There is limited evidence-based literature on mental and emotional health in people with severe asthma specifically. However, there is growing awareness of a link between mental health, the course of asthma, and the outcomes of asthma treatment. It is not uncommon for people with chronic illness to develop feelings of depression and anxiety, and panic disorder. Although the relationship is not completely understood, it is clear that anxiety and depression can negatively affect the course of asthma, resulting in increased symptoms, increased use of health care services, and frequent asthma attacks / exacerbations. Having a potentially life-threatening disease such as severe asthma also increases anxiety and depression in many patients and may trigger panic attacks in some. In addition, people with depression and anxiety are often physically and emotionally drained, which may limit their ability to self-manage their asthma. For more information about asthma and mental health see Anxiety & Depression for detailed assessment / treatment recommendations.
Severe Asthma and Mental Health
“I was annoyed with myself, because I was so out of breath…I felt a little bit isolated….I was frustrated with myself, because I wasn’t keeping up”
Video provided by Associate Professor Lorraine Smith and Ms. Daniela Eassey, University of Sydney.
Steroid treatment and mental health
People with severe steroid-dependent asthma have significantly more anxiety and depression symptoms than people with non-steroid dependent severe asthma or mild-moderate asthma. A recent study found 3.5 times higher depression symptoms and 2 times higher anxiety symptoms in individuals with steroid-dependent severe asthma compared to non-steroid dependent people (Amelink et al. 2014). For more information see Preventers/Controllers
This relationship is thought to be bi-directional – whereby the use of oral corticosteroids leads to higher levels of anxiety and depression, while the underlying psychopathology reduces asthma control and increases the requirement for steroid treatment. Therefore, people with steroid-dependent asthma are likely to benefit most from psychological-based interventions that also address asthma control. It is important to consider potential effects of corticosteroids on mental health when prescribing, monitoring treatment response or assessing adherence, especially during asthma exacerbations.
Anxiety and asthma
Asthma can be distressing, and for those with severe asthma, it poses a persistent threat to life. Anxiety causes worry and stress, along with physical symptoms that can cause further anxiety and panic attacks. The relationship between asthma and anxiety is complicated and should not be assessed and managed in isolation. For more information see Anxiety & Depression
It is not clear why anxiety increases asthma symptoms, but the most likely reasons include:
Hyperventilation
Anxiety changes breathing habits. Many studies have shown that hyperventilation, whether it’s caused by a disorder (like anxiety) or no disorder at all, appears to increase the likelihood of an asthma attack. So those with anxiety that may be more prone to hyperventilating may be unintentionally forcing their own attack symptoms.
Inflammation
Stress can lead to inflammation. Asthma is the inflammation of airways. It’s unlikely that stress causes the inflammation that leads to asthma, but it’s possible that stress makes it harder to control inflammation when your asthma symptoms are acting up.
General Physiological Changes
On a physical level, stress does cause some issues that may contribute to asthma. For example, anxiety can release an excess of histamine (the chemical that causes allergies) that can lead to asthma attacks. Stress may also weaken your immune system in such a way that you become more vulnerable to viruses and external asthma triggers.
Muscle Constriction
Muscle constriction is also very common with anxiety. Muscle constriction can lead to tighter chest and other issues that may trigger asthma.
It doesn’t appear that asthma can be caused by anxiety, but there are strong indications that anxiety can make it much worse, especially if you are living with persistent anxiety or stress.
Management strategies
Stress, anxiety, and depression are likely to interrupt a person’s regular asthma self-management routines and increase the risk of an exacerbation. However, very few studies have examined the benefit of psychological-based interventions for people with severe asthma. Preliminary findings from a qualitative study into Australian’s experiences of living with severe asthma suggest that most participants stressed the importance of adherence to medications, and fear of the unpredictable nature of their condition seems to drive taking their medication.
There is general support for the use of psychological therapies, including relaxation and breathing techniques, to complement pharmacological therapy. Benefit is demonstrated in some clinical trials, but the evidence is not consistent. Despite this weak evidence base, the rationale for psychological therapies is plausible but further robust studies are needed.
One promising therapy is Cognitive Behavioural Therapy (CBT); a talking therapy that aims to help people recognise how their behaviour affects their thoughts and feelings. However, a recent Cochrane systematic review on CBT was not able to produce recommendations for clinical practice, due to low quality of included trial. Only one trial specifically focused on CBT for people with severe asthma (Yorke et al. 2017). This trial included small patient groups and reported high attrition. It was designed to assess the feasibility and acceptability of CBT for people with severe asthma and was not powered to detect effectiveness.
Useful additional readings and links:
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