Vol. 12 •Issue 7 • Page 26
The Asthma Blues
Patients at Risk for Developing Depression
More than 60 years ago, researchers hypothesized that children with asthma substitute wheezing for crying because they fear the latter will result in a loss of their mother’s love.1 Treatment required a visit to a Freudian psychotherapist who focused on patients’ unconscious minds.
In the second half of the 20th century, medical, immunological and pharmacological research dispelled that notion, and pharmaceutical research has revolutionized the treatment of asthma. But at the same time, there has been a significant reduction in psychologically based asthma research.
One issue that begs further study is the relationship between asthma and depression. Some research indicates that such comorbidity may be as high as 50 percent.2
Asthma patients’ daily experiences of living with an uncontrolled chronic disease may contribute to the development of depression. For example, missing school or work or waking up in the middle of the night with an acute asthma episode can lead to considerable learned helplessness.
In addition, people with asthma may have a negative self-focusing style whereby they react to acute asthma episodes by blaming themselves.3 Such behavior can negatively affect self-efficacy, problem-solving skills and family interactions.4
Self-efficacy is defined as a person’s perceived ability to accomplish a task; a depressed individual may believe that he can’t successfully perform any task. Self-efficacy in asthma can be defined as one’s perceived ability to accomplish self-management behaviors, such as taking prescribed medication, removing triggers and practicing stress management techniques.
Intervention programs
Intervention research suggests that enrollment of asthma patients (either with or without depression) into multiple week intervention programs that combine traditional pharmacological treatment with cognitive-behavioral treatment may lead to strong self-efficacy. These types of programs have been developed in both the United States and in other countries.
One American research team designed a seven-week, self-management program for groups of about 15 adults with asthma.5 The content was based on symptoms, medications and problem solving. There were substantial increases in self-management skills and cognitive measures, and significant decreases in symptoms and hospitalization.
Another team designed an eight-week classroom intervention for groups of 20 individuals.6 The content focused on stress management and traditional asthma topics, such as basic pathophysiology and medication management. The researchers noted high patient satisfaction, significant increases in asthma knowledge, self-efficacy and quality of life, and decreases in hospitalization and urgent care visits.
In a study with preschool children with asthma and their caregivers, investigators combined education focused on traditional content (e.g., medical management, triggers) with complementary behavioral change techniques (e.g., hypnosis, storytelling, relaxation).7 The structure included seven sessions taught by a variety of teachers, including a psychologist, pediatrician, pharmacist, allergist and nurse. In the 12 months following the program, there were fewer office visits, decreases in self-rated disease severity and increases in parent/child self-confidence.
Results in other countries have been similar to outcomes in the United States. In a six-month asthma intervention in Venezuela, children attended workshops focused on relaxation, imagery and self-esteem.8 The researchers found a sizeable increase in lung function and significant decreases in acute asthma episodes and bronchodilator use.
Investigators in Italy examined a treatment approach where pharmacological education was added to a family intervention.9 The research design included one group of children who received medications while a second group received medications and then had several psychotherapy sessions with the family. The content for the psychotherapy session focused on problem solving and family cohesion. The second group had better outcomes, including fewer asthma attacks, fewer hospitalizations, less overprotectiveness, and more conflict discussion and resolution.
PATIENT-CENTERED COMMUNICATION
When a health care professional (HCP) interacts with asthma patients, effective communication is essential in treating their physical and psychological state. However, in most situations the exchange of information between the patient and an HCP is didactic and based on the HCP asking questions regarding health status.
Such an approach may not optimize patient self-efficacy and locus of control. A HCP who communicates in a more patient-centered manner will facilitate strong patient outcomes, both medical and psychological.
Effective communication begins with the HCP asking questions about the patient’s knowledge, emotions, beliefs, goals and .expectations.10 Humanistic communication skills that provide empathy, validation and .psychosocial support should be used in order to enhance the relationship.
In addition, effective nonverbal communication skills, such as eye contact, attentiveness and voice quality, will enhance the relationship and trust between the HCP and the patient, which in turn will lead to more self-disclosure and improved self-efficacy.
One-on-one communication between the HCP and the individual with asthma and depression is essential in achieving optimal outcomes. Collaborative decision-making can be much more effective in changing patient .behavior than direct recommendations.
In one study, 50 percent of patients were dissatisfied when physicians didn’t involve them in the decision-making process.11 The dissatisfied patients also had the lowest medication adherence in the study.
A strong support network in the outpatient setting is especially important for individuals with asthma and depression. Research indicates that a secure relationship between a child with asthma and a caregiver can lead to positive psychological outcomes for the family.12
Inner-city research has shown that non-asthmatic adult caregivers frequently have depression that can impair their ability to assist their children with asthma.2 Improving the caregiver’s knowledge base has been shown to improve the locus of control for children with asthma and increase the child’s medication adherence. Social support from others and role models can break the cycle of negative attributions.
Patients with asthma and depression frequently have high health care utilization rates and low medication adherence rates. To achieve good outcomes in this complex patient population, both the asthma and the depression must be treated appropriately.
References
1. French T, Alexander F. Psychogenic factors in bronchial asthma. Psychosomatic Medicine. 1942;236.
2. Goethe JW, Maljanian R, Wolf S, Hernandez P, Cabrera Y. The impact of depressive symptoms on the functional status of inner-city patients with asthma. Ann Allergy. 2001;87:205-10.
3. Chaney JM, Mullins LL, Uretsky DL, Pace TM, Werden D, Hartman VL. An experimental examination of learned helplessness in older adolescents and young adults with long-standing asthma. J Ped Psychol. 1999;24:259-70.
4. Abramson LY, Metalsky GI, Alloy LB. Hopelessness depression: a theory-based subtype. Psychol Rev. 1989;96:358-72.
5. Kotses H, Berstein L, Berstein D, Reynolds VC, Korbee L, Wigal JK, et al. A self-management program for adult asthma. Part I: development and evaluation. J Allergy Clin Immunol. 1995;95:529-40.
6. Lucas DO, Zimmer LO, Paul JE, Jones D, Slatko G, Liao W, Lashley J. Two-year results from the asthma self-management program: long-term impact on health care services, costs, functional status and productivity. J Asthma. 2001;38:289-97.
7. Kohen DP, Wynne E. Applying hypnosis in a preschool family asthma education program: use of storytelling, imagery, and relaxation. Amer J Clin Hypn. 1997;39:169-81.
8. Castes M, Hagel I, Palenque M, Conelones P, Corao A, Lynch NR. Immunological changes associated with clinical improvement of asthmatic children subjected to psychosocial intervention. Brain Behav Immun. 1999;3:1-13.
9. Onnis L, Di Gennaro A, Cespa G, Dentale RC, Benedetti P, Forato F, et al. Prevention of chronicity in psychosomatic illness: a systemic research study into the treatment of childhood asthma. Fam Systems & Health. 2001;19:237-50.
10. Marvel MK, Doherty WJ, Weiner EW. Medical interviewing by exemplary family physicians. J Fam Pract. 1998;47:343-8.
11. Adams RJ, Smith BJ, Ruffin RE. Patient preferences for autonomy in decision making in asthma management. Thorax. 2001;56:126-32.
12. Bleil ME, Ramesh S, Miller BD, Wood BL. The influence of parent-child relatedness on depressive symptoms in children with asthma: tests of moderator and mediator models. J Pediatr Psychol. 2000;25:481-91.
Dr. Tousman, a life-long asthmatic, is associate professor of psychology at Rockford College, Rockford, Ill., and a board member of the Association of Asthma Educators. Dr. Zeitz is director of the division of allergy, asthma and immunology at the University of Illinois College of Medicine at Rockford.
MONKEY BUSINESS
Psychology research has linked depression to learned helplessness and negative attributions. A classic series of psychology experiments termed “The Executive Monkey Studies” provided evidence for the concept of learned helplessness.1
In side-by-side cages, two monkeys received a foot shock. However, in the executive monkey’s chamber (the monkey in control) there was a lever that the monkey could move to turn off the shock for both itself and the passive monkey.
In the first phase of the experiments, it took the executive monkey 13 trials to learn how to turn off the shock. After the executive monkey learned to turn off the shock, the researchers would put a second and third executive monkey through the same procedure while keeping the same passive monkey.
The two new executive monkeys also took 13 trials to learn how to turn off the shock for both itself and the passive monkey. By the end of the experiment, the passive monkey had ulcers. The researchers hypothesized the ulcer formation was due to the lack of controllability and predictability of the electric shocks with the subsequent development of learned helplessness.
Research in psychology has shown that several poor health outcomes, including depression, occur when individuals believe that they have no ability to control or predict the outcome of negative events.
REFERENCE
1. Brady JV. Ulcers in “executive” monkeys. Scientific Amer. 1958;77:55-9.
–Stuart Tousman, PhD, and Howard J. Zeitz, MD
REVOLUTIONARY PHARMACOTHERAPY
The National Institutes of Health guidelines for asthma focus on avoidance of asthma triggers, pharmacotherapy with asthma controller medications, and effective cognitive-behavioral treatment with the possible addition of an anti-depressant.1 This approach will provide the greatest chance for a good outcome.
Biochemically, depression has been linked to low levels of serotonin. The advent of selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac®, Eli Lilly and Co.), paroxetine (Paxil®, GlaxoSmithKline) and sertraline (Zoloft®, Pfizer) has revolutionized depression pharmacotherapy in the same manner that the development of inhaled corticosteroids has revolutionized asthma pharmacotherapy.
The SSRIs are effective because they block the reuptake of serotonin at the synaptic junction in the brain, thereby increasing the amount of serotonin available in the synapse between the neurons. The increase in serotonin leads to a reduction in symptoms of depression.
Fortunately, the side effects of the SSRIs usually are quite limited, and there’s no scientific evidence that pharmacotherapy for depression exacerbates coexisting asthma.
REFERENCE
1. Schulberg HC, Katon WJ, Simon GE, Rush AJ. Best clinical practice: guidelines for managing major depression in primary medical care. J Clin Psychiatry. 1999;60 Suppl 7:19-26; discussion 27-8.
–Stuart Tousman, PhD, and Howard J. Zeitz, MD
FACT: Depression is the most commonly diagnosed mental disorder with prevalence rates of 12.7 percent for men and 21.3 percent for women, according to the Diagnostic and Statistical Manual, Version 4. Major depressive disorder is diagnosed when five or more of the following symptoms are present during a two-week period:
• depressed mood
• markedly diminished interest in activities
• significant weight loss or weight gain
• insomnia or hypersomnia
• psychomotor retardation
• fatigue
• feelings of worthlessness
• diminished ability to think or concentrate
• recurrent thoughts of death.
