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Asthma and psychological problems Mike Thomas

Professor of Primary Care Research, University of Southampton

Chief Medical Advisor, Asthma UK

Thomas M, Bruton A, Moffat M, Cleland J. Asthma and psychological dysfunction. Prim Care Respir J. 2011 Sep;20(3):250-6. 2

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Why should we be interested?

• Asthma Outcomes are sub-optimal and unequal

• In 2008, 57% of asthmatics had ‘not well controlled’ asthma (ACT<20), with no improvement since 2006)

• Asthma mortality and admission rates have not improved since millenium

Key questions 1. Are anxiety and depression more common in people with

asthma

2. Is asthma control worse in those with co-morbidity?

3. Which direction is the relationship?

4. What’s the mechanism?

5. Does treatment help asthma control?

6. What treatments can we use?

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1. Anxiety and Depression are common on asthma

• Numerous cross-sectional surveys using different methods show anxiety (and depression) are more common in adults and children with asthma

– Prevalence 16 - >50% depending on definitions/ instruments (questionnaires, interviews etc)

– Up to 6 times higher than national rates

– Particularly in ‘difficult to treat’ asthma (ITU etc)

• Serious disorders (panic, severe anxiety, severe depression) higher. Particularly in ‘difficult asthma’ clinics

• UNDIAGNOSED in the majority (20% on Rx in one study)

– Lavoie et al Chest 2006;130(4):1039-47

– Goodwin et al. Arch Gen Psychiatry 2003;60:1125-30

– Oraka Eet al. Chest2010;137(3):609-16. 5

2. Anxiety and Depression are associated with poor outcomes

• Surveys consistently show poor asthma outcomes in patients with anxiety and depression

– Worse symptoms, greater QOL impairment

– More medical contacts, rescue medication use

– Greater perception of breathlessness

– More attacks, hospitalisation, death

• Relationship is independent of potential confounders

– Age, sex, asthma treatment, deprivation, smoking

• In a regression model, psychiatric co-morbidity accounted for 30% of the variance in Asthma Control Questionnaire score

• ten Brinke et al Am J Respir Crit Care Med 2001;163:1093-6.

• Rimington ey al Thorax 2001;56:266-71. 6

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3. Which direction is the relationship? • Does having asthma predispose to psychological dysfunction or do

psychological problems predispose to asthma?

• Swiss Longitudinal study

– Asthma at baseline predicted new panic/anxiety (OR 4.5)

– Anxiety at baseline predicted new asthma (OR 6.3)

• US population study: Anxiety predicted asthma, even in those without baseline respiratory symptoms

• Paediatric UK cohort study: asthma predicted behavioral problems, behavioral problems predicted asthma

– Hasler et al. Am J Respir Crit Care Med 2005;171(11):1224-30)

– Jonas et al. J Appl Biobeh Res 1999;4:91-119.

– Calam et al. Am J Respir Crit Care Med 2005;171:323-7. 7

4. What’s the mechanism

• Mechanism not clear- several possible explanations

– Effects on behavior:

• poor self management, over-use of rescue medication, poor adherence, smoking

– Hyperventilation/ VCD/ Dysfunctional breathing

– Altered symptom perception

– Biological effects of stress

– Other unidentified genetic or environmental factor…

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5. Can treating anxiety and depression improve asthma control?

• Literature scanty and inconclusive

• Extraordinarily little studied!

• Cochrane reviews of psychological interventions in adults (20090 and children (2009):

– Studies too small and diverse to say

– Some suggestions of improvements (e.g. CBT, relaxation, biofeedback) and Psychological support in high-risk groups

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6. What types of psychological intervention could help?

• ? Medication: V little evidence

– Brown el al. A randomized trial of citalopram versus placebo in outpatients with asthma and major depressive. Biol Psychiatry 2005;58:865-70

• Co-consultation with ‘liaison psychiatrist’, family therapist

• Non-drug treatments: issues of access and availbility

– CBT

– Psychotherapy, of various types, NLP

– Physical exercise programmes

– Mindfulness-based stress reduction

– Breathing exercises

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For discussion: Should we be screening for anxiety/depression? How? In whom? How should we react when we find it?