A small number of studies have investigated the links between specific asthma symptoms and depression. One of these, a population study by Goldney et al [ 39 ], examined the relationship between depression as measured by the Prime-MD and a number of symptoms known to be related to asthma severity, and found that dyspnoea, wakening at night, and morning symptoms were particularly strongly associated with depression.
Another study by Janson et al [ 27 ] found significant positive correlations between depression as determined by the Hospital Anxiety and Depression Scale HADS and various, but not all, symptoms of asthma. However, while specific symptoms of asthma may be linked to depression, it is also possible that the assessment of depression in the afore-mentioned studies could have been inaccurate due to the misinterpretation of asthma symptoms as symptoms of depression. Alternatively, it is possible that the findings and their interpretation are accurate, and certain symptoms of asthma may be related to depression due to their effect on the individual's quality of life [ 39 ].
The finding of Goldney et al [ 39 ] relating asthma symptoms to significant decrement in the quality of life also leads to the question of whether experiencing certain specific asthma symptoms might lead to person with asthma becoming depressed, rather than depression resulting from simply 'having' asthma. The influence of emotional states on pulmonary function in asthma has been studied extensively [ 40 ]. Recent findings indicate that airways are reactive to psychological states, with these reactions causing changes consistent with greater airway instability and asthma exacerbations [ 41 ].
Consistent with this finding, personal retrospective accounts of asthma exacerbations have also suggested that changes in emotional states often result in asthma exacerbations [ 42 ]. In the laboratory, Ritz et al [ 43 ] found increased total respiratory resistance in subjects with asthma but not those without asthma following exposure to depressing stimuli.
It is not clear from this study, however, whether the results are due to the depression or the depression is due to the reduced lung function. Further, a study of overall physical vulnerability to asthma by Miller and Wood [ 45 ] suggested that depressive emotions in children evoked whilst viewing selected scenes from the film 'ET: The Extra Terrestrial' may be associated with greater cholinergic influence and instability of oxygen saturation, consistent with poorer airway function in asthma.
In contrast, happiness appeared to be related to effects that were more likely to relieve airway constriction. Ritz and Steptoe [ 40 ] conducted a study consisting of both laboratory and field measurements, and demonstrated a consistency between both situations. Overall, the research on affect and pulmonary function indicates that depressed or sad mood, even when only short-lived and mild, can produce respiratory effects that are consistent with heightened airway vulnerability or asthma exacerbations.
Further investigations are needed to establish whether this effect commonly occurs in the everyday lives of persons with asthma. Self-management of asthma can be challenging, due to the often complicated and onerous nature of treatment [ 41 , 46 ].
The individual with asthma may need to avoid allergens; take preventive medication regularly; and decide when reliever medications are required and whether further medical assistance should be sought [ 41 , 46 ]. Further, the potential implications of poor management and reduced compliance are serious, with consistently negative effects for individuals with asthma being reported, including increased morbidity [ 47 ] and mortality [ 48 , 49 ].
Depression, which has negative effects on cognitive functioning, energy, and motivation [ 41 ], has been identified as one factor which may decrease the effectiveness of asthma self-management and compliance. A meta-analysis by DiMatteo et al [ 50 ] revealed that patients with a chronic disease and depression were three times more likely to be noncompliant with medical treatment than non-depressed patients.
Depression might interfere with asthma treatment compliance and self-management via several pathways: firstly, depression-related hopelessness may lead to a patient seeing little point in taking their medication as instructed [ 52 ]; depression can also result in isolation from family and friends who could offer the support that has often been noted as important for compliance [ 52 ]; and finally, depression may also be associated with declines in areas of cognitive functioning such as problem solving, complex task performance, concentration, attention span, and memory that are vital for compliance with treatment recommendations [ 37 , 53 — 55 ].
Unfortunately, the correlational studies mentioned here cannot determine whether depression causes reduced compliance or vice-versa, whether there are mediating factors in the relationship, or whether the relationship between depression and compliance may be bi-directional [ 50 ]. DiMatteo et al [ 50 ] have also hypothesised the possibility of a 'feedback loop', in which depression leads to treatment non-compliance, non-compliance further exacerbates asthma, asthma exacerbations lead to increased depression, and so on, resulting in a cycle of ever-worsening outcomes for the individual.
Corticosteroid use has also been hypothesised as a link between asthma and depression [ 18 , 46 , 56 ]. The creation of more potent inhaled corticosteroids ICS , together with more efficient delivery systems, has greatly increased the use of ICS in the last 20 years [ 18 ]. While these changes have had positive effects on overall health, they have also been related to adverse side effects [ 57 ]. Although early reports of a possible relationship between asthma medications and depression were rare, and often anecdotal, recent studies in this area seem to suggest a stronger link than first believed.
For example, an investigation by Patten and Lavorato [ 58 ] found that corticosteroid use was significantly associated with a 'syndrome resembling major depression' measured by the Composite International Diagnostic Interview Short-Form CIDI-SF , and in a study by Patten [ 59 ] of 73, community members, it was found that among individuals taking corticosteroids current or within the past month , the prevalence of major depression Perceived health status was not a confounder in this study.
There appear to be a number of gaps and problems in the literature to date on ICS and depression in asthma. For example, some studies seem to have overlooked the possibility that the illness for which the corticosteroid was being taken may have been responsible for the increased levels of depression, instead of the medication.
Also, it is unclear if depression related to corticosteroid use is actually a common problem. As mentioned, earlier accounts of this relationship were infrequent, and it may be that as ICS have become more potent and prescribed, the problem has increased exponentially. Another possible explanation for increased recognition of depression in persons using ICS for asthma treatment may simply be that medical practitioners have become more adept in recognising depression.
A number of researchers have suggested that a so-called 'feedback loop' may exist between asthma and depression [ 42 , 45 ]. Lehrer et al [ 42 ] noted that negative emotion such as depression often experienced by people with asthma may be as much a result of having asthma, as it is a cause of it, and that this bidirectional association may lead to a continual cycle of asthma and depression, resulting in ever-worsening physical and mental health.
DiMatteo et al [ 50 ] noted the possibility that non-compliance with medical treatment might also be a component in this cycle.
As discussed above, the coexistence of asthma and depression has been linked to a number of negative effects on both the physical and mental health of the individual. These adverse effects have led several researchers to propose that the most successful treatment is likely to require an integrated treatment approach, using interventions to address the physical, psychological, and social consequences of asthma [ 45 , 60 ].
One suggested treatment combination has been to treat depression and asthma together using antidepressants with anticholinergic properties, such as tricyclic antidepressant medication [ 4 , 45 , 60 ]. However, some who have advocated the use of antidepressant medications have also warned that antidepressants alone may not be the entire answer for a chronic disease such as asthma, because people with asthma need to be able to "successfully grieve over physical losses, combat changes in self-esteem, and overcome the social isolation that illness can cause" [[ 60 ], p.
For these reasons, counselling and psychosocial aspects in treatment are likely to have a very important role in successful asthma treatment, and cognitive-behavioural therapy CBT and group and individual counselling are already being combined with asthma self-management information to try to improve health outcomes for asthma sufferers [ 61 ].
It is hoped that by treating depression in asthma, the negative effects of this coexistence can be minimised [ 33 , 51 ]. While treating depression may increase adherence and lead to more effective asthma self-management, decrease asthma symptoms, and possibly even decrease asthma-related mortality [ 11 , 44 , 61 — 63 ], at a minimum, treating depression is likely to dramatically improve the HRQOL of individuals with asthma [ 64 ]. To date, only one study is believed to have examined the impact of treating depression in asthma.
Grover et al [ 65 ] recruited a sample of 10 asthma out-patients, with participants sequentially allotted to either the experimental group CBT and standard pharmacotherapy for asthma or control group standard pharmacotherapy only.
CBT in the experimental group consisted of 15 individual sessions involving asthma education, muscle relaxation techniques, behavioural techniques, cognitive restructuring, and coping skills. Following the full course of therapy and medication, the experimental group had significant decreases in asthma symptoms, anxiety, and depression measured by the Beck Depression Index , and a significant increase in quality of life, while the control group did not show any significant changes.
Although these results are promising, further investigation into the effects of employing combined treatment approaches is obviously necessary. A number of problematic methodological issues were observed in the studies examined in this review, many of which limited interpretations of the findings.
Firstly, the majority of the reviewed studies were cross-sectional and retrospective in design, meaning that neither directionality nor causality could be reliably inferred from the results [ 22 , 28 , 37 , 42 , 50 , 66 ]. Instead, many researchers hypothesised causality and relationship direction in their own findings based on the conclusions of other studies. The different measurement instruments used and names given to the constructs of depression examined in the studies, 'depression', 'depressive symptoms', 'major depression', 'a syndrome resembling major depression', etc also made it difficult both to understand what was actually being measured and investigated, and to compare results and interpretations between studies.
Comparatively few studies used standardised diagnostic instruments such as the DSM and SCID, or standardised clinical rating scales such as the Hamilton Rating Scale for Depression, the consistent use of which would make interpretation and cross-study comparisons more straightforward.
The problems of unclear definitions of depression and lack of standardised assessment measures were also noted by Rodin and Voshart [cited in [ 67 ]] as issues hindering progress on research in the medically ill. Because asthma and depression share a number of symptoms, there is also potential for the use of self-report measures in studies to result in inaccurate diagnoses of depression or depressive symptoms [ 23 , 37 , 68 ].
Sherwood Brown et al [ 23 ] noted that on some measures, secondary symptoms of asthma such as decreased sleep or fatigue may elevate scores on measures of depression, even if these symptoms are actually unrelated to psychological problems.
This issue will require careful selection of instruments to measure depression. Finally, most samples utilised in studies investigating asthma and depression have been drawn from in-patient or outpatient samples, with very few population or primary care studies conducted thus far.
Although these studies have been instrumental in highlighting links between asthma and depression, the generalisability of these findings to the broader asthma population is not yet well understood [ 39 ]. There are many potential research avenues to consider in regards to the coexistence of asthma and depression. Firstly, further investigation of the various links considered in this review especially those explored in studies that may have been limited by methodological issues would serve to provide a clearer understanding of the relationships between asthma and depression, and the potential repercussions of this association.
Future research should also consider 'big picture' studies, in which a number of different variables such as medication compliance, asthma self-management, quality of life, and lung function might all be examined in one investigation. These studies are likely to be particularly vital in aiding our understanding of possible 'feedback loops' of asthma and depression, more fully exploring how asthma and depression coexist, and may be valuable in determining how best to reduce or eliminate the negative effects of this coexistence.
Researchers have been suggesting for some time that the most important next step in asthma and depression research is to investigate the effects of treating the depression of persons with asthma. However, as previously mentioned, only one small study appears to have attempted this so far [ 65 ].
The most sought after knowledge, however, would result from studies using these integrated programs to actually treat the depression of individuals with asthma, and assessing the effects of this treatment on variables such as the depression itself, compliance, self-management, HRQOL, pulmonary function, asthma symptom exacerbations, overall asthma severity, and asthma-related mortality.
Large scale studies of this type would be complex to set up, expensive to carry out, and require long-term commitment to the research. Although they are most likely to be targeted toward patients already suffering from both asthma and depression, integrated treatment programs may also be valuable from a prevention focus, working to inhibit the development of depression and the negative psychological and physical health effects that may follow. Large scale, long-term research also needs to be carried out to examine this important possibility.
While a great deal of investigation still needs to be carried out, the move into this new phase of asthma and depression research has great potential to result in more effective ways of caring for people living with these coexisting illnesses, and significantly improve the lives of many individuals. Ethical clearance was not required for this literature review. You'll usually need to take 1 or 2 puffs from your inhaler in the morning and 1 or 2 puffs in the evening.
It's important to keep using your inhaler, even if you feel better. It will only stop your symptoms if it's used every day. If you forget to take a dose, take it as soon as you remember. If it's nearly time for your next dose, skip the one you missed. Accidentally taking too many puffs from a steroid inhaler is unlikely to be harmful if it's a one-off. Speak to a doctor, nurse or a pharmacist if you're worried. Using a steroid inhaler too much over a long period can increase your chances of getting side effects.
When you stop your treatment, you usually need to reduce your dose gradually. This can help avoid unpleasant side effects withdrawal symptoms , such as severe tiredness, joint pain , being sick and dizziness. Steroid inhalers usually cause few or no side effects if used correctly and at normal doses.
If you're taking a high dose for a long time, there's also a small chance you could get some of the side effects of steroid tablets , such as an increased appetite, mood changes and difficulty sleeping. You can report any suspected side effect to the Yellow Card scheme.
If you're taking a high dose for a long period of time, you may be given a steroid treatment card that explains how you can reduce the risk of side effects. Some medicines can interfere with the way steroid inhalers work, but this is uncommon if you're only taking low doses for a short period.
Tell a doctor if you take any other medicines, including herbal remedies and supplements, before starting to use a steroid inhaler. The MHRA says patients should be informed of the benefits of steroid treatment and advised of these safety issues. In , the MHRA wrote to healthcare professionals to remind them of the psychiatric side effects that can occur with systemic steroids. The Drug Safety Update also includes a reminder on the appropriate use of long-acting beta agonists.
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