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Breakout 3.4 Asthma and psychological problems - Mike Thomas

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Breakout 3.4 Asthma and psychological problems - Mike Thomas …

Breakout 3.4 Asthma and psychological problems - Mike Thomas
Professor of Primary Care Research, University of Southampton
Chief Medical Advisor, Asthma UK
Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013,
Guoman Tower Hotel, London
How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

Published in: Health & Medicine

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  • 1. Asthma andpsychologicalproblemsMike ThomasProfessor of Primary Care Research,University of SouthamptonChief Medical Advisor, Asthma UKThomas M, Bruton A, Moffat M, Cleland J.Asthma and psychological dysfunction.Prim Care Respir J. 2011 Sep;20(3):250-6. 2 1
  • 2. Why should we be interested?• Asthma Outcomes are sub- optimal and unequal• In 2008, 57% of asthmatics had ‘not well controlled’ asthma (ACT<20), with no improvement since 2006)• Asthma mortality and admission rates have not improved since millenium 3 Key questions 1. Are anxiety and depression more common in people with asthma 2. Is asthma control worse in those with co-morbidity? 3. Which direction is the relationship? 4. What’s the mechanism? 5. Does treatment help asthma control? 6. What treatments can we use? 4 2
  • 3. 1. Anxiety and Depression are common on asthma • Numerous cross-sectional surveys using different methods show anxiety (and depression) are more common in adults and children with asthma – Prevalence 16 - >50% depending on definitions/ instruments (questionnaires, interviews etc) – Up to 6 times higher than national rates – Particularly in ‘difficult to treat’ asthma (ITU etc) • Serious disorders (panic, severe anxiety, severe depression) higher. Particularly in ‘difficult asthma’ clinics • UNDIAGNOSED in the majority (20% on Rx in one study) – Lavoie et al Chest 2006;130(4):1039-47 – Goodwin et al. Arch Gen Psychiatry 2003;60:1125-30 5 – Oraka Eet al. Chest2010;137(3):609-16. 2. Anxiety and Depression are associated with poor outcomes• Surveys consistently show poor asthma outcomes in patients with anxiety and depression – Worse symptoms, greater QOL impairment – More medical contacts, rescue medication use – Greater perception of breathlessness – More attacks, hospitalisation, death• Relationship is independent of potential confounders – Age, sex, asthma treatment, deprivation, smoking• In a regression model, psychiatric co-morbidity accounted for 30% of the variance in Asthma Control Questionnaire score• ten Brinke et al Am J Respir Crit Care Med 2001;163:1093-6. 6• Rimington ey al Thorax 2001;56:266-71. 3
  • 4. 3. Which direction is therelationship?• Does having asthma predispose to psychological dysfunction or do psychological problems predispose to asthma?• Swiss Longitudinal study – Asthma at baseline predicted new panic/anxiety (OR 4.5) – Anxiety at baseline predicted new asthma (OR 6.3)• US population study: Anxiety predicted asthma, even in those without baseline respiratory symptoms• Paediatric UK cohort study: asthma predicted behavioral problems, behavioral problems predicted asthma – Hasler et al. Am J Respir Crit Care Med 2005;171(11):1224-30) – Jonas et al. J Appl Biobeh Res 1999;4:91-119. – Calam et al. Am J Respir Crit Care Med 2005;171:323-7. 74. What’s the mechanism• Mechanism not clear- several possible explanations – Effects on behavior: • poor self management, over-use of rescue medication, poor adherence, smoking – Hyperventilation/ VCD/ Dysfunctional breathing – Altered symptom perception – Biological effects of stress – Other unidentified genetic or environmental factor… 8 4
  • 5. 5. Can treating anxiety anddepression improve asthma control?• Literature scanty and inconclusive• Extraordinarily little studied!• Cochrane reviews of psychological interventions in adults (20090 and children (2009): – Studies too small and diverse to say – Some suggestions of improvements (e.g. CBT, relaxation, biofeedback) and Psychological support in high-risk groups 96. What types of psychologicalintervention could help?• ? Medication: V little evidence – Brown el al. A randomized trial of citalopram versus placebo in outpatients with asthma and major depressive. Biol Psychiatry 2005;58:865-70• Co-consultation with ‘liaison psychiatrist’, family therapist• Non-drug treatments: issues of access and availbility – CBT – Psychotherapy, of various types, NLP – Physical exercise programmes – Mindfulness-based stress reduction – Breathing exercises 10 5
  • 6. For discussion:Should we be screening foranxiety/depression?How?In whom?How should we react when we find it? 6