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Anxiety & Depression

Home Co-Morbidities Extra-Pulmonary Anxiety & Depression

Anxiety & Depression Impacts:

  • Poor asthma control
  • Impaired quality of life
  • Reduced lung function
  • Impaired functional outcomes
  • Increased healthcare utilisation

Anxiety and depression are two common mental health problems.

Anxiety involves ongoing and disproportionately strong feelings of fear, worry or stress, which can happen out of the blue or in response to particular situations or objects. It also involves avoiding situations and objects that may cause fear or worry.

Specific Types of Anxiety Disorder

Agoraphobia

Panic attacks / Panic disorder

Generalised anxiety disorder

Social phobia

Specific phobias

Depression involves ongoing feelings of sadness, emptiness or irritability. Below is an example of some symptoms associated with depression.

Depression

Both anxiety and depression impair a person’s ability to function in their lives, and are associated with various behavioural, cognitive and physiological changes. Anxiety and depression often occur together.

asthma and anxiety info-graphic on symptoms of panic attack

Symptoms of a panic attack can occur out of the blue or in response to a certain situation or object. Experiencing many panic attacks is known as panic disorder.

Prevalence

Anxiety and depression are 1.5 to 2.4 times more common in people with asthma than people without asthma (Scott et al. 2007, Strine et al. 2008). This difference is maintained across the lifespan, from childhood to older age (Meuret et al. 2006, Ng et al. 2007, Lu et al. 2012). Children and young people with asthma are also at risk of developing mental health problems in the future (Alati et al. 2005, Hasler et al. 2005).

The prevalence of anxiety and depression in people with asthma varies across settings and countries. One in three people with asthma will have an anxiety disorder at some point in their lives, most commonly panic attacks (25%) or panic disorder/agoraphobia (12%) (Weiser 2007). In the general community, 12-month prevalence of different anxiety disorders is around 4-5% and depression is 6% (Scott et al. 2007). In treatment settings, the prevalence is much higher (Valença et al. 2006).

  • Asthma
  • No asthma

Estimated prevalence of mental health problems in people with asthma in the general population. Weighted averages based on World Mental Health Survey data (Scott et al. 2007)

Across countries, estimates as high as 12.5% are seen for agoraphobia or panic disorder in South Africa and 25.5% for depression in Ukraine (Scott et al. 2007).
Anxiety Depression Prevalence

Prevalence of anxiety and depression in asthma worldwide, represented from (Scott et al. 2007)

In people with severe or uncontrolled asthma, anxiety and depression are even more common (Carvalho et al. 2007, Amelink et al. 2014, Shaw et al. 2015). In people with severe asthma, 38% report current symptoms of anxiety and 25% report depression (McDonald et al. 2019). Anxiety was 1.4 times more common in people with severe compared with non-severe asthma and depression was 3.3 times more common.
Anxiety Depression Ratio

What is the impact?

As shown below, anxiety and depression impact people with asthma and the community in many ways.

impact of anxiety and depression for people with asthma

Alongside poor asthma control, asthma and depression make a large contribution to impairments in quality of life amongst people with asthma (Sundbom et al. 2016). Anxiety and depression are associated with impaired functional outcomes and increased health care utilisation in adolescents and adults with asthma (Deshmukh et al. 2007, McCauley et al. 2007, Roy-Byrne et al. 2008, Schneider et al. 2008, Baiardini et al. 2015). Health care costs are much higher for people with comorbid asthma and mental health problems and there may be broader economic costs due to reduced productivity at work and school and premature mortality (Hutter et al. 2011, Walters et al. 2011).

People with anxiety and depression are more likely to have risk factors associated with poorer asthma outcomes. These include smoking, poor self-management, reduced treatment adherence or overuse of medication, low physical activity, fear in response to asthma symptoms, higher body mass index, lack of social support, and negative thoughts and emotions, such as hopelessness or reduced self-efficacy (belief in your ability to perform tasks) (Bender 2006, Deshmukh et al. 2007, McCauley et al. 2007, Shaw et al. 2015).  Anxiety and depression may directly impact on lung function, which may increase vulnerability to exacerbation (Han et al. 2016). This may happen through panic symptoms such as hyperventilation (Deshmukh et al. 2007) or negative emotions such as sadness (Opolski et al. 2005).

How do we assess it?

Anxiety and depression are formally diagnosed after assessing an individual’s symptoms and impairment against specified diagnostic criteria and ruling out other possible causes of symptoms, such as other mental disorders or medical conditions (World Health Organisation, APA DSM-5 2013). Relevant to asthma would be to consider hyperventilation or dysfunction breathing as an alternative or co-existing diagnosis (Australian Asthma Handbook). The figure above indicated the symptoms assessed for depression diagnosis (APA DSM-5 2013).

Subthreshold symptoms that do not meet the formal criteria for diagnosis but are distressing and cause impairment are also recognised as important.

assessing the Mental Health Severity for people with anxiety and depression

In practice, anxiety and depression are most commonly assessed through self-report questionnaires. Responses to validated questionnaires can describe symptom severity, increase the chance of detecting mental health problems, and can inform and evaluate treatment (Radhakrishna et al. 2017). Unfortunately, anxiety and depression are under-diagnosed and undertreated in people with respiratory disease.  A systematic review of asthma multidimensional assessment revealed that psychological health status was only assessed in two thirds of patients (Clark et al. 2017).

Screening for anxiety and depression in people with severe asthma is recommended and they are simple validated screening tools that can be easily implemented in the clinic.

Scales for assessing anxiety and depression

See Resources – Comorbidity Components for more information.

Hospital Anxiety & Depression Scale
Kessler Psychological Distress Scale (K10)
Other Assessment Scales
Hospital Anxiety & Depression Scale
  • The HADS is a 14 item self-administered screening tool for possible or probable anxiety and depression in non-psychiatric hospital clinics (Zigmond et al. 1983)
  • Focusses on emotional and cognitive symptoms of anxiety and depression, rather than somatic symptoms
  • Has been validated and translated into a range of languages
  • A score of > 8 in either domain indicates possible anxiety or depression.
  • For more information see Resources – Comorbidity Components
Kessler Psychological Distress Scale (K10)
  • The K10 is a 10-item self-administered questionnaire that is useful as a general indicator of psychological distress
  • The K10 is available for use on the BeyondBlue website
  • Additional information on administration and interpretation are available on the ABS website
Other Assessment Scales
  • Other validates scales include
    • Depression Anxiety Stress Scale (DASS)
    • Center for Epidemiological Studies Depression Scale (CES-D)
    • Beck Depression Inventory (BAI)
    • 3-item Mini-Social Phobia Inventory (Mini-SPIN)
    • Patient Health Questionnaire (PHQ)
  • Clinician rating scales
    • Hamilton Anxiety Rating Scale (HAM-A)
    • Hamilton Depression Rating Scale (HAM-D)

Examples of questions to ask

example question to ask people with asthma and anxiety and depression

Adapted from (NICE 2009, NICE 2013)

How do we manage it?

Mental health problems in people with asthma are undertreated (Valença et al. 2006). Recognising and treating anxiety and depression quickly aids recovery. Shown below is the range of evidence-based options to improve anxiety and depression.

managing Mental health problems in people with asthma

Psychological therapy or counselling services can be delivered face-to-face through specialist practitioners including psychologists, counsellors, social workers, psychiatrists and mental health nurses. Internet or telephone-delivered psychological therapies are also effective, either as a stand-alone service or therapist-supported service (RACGP 2015).

Some validated programs from Australia include:

  • Moodgym
  • This Way Up
  • Mindspot.

Antidepressants (e.g., selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants) help both depression and anxiety. Benzodiazepines may be useful for managing short-term crises however are not recommended for long term use due to poor long term outcomes and adverse effects (NICE 2011).

People with anxiety and depression may also find benefits in engaging in physical activity, yoga, meditation, relaxation and healthy eating.

For people in crisis or at risk of suicide, there are 24-hour crisis counselling services available over the telephone or internet. In Australia, this includes:

  • Lifeline 13 11 14
  • Suicide Call Back Service 1300 659 467

Stepped care is recommended for managing anxiety and depression (NICE 2011, Malhi et al. 2015). The individual is offered the least intensive treatment that might relieve their symptoms and treatment is advanced to the next, more intensive, step if they do not improve.

treatment solutions for people with asthma and anxiety and asthma and depression

Stepped care for anxiety and depression, adapted from (Malhi et al. 2015, NICE 2011).

Although evidence in people with severe asthma is sparse, studies show that psychological therapies, particularly cognitive behavioural therapy (CBT) and relaxation therapy, improve quality of life and asthma-specific anxiety (Yorke et al. 2007, Parry et al. 2012). Aerobic training in moderate-severe asthma and self-management education for asthma have also shown to benefit for symptoms of depression (Mancuso et al. 2010, Mendes et al. 2010)

Useful Australian resources:

  • Mental Health Online
  • BeyondBlue website
  • BeyondBlue YouTube channel
  • Black Dog Institute
  • Clinical Research Unit for Anxiety and Depression

For young people:

  • Headspace
  • Reach Out
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Click here to download a printable version of the infographic below.

Access the full suite of infographics here.

anxiety depression asthma infographic

Last Updated on September 19, 2019

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For considerations relevant to the paediatric and adolescent population, please see Alternative Diagnoses & Co-Morbidities in Paediatrics or Asthma in the Adolescent Population

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