Asthma Management Handbook

Mental illness and asthma

Recommendations

In patients with moderate-to-severe asthma or asthma that is difficult to control, screen for depression, panic disorder and anxiety disorder, and offer comprehensive assessment, treatment or referral as appropriate.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Alvarez and Fitzgerald, 20071
  • Boulet, 20092
  • Lavoie et al. 20113
  • Parry et al. 20124
  • Theoharides et al. 20125
  • Weinberger and Abu-Hasan, 20076

Consider hyperventilation as an alternative or coexisting diagnosis when investigating asthma-like symptoms.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Weinberger and Abu-Hasan, 20076

Consider potential effects of oral corticosteroids on mental health when prescribing, monitoring treatment response or when assessing adherence during flare-ups.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Prevalence of mental illness among people with asthma

Epidemiological studies show that anxiety, depression and panic disorders are more common among people with asthma than in the general population:2, 7

  • A large international population study found that, compared with those without asthma, people with asthma were approximately 1.6 times more likely to have a depressive disorder, approximately 1.5 times more likely to have an anxiety disorder, and approximately 1.7 times more likely to have an alcohol use disorder.8
  • Population studies have shown a higher prevalence of major depressive episodes among adolescents with asthma than adolescents without asthma.9
  • Depression and anxiety disorders are common among people with severe asthma and may be either a consequence of, or a contributor to asthma.2 Data from a prospective birth cohort suggest that there is a positive correlation between the risk of mental health problems and asthma severity in children and adolescents.10

Population studies also suggest higher rates of behavioural problems in children with asthma than the general population.11 Several studies have shown an association between asthma and attention-deficit hyperactivity disorder in children and adolescents.12

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Effects of mental illness on asthma

Psychological factors may trigger asthma symptoms and affect patients’ asthma symptom perception, but also may influence medication compliance.2

Anxiety, depression and personality disorders have been thought to be risk factors for near-fatal asthma, but the association is unclear.1 Psychological factors may trigger asthma symptoms.2 High levels of asthma-related fear and panic can exacerbate asthma symptoms.4 However, anxiety and hyperventilation attacks can also be mistaken for asthma.6

Data from a cohort study of patients with asthma attending a specialist asthma clinic suggest that comorbid generalised anxiety disorder is associated with worse asthma morbidity (poorer overall asthma control, increased bronchodilator use, and worse asthma quality of life) than patients with asthma overall.3 Several studies have reported an association between stress (socioeconomic status, interpersonal conflicts, emotional distress, terrorism) and asthma flare-ups.5 The mechanism is not yet understood, but may involve circulating adrenaline levels, altered sensitivity to corticosteroids, or mast cell activation.5

Psychological factors may influence adherence to the treatment regimen.2 The experience of euphoria or dysphoria during oral corticosteroid therapy13 may influence a person’s adherence to their written asthma action plan and could lead to delays in seeking medical care during flare-ups.

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Hyperventilation and asthma

Attacks of hyperventilation can be confused with asthma symptoms in people with asthma and in those without asthma.6 Some patients with asthma who experience hyperventilation attacks cannot readily distinguish the sensation of dyspnoea associated with hyperventilation from that associated with their asthma.6

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Screening for depression

There is a range of validated screening tools that can be used to identify symptoms of mental illness, including depression and anxiety. For adults, asking two simple screening questions in primary care can help identify those who need further investigation for depression:14

Over the past 2 weeks, have you felt down, depressed or hopeless?

Over the past 2 weeks, have you felt little interest or pleasure in doing things?

A list of screening and assessment tools appropriate for adolescents and young adults is included in beyondblue’s Clinical practice guidelines: Depression in adolescents and young adults (2010).15

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Effects of mental health treatments on asthma

Few randomised controlled clinical trials have investigated whether specific treatments for depression or anxiety in people with asthma can improve symptom control or overall function:7 In one placebo-controlled antidepressant trial, improvement in depression was associated with improvement in asthma control, irrespective of treatment received.16

Other studies have reported psychosocial benefits with various interventions:

  • In highly anxious patients with asthma, a brief cognitive behavioural intervention may reduce asthma-specific fear.4
  • Asthma self-management education and asthma monitoring (either written information and frequent follow-up, or more intensive coaching) has been associated with improvement in quality of life, particularly among patients with depressive symptoms.17
  • Physical activity (aerobic training) has been associated with improvement in anxiety and depression in people with asthma.18
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Systemic corticosteroids: psychiatric effects

Systemic corticosteroids can have a range of psychological effects. Large doses of prednisone or prednisolone can cause mood and behavioural changes, including nervousness, euphoria or mood swings, psychotic episodes including manic or depressive states, paranoid states and acute toxic psychoses.13 These adverse effects can occur in people without a previous history of psychiatric illness.13

Systemic corticosteroid treatment has been associated with elevated mood and reduction in depression among patients with asthma.1920 With long-term prednisone or prednisolone therapy, initial mood changes appear to stabilise over time.21

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Montelukast for adults and adolescents: psychiatric effects

Post-marketing surveillance reports led to concerns about a possible association between leukotriene receptor antagonist use and suicide risk.22 A recent case-control study reported a statistically significant association between the use of leukotriene receptor antagonists and suicide attempts in people aged 19–24 years. However, this association was no longer statistically significant after adjusting for potential confounding factors, including previous exposure to other asthma medicines and previous exposure to other medicines associated with suicide.22

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Montelukast for children: warning parents about potential psychiatric adverse effects

Montelukast is generally very well tolerated.23 However, post-marketing surveillance reports suggested a slight increase in the rate of psychiatric disorders that was possibly associated with use of leukotriene receptor antagonists in children;24 this association may have been confounded by asthma severity and concomitant medication.23 Montelukast use has also been associated with suicidal ideation, but a recent nested case-control study concluded that children with asthma aged 5–18 years taking leukotriene receptor antagonists were not at increased risk of suicide attempts.22 Behavioural and psychiatric adverse effects were rare in clinical trials.25,26

The Thoracic Society of Australia and New Zealand advises that it is prudent to mention to parents the potential association of montelukast with behaviour-related adverse events when commencing treatment, and to cease therapy if such adverse events are suspected.23

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Psychological interventions for asthma

Various psychological interventions have been evaluated for patients with asthma who do not have a diagnosis of mental illness.

A systematic review27 of psychological interventions for adults with asthma found that:

  • relaxation therapy reduced the use of relievers
  • cognitive behavioural therapy improved asthma-related quality of life
  • bio-feedback therapy may improve peak expiratory flow rate.

A systematic review assessing whether psycho-educational interventions improve health and self-management outcomes in adults with severe or difficult asthma found that positive effects observed were mainly short term.28 However, studies were generally poor quality.28

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References

  1. Alvarez GG, Fitzgerald JM. A systematic review of the psychological risk factors associated with near fatal asthma or fatal asthma. Respiration. 2007; 74: 228-36. Available from: http://www.karger.com/Article/FullText/97676
  2. Boulet LP. Influence of comorbid conditions on asthma. Eur Respir J. 2009; 33: 897-906. Available from: http://erj.ersjournals.com/content/33/4/897.long
  3. Lavoie KL, Boudreau M, Plourde A, et al. Association between generalized anxiety disorder and asthma morbidity. Psychosom Med. 2011; 73: 504-13. Available from: http://www.psychosomaticmedicine.org/content/73/6/504.long
  4. Parry GD, Cooper CL, Moore JM, et al. Cognitive behavioural intervention for adults with anxiety complications of asthma: prospective randomised trial. Respir Med. 2012; 106: 802-10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22398158
  5. Theoharides TC, Enakuaa S, Sismanopoulos N, et al. Contribution of stress to asthma worsening through mast cell activation. Ann Allergy Asthma Immunol. 2012; 109: 14-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22727152
  6. Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics. 2007; 120: 855-864. Available from: http://pediatrics.aappublications.org/content/120/4/855.full
  7. Van Lieshout RJ, Macqueen GM. Relations between asthma and psychological distress: an old idea revisited. Chem Immunol Allergy. 2012; 98: 1-13. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16757162
  8. Scott KM, Von Korff M, Ormel J, et al. Mental disorders among adults with asthma: results from the World Mental Health Survey. Gen Hosp Psychiatry. 2007; 29: 123-33. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1913936/
  9. Delmas MC, Guignon N, Chee CC, et al. Asthma and major depressive episode in adolescents in France. J Asthma. 2011; 48: 640-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21609306
  10. Goodwin RD, Robinson M, Sly PD, et al. Severity and persistence of asthma and mental health: a birth cohort study. Psychol Med. 2013; 43: 1313-22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23171853
  11. Feitosa CA, Santos DN, Barreto do Carmo MB, et al. Behavior problems and prevalence of asthma symptoms among Brazilian children. J Psychosom Res. 2011; 71: 160-5. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160547/
  12. Schmitt J, Buske-Kirschbaum A, Roessner V. Is atopic disease a risk factor for attention-deficit/hyperactivity disorder? A systematic review. Allergy. 2010; 65: 1506-24. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.2010.02449.x/full
  13. Aspen Pharmacare Australia Pty Ltd. Product information: Panafcort (prednisone) and Panafcortelone (prednisolone). Therapeutic Goods Administration, Canberra, 2010. Available from: https://www.ebs.tga.gov.au
  14. Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 8th edn. Royal Australian College of General Practitioners, East Melbourne, 2012. Available from: http://www.racgp.org.au/your-practice/guidelines/redbook/
  15. Beyondblue. Clinical practice guidelines: Depression in adolescents and young adults. beyondblue: the national depression initiative, Melbourne, 2010. Available from: http://www.nhmrc.gov.au/guidelines/publications/ext0007
  16. Brown ES, Howard C, Khan DA, Carmody TJ. Escitalopram for severe asthma and major depressive disorder: a randomized, double-blind, placebo-controlled proof-of-concept study. Psychosomatics. 2012; 53: 75-80. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22221724
  17. Mancuso CA, Sayles W, Allegrante JP. Randomized trial of self-management education in asthmatic patients and effects of depressive symptoms. Ann Allergy Asthma Immunol. 2010; 105: 12-9. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2964839/
  18. Mendes FA, Goncalves RC, Nunes MP, et al. Effects of aerobic training on psychosocial morbidity and symptoms in patients with asthma: a randomized clinical trial. Chest. 2010; 138: 331-7. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1086590
  19. Brown ES, Suppes T, Khan DA, Carmody TJ. Mood changes during prednisone bursts in outpatients with asthma. J Clin Psychopharmacol. 2002; 22: 55-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11799343
  20. Brown ES, Denniston D, Gabrielson B, et al. Randomized, double-blind, placebo-controlled trial of acetaminophen for preventing mood and memory effects of prednisone bursts. Allergy Asthma Proc. 2010; 31: 331-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20819324
  21. Brown ES, Vera E, Frol AB, et al. Effects of chronic prednisone therapy on mood and memory. J Affect Disord. 2007; 99: 279-83. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1852520/
  22. Schumock GT, Stayner LT, Valuck RJ, et al. Risk of suicide attempt in asthmatic children and young adults prescribed leukotriene-modifying agents: a nested case-control study. J Allergy Clin Immunol. 2012; 130: 368-75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22698520
  23. van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: http://www.thoracic.org.au/clinical-documents/area?command=record&id=14
  24. Wallerstedt SM, Brunlöf G, Sundström A, Eriksson AL. Montelukast and psychiatric disorders in children. Pharmacoepidemiol Drug Saf. 2009; 18: 858-864. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19551697
  25. Philip G, Hustad C, Noonan G, et al. Reports of suicidality in clinical trials of montelukast. J Allergy Clin Immunol. 2009; 124: 691-6.e6. Available from: http://www.jacionline.org/article/S0091-6749(09)01247-0/fulltext
  26. Philip G, Hustad CM, Malice MP, et al. Analysis of behavior-related adverse experiences in clinical trials of montelukast. J Allergy Clin Immunol. 2009; 124: 699-706.e8. Available from: http://www.jacionline.org/article/S0091-6749(09)01248-2/fulltext
  27. Yorke J, Fleming SL, Shuldham C. Psychological interventions for adults with asthma: a systematic review. Respir Med. 2007; 101: 1-14. Available from: http://www.resmedjournal.com/article/S0954-6111(06)00213-7/fulltext
  28. Smith JR, Mugford M, Holland R, et al. Psycho-educational interventions for adults with severe or difficult asthma: a systematic review. J Asthma. 2007; 44: 219-41. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17454342