AUCKLAND, NEW ZEALAND—Are anxious patients more likely to suffer severe asthma attacks? Or do asthma attacks make patients anxious? Two new studies shed light on these questions; their results suggest that the connection between mind and body in asthma patients is far from simple.

One of the studies attempted to spot psychological differences between patients with severe life-threatening asthma (SLTA) and those with moderate or mild disease.[1] It found that patients hospitalized for asthma were more likely to suffer from anxiety and depression than were community controls. Surprisingly, though, the SLTA patients were no more likely to have psychological problems than were patients hospitalized for asthma on general wards; the investigators had expected to find more serious disorders in the SLTA patients.

Another study found that anxiety and depression were more common in patients who had suffered a recent asthma attack than in those with well controlled disease.[2] But its results also suggested that how patients react psychologically to an asthma attack can help predict whether they will require emergency care for asthma in the future.

ANXIETY LINKED TO HOSPITALIZATION

The first study included three groups:

• 77 patients who were admitted to an intensive care unit (ICU) for SLTA.

• 239 patients treated for acute asthma on a general medical ward.

• 100 randomly selected community controls with asthma.

All subjects completed a detailed questionnaire on adverse psychological factors related to asthma. The questionnaire was administered by one of the investigators and included questions about anxiety, depression, social support, difficult life events, and attitudes and beliefs about asthma.

The likelihood of SLTA was found to increase with age and was lower in women than in men. Thus, all between-group comparisons were adjusted for age and sex.

Anxiety was detected in 36% of the SLTA patients and in 38% of the ward patients, but in only 28% of the community group. The three groups’ respective rates of depression were 8%, 8%, and 2%. Furthermore, patients hospitalized for asthma (on the ward or in the ICU) were more likely to have experienced an adverse life event within the past year, such as prolonged unemployment or the death or imprisonment of a close relative or friend.

There were no differences between the SLTA patients and the other hospitalized subjects in attitudes and beliefs about asthma or in the availability or quality of social support. The SLTA patients were less likely to have received previous counseling for emotional problems, however. (These areas were not included in the questionnaire given to community controls.)

Lead investigator John Kolbe, MD, Associate Professor of Medicine at the University of Auckland in New Zealand, said that these data support the conclusion that adverse psychological factors, such as anxiety, do not reliably predict the onset of SLTA but do raise the risk of hospitalization for acute asthma. He acknowledged, though, that the relationship between adverse psychological factors and asthma risk may not be causal; rather, underlying problems in patients’ lives may increase their likelihood both of having anxiety and of needing hospitalization for asthma. However, because anxiety can impair patients’ ability to make decisions, it could diminish their ability to manage their asthma and thereby contribute to increased risk, even if it is not a causal factor per se.

Clinicians should, therefore, take adverse psychological factors into account when assessing asthma patients. “We must regard all patients [with both asthma and anxiety] as a population at risk for life-threatening asthma or asthma death,” Dr. Kolbe noted. In addition, he recommended that adverse social factors be considered as well. “For example, you would not tell patients with no social support to ask someone for help during asthma attacks,” he explained.

PSYCHOLOGY OF RECENT ATTACKS

In the second study, Colin J. Greaves and coworkers measured two variables—“panic fear” and confidence about asthma control—in two groups of asthma patients: 37 subjects who had recently suffered an asthma attack and 37 matched controls with stable disease. The researchers sought to determine how these psychological variables predicted future use of emergency services for asthma. They found that the variables had diametrically opposite effects, depending on whether a patient had recently had an asthma attack, reported Mr. Greaves, a doctoral candidate in the School of Psychology at the University of Exeter in the United Kingdom.

This study, like the investigation by Kolbe et al, used a questionnaire to assess both the frequency of fear symptoms during asthma attacks (panic fear) and the patients’ degree of confidence about future asthma control. Overall, the patients with recent asthma attacks had higher panic fear scores and lower confidence scores than did the controls. They were also more likely to have been treated for depression in the past three years. During follow-up, the recent-attack group was also more likely than the control group to use emergency services for asthma.

At first, no relationship was seen between the psychological variables studied and future emergency service use. However, when the two groups of patients were analyzed separately, contrasting findings emerged:

• Among the patients with recent asthma attacks, a low level of fear or high degree of confidence predicted increased future use of emergency services.

• On the other hand, among the patients with stable asthma, increased emergency services use was linked to a high fear or low confidence level.

The researchers suggested the following explanation: In asthma patients who have recently suffered an acute attack, a low confidence and/or high fear level may be an appropriate emotional response to the attack. This type of response may increase patients’ willingness to accept advice on how to properly manage their disease, Mr. Greaves added.

In contrast, patients who respond to acute asthma attacks with a low fear and/or high confidence level may be underestimating the severity of their disease; as a result, they may not manage their asthma as well as they should, which would increase the likelihood that they would eventually need emergency treatment. “We might view these patients as being in denial about their asthma and try to get them to see that it is a problem,” Mr. Greaves suggested.

In patients with stable disease, low fear/high confidence levels would be appropriate; high fear/low confidence levels might be a warning sign of future problems.

—Timothy Begany