Original article
Asthma, lower airway diseases
The relationship between asthma and self-reported anxiety in a predominantly healthy adult population

https://doi.org/10.1016/j.anai.2013.08.027Get rights and content

Abstract

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.

Introduction

Asthma, a chronic inflammatory lung disease characterized by reversible airflow obstruction and airway hyper-responsiveness, is increasing in prevalence worldwide. Global estimates suggest that there are approximately 300 million people with asthma,1 with an additional 100 million expected by 2025.2 From 2002 through 2007, the cost of asthma was higher than $3,000 annually per person.3 A significant portion of total expenditures has been attributed to emergency room use, hospitalization, and death.4 Appropriate control of asthma remains the highest goal,2 because good management of this disease can result in increased quality of life, decreased morbidity, and lower health care costs.5

Anxiety disorders are characterized by feelings of stress or worry about everyday events and activities. Global estimates of the current prevalence of anxiety disorders range from 5.3% to 10.4%.6 The total annual cost of anxiety disorders in 2 studies from the late 1990s was estimated to be more than $40 billion.[7], [8] Anxiety disorders have been associated with several chronic medical conditions, including coronary heart disease,9 diabetes,10 chronic obstructive pulmonary disease,11 and asthma.12 The role of anxiety disorders in these conditions, particularly asthma, remains to be fully elucidated.

Several studies involving patients with severe asthma have reported a relation between asthma and anxiety.[12], [13], [14], [15], [16] The literature on associations with asthma and anxiety in patients with milder asthma is not as robust. Two smaller studies found no significant differences in the psychological characteristics or prevalence of anxiety disorders in patients with mild asthma vs severe asthma.[17], [18] Goodwin et al12 noted lifetime nonsevere asthma to be associated with an increased odds of any anxiety disorder (odds ratio [OR] 1.51, 95% confidence interval [CI] 1.0–2.32, P < .05).12

The Cooper Clinic is a preventive medical center in Dallas, Texas, which presents an opportunity to investigate a population of predominantly healthy individuals who extensively report their medical history and undergo screening pulmonary function testing. Using this cohort, the authors sought to evaluate the relation between less severe asthma and anxiety.

Section snippets

Methods

From March 2000 through January 2013, 15,675 generally healthy adult patients were seen at the Cooper Clinic for preventive medical examinations that included an extensive medical history, physician-based physical examination, laboratory testing, and spirometry. Participants gave informed consent for the use of their data in the Cooper Center Longitudinal Study database maintained by the Cooper Institute and approved by the institute's institutional review board.

Results

Of 15,675 patients, 1,403 (9%) had an asthma diagnosis. Participant characteristics are listed in Table 1 for those with and without asthma. In general, patients at the Cooper Clinic composed a predominantly male, white, well-educated, nonsmoking patient population. Patients with asthma were slightly younger (P = .002), reported lower self-reported health ratings (P < .001), and had higher body mass indices (P = .036). They more often listed ICS or ICS/LABA use (P < .001) and had evidence of

Discussion

This study shows a significant association between asthma and anxiety in adults, most of whom appeared to have relatively mild asthma. In the present sample, 9% of patients screened had asthma, which approaches the rates of asthma in adults in the United States.1 However, owing to the preventive nature of the present sample, disease prevalence is likely underestimated. This study had several strengths, including a large sample and use of a control group. It measured a wide range of asthma

Acknowledgments

The authors thank the Cooper Clinic for data collection and the Cooper Institute for data management.

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    Disclosures: Dr Khan has served as speaker for Merck, Genentech, Baxter, and ViroPharma and received research funds from the Vanberg Family Fund. Dr. Brown has received research funds from Sunovion and Forest.

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