Psychological distress and symptom-related burnout in asthma during the COVID-19 pandemic

The health, safety, and economic uncertainties posed by the coronavirus disease 2019 (COVID-19) pandemic have resulted in increased levels of psychological symptoms for populations around the world (Luo et al., 2020). However, the added stress of managing a chronic disease alongside increased vulnerability to severe COVID-19 may enhance this effect for those with underlying conditions (Alonzi et al., 2020; McElroy-Heltzel et al., 2022). For people with asthma, research has indicated that poorer perceived health, increased somatization, and experience of respiratory symptoms could underlie elevated psychological distress, and the overlap of asthma-typical symptoms with those of COVID-19 could result in additional health anxiety (Abrams et al., 2020; Philip et al., 2020). Further, although the full effect of asthma diagnosis on COVID-19 mortality risk remains to be elucidated and could depend on level of asthma control, initial Center for Disease Control (CDC) guidelines advised extra measures for people with asthma to prevent viral infection (Aveyard et al., 2021; Chung, 2021; Mena et al., 2022). While warranted to protect health, strict quarantine measures have led to elevated anxiety and depression in the general population as well as additional barriers to healthcare in those with asthma (Brooks et al., 2020). Indeed, whereas emergency department (ED) admissions for asthma symptoms were lower during the pandemic, a higher rate of transfers from the ED to intensive care for people with asthma during this time could suggest more acute illness upon admission (Nourazari et al., 2021; Sheehan et al., 2021). While the postponement of ED visits during the pandemic may have not been specific to people with asthma, disruptions in routine disease management and immediate intervention for those with asthma can result in life-threatening exacerbations, rendering people with asthma particularly susceptible to long-term consequences from such disruptions. In addition, major trigger factors of asthma exacerbations have become specifically salient during the pandemic. Respiratory infections are among the most common precipitants of a worsening of asthma (Busse et al., 2010, National Heart Lung and Blood Institute/National Asthma Education and Prevention Program, 2020). Further, psychological factors are commonly reported as triggers of asthma symptoms and high levels of psychosocial stress may induce illness exacerbation (e.g., Ritz et al., 2016; Sandberg et al., 2004). Thus, on the most general level, the challenges people with asthma have experienced during the pandemic can be understood under the umbrella of a diathesis-stress model, where the specific vulnerabilities of this chronic respiratory illness interact with the general and illness-specific stressful challenges of this extraordinary life situation to predict adverse mental and physical health outcomes.

Already before the pandemic, people with asthma were more likely to experience anxiety and depression compared to the general population (Opolski & Wilson, 2005; Ritz et al., 2013). Anxiety and depression symptoms are differentially related to physical symptom burden in asthma. Both conditions have been linked to worse asthma control and more healthcare utilization (Schneider et al., 2008), although associations are most consistent for symptoms of depression, including fatigue and low mood (Ahmedani et al., 2013; Kullowatz et al., 2007; Richardson et al., 2008). While the psychological impact of chronic illness is often conceptualized as a “bottom-up” phenomenon (i.e., somatic symptoms cause fatigue and depression), newer models based in computational psychiatry provide a framework to additionally understand psychological symptoms in chronic illness from a “top-down” perspective (Greenhouse-Tucknott et al., 2022). The metacognitive theory of dyshomeostasis (Stephan et al., 2016) posits that detection of “errors” in bodily homeostasis—called “dyshomeostasis”—induces a brain state of fatigue as an initial adaptive response as energy is diverted to regulate bodily processes. However, if dyshomeostasis persists, fatigue gives way to low allostatic self-efficacy (i.e., perceived inability to control one’s symptoms), and then to generalized low self-efficacy, hopelessness, and depression. These psychological symptoms can be expected to exacerbate the patient’s asthma and/or result in decreased motivation to attempt to control symptoms, which, if not addressed, may underlie the link between depression and reduced asthma control.

Interestingly, some studies have found increased prescriptions for inhaled and oral corticosteroids and may suggest that adherence to asthma control measures improved at the start of the COVID-19 pandemic (for a review, see Skene & Pfeffer, 2021). However, recent studies investigating self-reported asthma symptoms have shown that people with asthma more often rated their symptoms as worse since the start of the pandemic—particularly if they had contracted the virus themselves—and that this impacted their psychological well-being (Gomes et al., 2023; Muntean et al., 2023). Unfortunately, the spike in psychopathology during the COVID-19 pandemic has persisted despite the availability of vaccines and rollback of COVID-19 restrictions—an effect particularly strong in those whose physical health was impacted by COVID-19 (Daly and Robinson, 2023). Further, the high likelihood of future pandemics and the strong link between psychological symptoms and asthma control lends a particular urgency to research dedicated to understanding differences in psychological distress in those with asthma during this time (Dodds, 2019).

The current study investigated between-group differences in people with asthma and a non-asthmatic control group to improve understanding of how asthma specifically impacted various domains of psychological well-being during the pandemic. Given that the COVID-19 pandemic can be expected to pose a particular physical and mental burden to people with asthma, we proceeded with the following aims: (1) Examine various domains of psychological distress in people with asthma while controlling for the experience of COVID-related hardships and years of education, (2) determine whether such effects exist beyond general anxiety and depression, and (3) investigate whether scores of perceived COVID-19 vulnerability, experience of COVID-19 symptoms, or symptom-related worry mediate differences in different domains of distress between asthma and controls. Additionally, we sought to determine whether asthma severity and/or control would affect the levels of COVID-19-related psychological distress in asthma.

The present study examined the effect of asthma on various domains of psychological distress during the COVID-19 pandemic. Results provide novel insight into the differential psychological experience of people with asthma during the COVID-19 pandemic. As predicted, our findings indicate that a current diagnosis of asthma was associated with elevated scores in multiple domains of psychological distress, though emotional exhaustion was the only outcome that was significantly elevated compared to controls when correcting for FDR and when controlling for general anxious and depressive symptoms (Higbee et al., 2021).

Psychological burnout is a state of emotional, physical, and mental exhaustion associated with functional impairment in one’s professional and/or daily life. These feelings are thought to result from the increased energy demand of coping in high-stress environments, with emotional exhaustion thought to be the first domain of burnout to appear in response to prolonged stress (Aronsson et al., 2017). We found that asthma-typical symptom experience accounted for a significant portion of variance in elevated emotional exhaustion, and this mediating effect was particularly strong for those symptoms that overlapped with symptoms of COVID-19 (e.g., chest tightness). A prior study found that experience of respiratory symptoms was cited as a main source of pandemic-era stress for people with asthma (Philip et al., 2020), and thus the increased energy required to cope with symptom exacerbations in a pandemic setting could hasten a progression to burnout for those with asthma (Foster et al., 2017; McDonald et al., 2018). While it must be noted that asthma-typical symptoms may have also been present in individuals who did not endorse a current diagnosis of asthma, our results revealed that a diagnosis of asthma was significantly associated with more asthma-typical symptoms but not COVID illness-typical symptoms. This finding lends further validity to the self-reported diagnosis of asthma used to create our groups and increases confidence in the conclusion that elevated emotional exhaustion in the asthma group is preceded by their increased experience of asthma symptoms compared to controls.

When viewed from the perspective of the metacognitive theory of dyshomeostasis framework (Stephan et al., 2016), persistence of dyshomeostasis in the form of reduced asthma control would generalize into perceived lack of control and hopelessness—two characteristics of burnout. Most individuals in this study (60.6%) experienced more exacerbations during the COVID-19 pandemic than they had prior. As psychological triggers of asthma are common among people with asthma (Ritz et al., 2016), this theory may be particularly well suited for understanding how burnout can manifest because of low allostatic self-efficacy. Indeed, this theory would suggest that a perceived worsening of asthma symptoms will lead to chronic fatigue and negative beliefs about one’s ability to regulate their health, resulting in the general exhaustion and decreased motivation endorsed by the asthma group on the MBI-GS (e.g., “I feel tired when I get up in the morning and have to face another day”). Further, people with asthma endorsed experiencing “death of friend or family member due to COVID-19” significantly more often than controls. Although this item was not independently associated with MBI-GS scores, it must be considered that it may have contributed to allostatic low self-efficacy in this population by strengthening their belief that individuals are unable to control their physical health. When viewed through the lens of the metacognitive theory of dyshomeostasis framework, this additional blow to one’s perceived allostatic self-efficacy could hasten and/or intensify the top-down progression from fatigue to a state of psychological burnout.

While the distinction of burnout from other psychological disorders has been a topic of debate (Schonfeld et al., 2018), the results of this study suggest that domains of psychological burnout could manifest differently from depression and anxiety in people with asthma. It has been established that anxiety and depression symptoms are related to physical symptom burden in asthma, negatively affect asthma management, and—particularly in the case of depressive symptoms—decrease control of asthma symptoms. However, our results suggest a separate, previously unidentified state of “symptom burnout”—that is, exhaustion of emotional resources associated with a diagnosis of asthma and experience of asthma-related symptoms. Recognizing this source of emotional exhaustion related to asthma symptom experience could be particularly relevant to symptom-focused clinical management of asthma. However, it should be noted the cross-sectional nature of our study precludes firm conclusions about causality at this time.

Contrary to our expectations, neither worry about asthma-typical symptoms nor perceived COVID-19 vulnerability mediated the relation between asthma and emotional exhaustion. Rather than representing worry about contracting COVID-19, results suggest that the emotional exhaustion endorsed by people with asthma could result from symptom experience itself—an interpretation that would be supported by the metacognitive theory of dyshomeostasis. Indeed, a significant amount of the difference in emotional exhaustion between asthma and control groups was accounted for by experience of symptoms typical in asthma. While some people without a current asthma diagnosis may experience occasional asthma-typical symptoms, our results show that, unsurprisingly, people with asthma endorsed significantly more asthma symptoms than controls, although this difference was not seen in illness-typical symptom scores. It is important to consider that chronic dyshomeostasis may have been present for this group before the threat of COVID-19, as also suggested by a recent survey that revealed high levels of fatigue in patients seeking specialist care for asthma (Salsman et al., 2021). However, their allostatic self-efficacy may have been further challenged in the face of pandemic-related barriers and stress. Asthma management was suboptimal in the U.S. before the pandemic, particularly in populations subject to financial, geographical, or other barriers to healthcare, with studies reporting up to 80% of American asthma patients experiencing suboptimal symptom control, according to clinical standards. These rates are reflected in substantial health and economic burdens to the country (Marcus et al., 2008; Yaghoubi et al., 2019).

Thus far, the results of studies investigating pandemic-related stress effects on asthma control have been mixed. While adherence to asthma control measures seemed to improve at the start of the COVID-19 pandemic and ED admissions dropped (Nourazari et al., 2021, Skene & Pfeffer, 2021), studies of self-reported symptoms suggest that people with asthma were more likely to rate their symptoms as worse since the start of the pandemic—particularly if they had contracted the virus themselves (Gomes et al., 2023; Muntean et al., 2023). The ACT scores of most people in the asthma group indicated that their asthma was “well-controlled”. Given reports of worsened asthma symptom experience during the same period, higher scores may reflect elements of medication adherence and level of symptom-related functional impairment not captured by our COVID-19 symptom experience measure. This finding is precedented by literature indicating that while asthma medication adherence improved at the start of the pandemic, self-report surveys generally indicated that asthma symptoms increased during the pandemic (Gomes et al., 2023; Muntean et al., 2023; Skene & Pfeffor,2021). If faced with novel uncertainty, perceived vulnerability, and barriers to healthcare in a pandemic setting, the metacognitive theory of dyshomeostasis would predict that perceived symptom burden would be associated with lowered allostatic self-efficacy, fatigue, and “symptom burnout”. Results highlight the importance of self-report asthma symptom measures alongside medication adherence and disease-related functional impairment, particularly if we are to move towards a patient-centered model of care for people with asthma that considers psychological well-being an important dimension of overall health.

There are several limitations to our study that should be considered. The generalizability of our results is hindered by a self-selected sample with a higher representation of white, urban, female individuals. However, a mean age of 55.7 years was an advantage of our study, in that it represents an older adult demographic that has traditionally been underrepresented in asthma research. These patients were at risk for more severe COVID-19 symptomology, and our cross-section of psychological health 3–6 months into pandemic restrictions provided insight into potential effects of sustained versus initial, more acute stress (Teague et al., 2018). Given that our sample lacked adequate representation of those with historical barriers to asthma care (i.e., minority groups, rural populations), the barriers to care presented by the pandemic may have been novel to many participants (Forno & Celedón, 2009; Smith et al., 2009). COVID-19 disproportionately affected ethnic minorities and people living in low-SES or rural settings (Karmakar et al., 2021), and further research is needed to understand how “symptom burnout” could manifest in those who lived already with suboptimal asthma care before COVID-19 restrictions. Additionally, it is difficult to determine the specificity of the observed elevations in distress to the pandemic without a pre-COVID-19 baseline measurement, and the cross-sectional nature of the study also hinders firm conclusions about the causal nature of the relationship between the variables studied here. Finally, because of pandemic-related considerations, it was necessary to rely on self-reported asthma diagnosis and mental health conditions versus in-person medical screening. Though not ideal, self-reported diagnosis of asthma has been demonstrated to be reliable and valid by previous research, and the inclusion of a validated measure of psychopathology as a control measure (PHQ-4) makes this a more conservative approach to estimating the amount of pandemic-related distress in asthma (Iversen et al., 2007; Mirabelli et al., 2014).

In summary, this study provides novel insight into the differential nature of psychological distress experienced by people with asthma during the COVID-19 pandemic. Results contribute to our understanding of how symptom burden contributes to the psychological functioning of people with asthma, especially in a period of heightened environmental stress. People with asthma suffered from stronger anxiety, perceived stress, and burnout symptoms during the pandemic compared to controls, and emotional exhaustion symptoms of burnout remained significantly higher after controlling for general anxiety and depression symptoms. Our results also show that increased experience of symptoms present in both COVID-19 and asthma partially mediated the relationship between asthma and burnout symptoms. The mediating role of asthma/COVID-19 symptom experience may indicate that allocation of more energy toward coping with asthma symptoms in the setting of a national emergency may have resulted in higher emotional exhaustion in those with asthma. To our knowledge, this phenomenon has not yet been identified in the literature. As worry about symptoms indicating COVID-19 infection and perceived COVID-19 vulnerability did not alter the effect of asthma on emotional exhaustion, more research is needed into the generalizability of “symptom burnout” to non-pandemic settings. Substantial barriers to care exist for many populations outside of a pandemic, and future research could provide insight into how experience of symptoms, while lacking access to healthcare resources, could lead to emotional exhaustion. Future work could also explore the potential contribution of individual health behaviors, perceived health status, and coping styles to management of anxiety, stress, and burnout symptoms during a pandemic, as well as the relationship of fatigue to “symptom burnout”.