FOR UK HEALTHCARE PROFESSIONALS ONLY
PSYCHOLOGICAL FACTORS: THE FORGOTTEN ELEMENT OF ASTHMA CARE
This feature has been funded by Chiesi Limited and written on behalf of Chiesi by M&F Health, based on an interview with Dr Stephen Gaduzo.
In 2016, approximately 1 person in 15 in the UK had asthma.1 Around 1 in 6 of those aged 16 years and older reported experiencing symptoms of a common mental disorder, such as depression or anxiety, in the week before being surveyed.2 Therefore, some people experience asthma and a common mental disorder by co-incidence.
However, the relationship between asthma and common mental disorders seems to be closer than co-incidence alone. A meta-analysis of eight studies reported that depression at baseline was associated with a 43% increased risk of developing adult-onset asthma. The 23% increased risk of developing depression in adults with baseline asthma was not statistically significant, most likely due to the small number of studies.3
A study of 14,621 people aged, on average, 65.5 years reported that 2.8% of males and 4.2% of females had diagnosed asthma. In 2016, the prevalence of depressive symptoms was twice that in people with asthma compared with controls (Odds Ratio 2.01).4 A study of 781 people with asthma aged 11 to 17 years reported a doubling (OR 1.92) in the prevalence of comorbid anxiety and depression compared with controls.5
Mental disorders can affect asthma in numerous ways including influencing patients’ perception of symptoms, compliance and self-monitoring. Indeed, mental disorders are associated with more frequent emergency care and hospitalisations.6
We asked Dr Stephen Gaduzo, a GP with special interest in respiratory medicine from Stockport, for his views and experiences about addressing psychological issues in asthma. “Tailoring psychological intervention to the person with asthma is an important element of care,” Dr Gaduzo says. “But it’s an element that’s been a bit forgotten.”
How do psychological factors present in people with asthma?
Patients with asthma may present with a range of psychological disorders. On one end of the scale, patients who understand their asthma, who are concordant with treatment and show good inhaler technique, and who attend their reviews often experience few or no psychological effects. On the other end, people whose symptoms interfere markedly with their daily lives, who are poorly concordant and who need regular hospital treatment can experience severe psychological effects. Most people with asthma are between these extremes.
But it’s not a simple relationship. Some people with severe asthma show relatively few psychological issues. Some people with mild asthma live with considerable anxiety and depression. Furthermore, asthma is dynamic and the psychological impact can vary, such as when environmental factors trigger exacerbations or following a severe attack.
In addition, media stereotypes tend to fuel misconceptions about the psychology of asthma. The media often portrays a person whose asthma worsens with stress and who reaches for an inhaler as a way to escape difficult situations. In fact, pure somatisation of a psychological issue into asthma is not common.
How can healthcare professionals assess psychological factors in people with asthma?
Assessing anxiety and depression in people with asthma can be difficult. So, it’s important to drill down into a patient’s responses, using a combination of open and closed questions. If you ask ‘how is your asthma?’ many people will answer ‘fine’. But if you ask ‘how many times a week do you wake because of your asthma?’ the same person may report ‘three or four’, which is a sign of poorly controlled asthma.
Future research could develop a validated measure that is not time consuming and easily integrated into routine consultations. In our chronic obstructive pulmonary disease (COPD) clinics, we routinely use the Generalised Anxiety Disorder Assessment (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9) for depression. These can identify people with extreme anxiety or depression, some of whom are not being managed for the mental condition by their GP.
Does improving asthma management improve psychological outcomes?
Patients often accept a reduced quality of life (QoL) and that their asthma means that they can’t do certain things. Living with mental and physical limitations imposed by asthma becomes ‘normal’. Patients should appreciate that it doesn’t need to be like this.
Treatment can make a big difference to patients’ respiratory health, QoL and psychological wellbeing. I compare the improvement to going to the opticians. Before you go, you think your vision seems OK. But there’s a marked improvement when you try the glasses. Improving concordance or optimising asthma treatment can make a big difference and help people realise their potential. It’s also worth reminding patients of motivational role-models, such as footballers and athletes, who participate in world-class events despite asthma.
How do common mental disorders affect asthma?
Concurrent depression and anxiety in people with asthma can contribute to a cycle of deteriorating control. Patients with depression, for instance, may lack the motivation to comply with their asthma treatment.
During a worsening of anxiety, people can become more breathless, which they may misinterpret as asthma. So, they overuse their short-acting beta-agonist (SABA). However, SABAs’ side effects include tremor and tachycardia, which are reminiscent of anxiety. If patients underuse their preventative treatment, breathlessness due to asthma can reinforce their anxiety. So, it’s important to ask people with asthma about their psychological problems and reinforce the importance of preventative treatment to reduce SABA overuse.
Does denial contribute to poor asthma outcomes?
Denial is a massive problem in people with asthma. You can tell a patient that in 2016 about 1400 people died from asthma in the UK.7 But many feel that this doesn’t apply to them: they haven’t been admitted to hospital and they don’t need a nebuliser.
Denial, of course, complicates the management of many chronic conditions, but it seems to be a particular issue in asthma. Most people accept taking an antihypertensive to prevent stroke. Patients seem less likely to accept that they need to take an ICS to prevent asthma attacks.
There are probably several reasons for this difference. Using an inhaler is more cumbersome than taking a pill. As mentioned, patients may see themselves as being in a different league to those with severe asthma. They may not fully appreciate the consequences of non-concordance or don’t like the idea of taking a steroid, especially as they don’t feel any immediate benefit in the short-term after taking an ICS. So, sometimes the review following a hospitalisation or a severe attack can be the ideal time to address these issues. You can stress that the aim is to prevent a recurrence.
How can healthcare professionals help improve psychological outcomes in asthma?
Management should empower patients to help themselves, such as by promoting lifestyle changes, avoiding triggers, encouraging smoking cessation and improving concordance.
GPs and nurses need more training in detecting and treating psychological issues in primary care asthma patients, including motivational interviewing and level one cognitive behavioural therapy (CBT). A recent study showed, for example, that CBT delivered by respiratory nurses is more clinically and cost-effective for anxiety management in COPD patients than offering self-help leaflets.8
What can the asthma team learn about psychological support from other conditions?
Within respiratory medicine, the detection and management of psychological issues is routine in COPD in a way that isn’t the case in asthma. When a person books into our COPD clinic, the receptionist passes them a clipboard and asks them to fill out the GAD-7 and PHQ-9 in the waiting room. This works well and the results are extremely useful: depression and anxiety are important red flags in respiratory medicine.
Nevertheless, respiratory medicine in general has much to learn from other areas. People with newly diagnosed diabetes, for example, are offered structured education that covers the disease, management and common problems. We don’t have the same for asthma. However, we should be better at signposting people to resources, such as those produced by Asthma UK and the British Lung Foundation, and videos demonstrating the correct inhaler technique.
What are your take-home messages?
Traditionally, we’ve thought of mental disorders and physical illness as separate. But they’re intertwined. Two people with the same degree of osteoarthritis on radiography may have very different functional abilities. Psychological factors may be responsible for the difference. I think the same applies to asthma.
For example, a patient can have severe asthma confirmed in tertiary care and who is eligible for monoclonal antibody treatment or even endobronchial thermoplasty, but whose asthma improves when they are on holiday. So there’s still clearly a psychological component that isn’t being adequately addressed. We need more research into the importance of psychological factors in asthma and the most appropriate screening tools and interventions.
In the meantime, we need to address psychological problems in primary care, which can, admittedly, pose a challenge given the short time usually available in a review. When we’re faced with a patient with poorly controlled asthma we naturally focus on inhaler technique, concordance and trigger factors. These are vital, of course. In many patients, however, psychological factors are also an important part of the clinical presentation. If we don’t identify and manage these psychological factors, we’re not addressing what may be the root cause of their symptoms, poor QoL or inability to live life to the full.
- Bloom CI, Saglani S, Feary J et al. (2019) Changing prevalence of current asthma and inhaled corticosteroid treatment in the UK: population based cohort 2006–2016. European Respiratory Journal, DOI: 10.1183/13993003.02130-2018.
- Baker C. (2018) Mental health statistics for England: prevalence, services and funding. House of Commons Briefing Paper 6988. House of Commons. Available at researchbriefings.files.parliament.uk/documents/SN06988/SN06988.pdf. Accessed May 2019.
- Gao Y-H, Zhao H-S, Zhang F-R et al. (2015) The relationship between depression and asthma: a meta-analysis of prospective studies. PloS One, DOI: 10.1371/journal.pone.0132424.
- de Roos EW, Lahousse L, Verhamme KMC et al. (2018) Asthma and its comorbidities in middle-aged and older adults: the Rotterdam Study. Respiratory Medicine, 139: pp. 6-12.
- Katon W, Lozano P, Russo J et al. (2007) The prevalence of DSM-IV anxiety and depressive disorders in youth with asthma compared with controls. The Journal of Adolescent Health, 41(5): pp. 455-463.
- Boulet L-P and Boulay M-È. (2011) Asthma-related comorbidities. Expert Review of Respiratory Medicine, 5(3): pp. 377-393.
- Asthma UK. (2019) Asthma facts and statistics. Available at www.asthma.org.uk/about/media/facts-and-statistics/. Accessed May 2019.
- Heslop-Marshall K, Baker C, Carrick-Sen D et al. (2018) Randomised controlled trial of cognitive behavioural therapy in COPD. ERJ Open Research, DOI: 10.1183/23120541.00094-2018.
UK-CHI-1900146 | May 2019