Dennis K. Ledford; Richard F. Lockey


Curr Opin Allergy Clin Immunol. 2013;13(1):78-86. 

In This Article

Psychological Dysfunction

Chronic disease in general is associated with psychological dysfunction, most commonly depression and anxiety.[41] Anxiety, with or without depression, is the psychological dysfunction most commonly linked to asthma.[42] Anxiety is generally defined in the clinical literature with validated questionnaires, whereas in clinical practice the definitions are usually not quantitative. Anxiety and depression are common in the general community with estimates of 9.5% of US adults having depression at any given time and over 20% with a lifetime prevalence and 18% with anxiety disorder, and 29% with a lifetime prevalence ( There is significant overlap of these two conditions such that the combined prevalence is less than the sum of the two.

Relationship With Asthma

Anxiety and/or depression and panic disorder are reported in 16–52% of the population with asthma. A World Health Organization survey of 85000 adults in 17 countries using a standardized, structured psychiatric interview with trained interviewers reported an OR of 1.6 (95% confidence interval 1.4–1.8) for depression and 1.5 (95% confidence interval 1.4–1.7) for anxiety disorders in asthma. Other studies[42] describe a stronger relationship with anxiety rather than depression, although the presence of both has the greatest effect on asthma outcomes. Studies[43,44] also suggest a relationship of attention deficit disorder with asthma in both children and adults.

Limited longitudinal studies report that anxiety and depression increase the likelihood of developing asthma, and asthma is a risk factor for developing anxiety and depression. Some studies are limited by the absence of objective measures of asthma. A community-based study[45] in Switzerland reported that asthma increased the subsequent development of panic disorder by 4.5, and panic disorder increased the subsequent onset of asthma, with an OR of 6.3. A US study[46] of 5000 adults confirmed that anxiety and depression increased the risk of developing spirometry-confirmed asthma. The bidirectional risk of asthma and psychologic dysfunction was confirmed in a meta-analysis of pediatric studies. The development of asthma is more likely with a history of behavioral problems, and the development of behavioral problems is more likely with a preceding diagnosis of asthma.[47]

Diagnostic and Therapeutic Considerations

Asthma control is negatively associated with the comorbidity of anxiety with or without depression.[48] Depression or anxiety is found in more than 50% of individuals with difficult-to-treat asthma.[49] Medication adherence or modified symptom awareness may explain the relationship. Asthma deaths show a bimodal variation with age with one peak in adolescence, and this is likely due to psychological stressors affecting medication compliance or symptom awareness during the teenage years. Asthma control is based upon lung function, measured intermittently, and symptoms, which are the most consistent factor used by patients and clinicians to adjust asthma medications and assess control. Vague asthma symptoms, such as chest tightness or breathing difficulties, are frequently reported by individuals with anxiety without asthma. The variability of lung function confounds the problem because normal lung function does not exclude asthma as being responsible for symptoms. The common association of anxiety, with or without depression, in asthma confounds the interpretation of survey data assessing the control of asthma, as these studies depend almost exclusively on patient-reported symptoms. Finally, asthma therapy may be less effective with concomitant psychologic dysfunction due to corticosteroid resistance or enhanced inflammatory cell activity.[50,51]

The recognition of depression or anxiety in individuals with asthma may not be optimal. A Canadian study[52] of asthma showed that fewer than 20% of individuals with psychiatric disease were receiving therapy and less than 15% had been evaluated by a mental health specialist.

Treatment of anxiety and depression may improve asthma. A Cochrane review in 2006 reported inconclusive improvement of asthma with cognitive behavioral modification, counseling, and relaxation therapy with or without biofeedback. Small studies[53] of panic control programs or antidepressant medication suggest beneficial effects in asthma management. Aerobic exercise training reduces stress and improves depression scores as well as increases asthma symptom-free days and improves asthma health status. Although definite recommendations cannot be offered, common sense and clinical experience indicate that reduction of anxiety and depression improve asthma outcomes either by changing the perception of symptoms, improving compliance or modifying the asthma.