Xavier Flor-Escriche1*, Roser Poblet-Cortés2, Laia Lamarca-Fornell2, Judit Mendez-Gomez2, Sílvia Álvarez-Álvarez2, Sara-Anna Davies-Daunas2, MVictoria Feijoo-Rodriguez3
1Principal investigator, Spain
2These authors contributed equally to this work,Spain
3Health technical, Spain
Received: 11 July, 2015;Accepted: 16 March, 2016;Published: 18 March, 2016
Xavier Flor Escriche, M.D. phD. Family Medicine specialist. Associate professor at Autonomous University of Barcelona (UAB), CAP Chafarinas. Street Chafarinas 2-8, CP 08033. Barcelona, Spain. Tel: 608199515/93-3542222; E-mail:
Flor-Escriche X, Poblet-Cortés R, Lamarca-Fornell L, Mendez-Gomez J, Álvarez-Álvarez S, et al. (2016) Asthma, Anxiety and Depression are they walking together? Cross-Sectional Descriptive Study. Arch Pulmonol Respir Care 2(1): 010-015.
© 2015 Flor-Escriche X, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Asthma; Anxiety; Depression; Transversal; Descriptive; Mental health
Background/Objectives: The association between asthma and mental health disorders is well known, both anxiety and depression being the most common ones. The aim is to determine the proportion of anxiety and/or depression in an asthmatic population compared to a non-asthmatic one in a Primary Care centre. Secondary objectives: Assess the association between the severity of asthma and its level of control and anxiety and/or depression.
Methods: Cross-sectional descriptive study, 317 patients diagnosed of asthma and 306 without asthma, aged between 17 to 70 years old, recruited from a primary care centre. Goldberg test was performed to detect anxiety and/or depression. Other variables analysed were: age, sex, previous diagnosis of anxiety and/or depression, associated chronic diseases, type of asthma and degree of its control.
Results: 70% of the people in the asthmatic group were women and 52% in the non-asthmatic group. The mean age was of 43 (SD 16.89) and 48 (SD 14.09) years old, respectively. 57.1% had intermittent asthma. 62.7% of asthmatics had good control. Goldberg test in the group of asthmatic patients showed 51.1% (p = 0.0001) of anxiety and 57.4% (p = 0.0001) of depression. The results were adjusted for age and sex maintaining the association between asthma and anxiety with an OR = 1.8 (95% CI: 1.3-2.6) and depression OR = 2.1 (95% CI: 1.5 to 3.0). Patients with a higher level of asthma control had less anxiety (p = 0.002) and depression (p = 0.004).
Conclusions: Asthmatic patients had more anxiety and depression. Higher asthma control was associated with less anxiety and depression.
Asthma is a chronic inflammatory disease characterized by inflammation of the airway in which there is a wide variety of stimuli that can trigger subsequent hyperresponsiveness and consequently bronchial obstruction, which leads to dyspnoea, cough and wheezing. This first definition refers to GINA 2006. Although the latest definition according to GINA 2014 is the following: Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. Is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity together with variable expiratory airflow limitation [1,2].
Asthma is a very common disease, although underdiagnosed, with wide geographical variation, being more prevalent in urban areas. According to data published by the World Health Organization (WHO), asthma could now be affecting between 100 and 150 million people, with an annual direct mortality of 2 million. The European Asthma Study , which analysed the prevalence of this disease in five Spanish provinces, including adults aged between 20 to 44 years old, showed there was a 1% rate in the province of Huelva, 1.1% in Galakao, 1.7% in Oviedo. Being Barcelona 3,5% and Albacete 4.7% the ones with higher prevalence.
Asthma is a potentially fatal disease. Though thanks to the pharmacological advances in the last two decades, amongst other factors, it has become a chronic disease where a good control allows patients to have a high quality of life. At this point, health professionals play an important role.
Moreover, the association between asthma and mental health disorders is well known. Other chronic diseases such as heart disease, hypertension or diabetes mellitus have also been related to mental health disorders during decades. Several studies have shown the relation between this respiratory disease and the presence of psychiatric commorbidity [4-15], but a few were performed in primary care . In a study carried out in Barcelona city’s primary care area [17,18], with a sample of 338 asthmatic patients older than 14 years old, it was observed that 31% of the patients were diagnosed of some kind of psychiatric disorder.
43.5% of asthmatics had a depressive disorder, and 40.6% an anxiety disorder. Somatophorm and bipolar disorders obtained lower percentages (3,9 and 0,8% respectively). Likewise, patients with severe asthma had a higher prevalence of mental health disorders (p = 0.001), more exacerbations (p = 0.005), and required more rescue medication (p = 0.053). According to these results, the quality of life of asthmatic patients seems to be related to mental health commorbidity, particularly with anxiety and depression [18,19]. For this reason we decided to perform this study. Achieving an optimal level of symptoms is considered to have a potential impact on the basic activities of daily living. Besides, there are no studies in Spain that assess this association in primary care.
The basic aim of the study was:
• To see whether the association between asthma and anxiety and/or depression exists or not.
• To assess the association between asthma severity and the presence of anxiety and / or depression.
• To assess the association between the degree of asthma control and the presence of anxiety and / or depression.
This is a cross-sectional descriptive study performed in a Barcelona city primary care centre, neighbourhoods comprising Trinitat Nova and Prosperitat. With 14,951 people assigned older than 15 years old with a socio-economic medium-low level.
The asthmatic group collects patients between 17 and 70 years old assigned to the centre and diagnosed of asthma at least one year before the beginning of the study, CIM-10 code J45 (N = 536). Patients were recruited consecutively from a list of patients with this diagnosis.
From a total of non-asthmatic patients (N = 14 415), a randomized selection was made obtaining a list of 536 patients aged between 17 and 70 years old, where those who met the inclusion and exclusion criteria were recruited consecutively.
Accepting an alpha risk of 0.05 and a beta risk below 0.2 in a bilateral contrast, 365 subjects in the first group (asthma) and 365 in the second (non-asthmatic) are needed to detect a statistically significant difference between two proportions (percentage of anxiety and / or depression), expecting it to be 30% in the asthmatic group  and 20% in the non-asthmatic group. Loss rate of follow up of 20% has been estimated. The ARACSINUS approach was used. Calculated with the Granmo program, version 6.0.
Exclusion criteria: refusal to participate, not locating the patient after 7 telephone attempts at different times, the presence of dementia, severe psychiatric disorders (such as schizophrenia, bipolar disorder…), mentally handicapped, terminal cancer, chronic obstructive pulmonary disease (COPD) and/or language barrier. In the asthmatic group: to have severe asthma diagnosis, because in most cases the follow-up is made in the hospital.
The following variables were collected for all patients included in the study:
• Smoking status: divided into three categories (smoker, non smoker and ex-smoker). For smokers was recorded the number of packets per year: continuous numeric variable. The ex-smoker category was defined as patients who had stopped smoking at least one-year prior.
• Associated chronic pathologies among the 10 most prevalent in the area according to the computer record: hypertension, diabetes, dyslipidaemia, atrial fibrillation, acute myocardial infarction, glaucoma, cataracts, osteoporosis, back pain and osteoarthritis.
• Psychiatric disorder associated: divided into three categories (anxiety, depression or both), depending on the diagnosis registered.
• Goldberg Test Scores: Anxiety and depression scales.
• Some variables were added to the asthmatic patients:
• Presence of allergic rhinitis
• Number of hospital admissions related to asthma in the past three years.
• Number of exacerbations in the past three years.
• Baseline treatment of asthma: stratified by categories (none, inhaled short-acting beta-2-adrenergic agonists, inhaled long-acting beta-2-adrenergic agonists, inhaled corticosteroids: stratified according to low, medium or high doses, oral corticosteroids, anti-leukotriens, theophylline, anticholinergics, chromones, etc.). Not mutually exclusive.
• Asthma severity: divided into three categories according to 2007 GINAS’s guidelines (intermittent, mild persistent and moderate persistent asthma).
• Degree of asthma control: divided into three categories according to 2007 GINA’s guidelines (controlled, partly controlled or uncontrolled).
In order to assess the possible relationship between asthma and anxiety and / or depression, the Goldberg test (Spanish version) was performed [20-22]. It is an anxiety and depression screening test. It consists of 18 questions divided into two scales: anxiety and depression, 9 questions each. Each affirmative answer is one point. In terms of interpretation, the cut-offs are:
• Greater or equal to 4 for anxiety
• Greater or equal to 2 for depression
To homogenize the sample and facilitate the participation of patients that often do not come to the centre, the test was questioned by telephone.
Data was analysed with SPSS for Windows version 17. Quantitative variables with central tendency measurements and confidence intervals were calculated. Qualitative adjustment techniques were performed (logistic regression) for categorical variables or percentages to control possible confounders. Comparisons between qualitative variables were performed using Jhi-square test and quantitative variables by Student t test. P values ≤ 0.05 were considered statistically significant (Figure 1)
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