs may prove to be viable alternatives to current therapies that may be contraindicated, poorly tolerated, or lack efficacy in patients with these disorders.

Self-reported hay fever and panic attacks in the community

OBJECTIVE

The objective of this study was to determine the relationship between self-reported hay fever and common mental disorders among adults in the general population.

METHODS

Data were drawn from the Midlife Development in the United States Survey, a representative household survey of the adult US population (25 to 74 years old; n = 3,032). Multivariate logistic regression analyses were used to determine the relationship between self-reported hay fever and current major depression, panic attacks, generalized anxiety disorder, and alcohol/substance use disorders.

RESULTS

Self-reported hay fever was associated with a significantly increased odds of panic attack (odds ratio = 1.8 [1.2, 2.6]), which persisted after adjusting for differences in sociodemographic characteristics and comorbid mental disorders. Self-reported hay fever was not associated with a significantly increased likelihood of major depression, generalized anxiety disorder, or alcohol/substance use disorders.

CONCLUSIONS

Consistent with previous findings, these data show a relationship between self-reported hay fever and increased likelihood of panic attacks among adults in the general population. The mechanism of the observed association remains unknown. Future work that examines the relationship between hay fever and panic attacks, as well as other mental disorders using both self-report and objective measurement of allergic response in prospective, longitudinal, epidemiologic data may be useful in improving our understanding of this observed link.