ACAAI: Asthma Linked to Depression And Smoking in Teens

PHILADELPHIA, Nov. 16 -- Teens with asthma are more likely to be depressed and to smoke than their non-asthmatic peers, according to a preliminary analysis of CDC survey data.

About 45% of adolescents with asthma reported feeling sad or hopeless during the previous year, compared with less than 30% of those without asthma (P<.05), reported Bruce G. Bender, Ph.D., of the National Jewish Medical and Research Center in Denver, at an industry-sponsored symposium held in conjunction with the American College of Asthma, Allergy & Immunology meeting here.

Dr. Bender and colleagues analyzed data from the CDC's 2005 Youth Risk Behavior Survey, which includes U.S. students from ninth through 12^th grade. The survey results were released in June. The current analysis, not yet published, is the first to mine the data for information about links between asthma, depression, and risky health behavior, Dr. Bender said.

About 17% of asthmatic teens reported smoking during the preceding month, compared with about 14% of those without asthma (P<.05), the analysis found. This finding is "startling," Dr. Bender said, "because smoking is one of the worst things that kids with asthma can be doing."

Clinicians have speculated that the stigma of having a chronic disease may increase depression risk for teens, Dr. Bender said. Depression, in turn, may increase the odds that teens will try risky health behaviors such as smoking, he said.

The current analysis identified additional depression indicators for asthmatic teens: During the 12 months preceding the survey, asthmatic teens were significantly more likely than their peers to have considered suicide (nearly 30% versus about 17%), to have made a suicide plan (about 25% versus about 15%), and to have attempted suicide (about 15% versus about 10%; P<.05 for all three), Dr. Bender reported.

The study also found that asthmatic teens with depression were more than twice as likely to smoke, about 74% more likely to use marijuana, nearly 50% more likely to binge drink, and nearly 60% more likely to use cocaine than their healthy counterparts (P<.05 for all), Dr. Bender said.

Depression is also a risk factor for non-adherence to medication, Dr. Bender noted. In general, depressed patients (not just asthmatics) are three times more likely to be non-adherent than patients without depression, according to a study recently published in Archives of Internal Medicine, he said.

"So depression should be a red flag to all of us," Dr. Bender cautioned.

Adolescents with asthma should be routinely screened for depression and referred to a mental health care specialist if necessary, he advised.

Furthermore, Dr. Bender said that doctors and parents of teens with asthma should be especially vigilant about compliance with medication. "Teenagers will often tell their parents they took their medicine, even when they didn't," he said.

Adherence In Adults

For adults with asthma, two other determinants of adherence to medication are one's ethnicity and one's "attitude," said Andrea J. Apter, M.D., of the University of Pennsylvania here, a second speaker at the symposium.

Dr. Apter defined "attitude" as belief in the effectiveness of one's medication and freedom from unwarranted fear about its side effects. For example, some asthma patients mistakenly believe that inhaled corticosteroids can cause cancer or can become addictive, she said.

In a study published in the Journal of Allergy and Clinical Immunology in 2003, Dr. Apter and colleagues found that patients with a positive attitude were about 20% more likely to be adherent to their asthma medication (odds ratio=1.21; 95% confidence interval=1.07 to 1.37; P=.002), she said.

In addition, the study found that African Americans were 65% less likely to be adherent to asthma medication (OR=0.35; 95% CI=0.13 to 0.95; P=.04), she reported. One reason for the racial difference may be poor patient-physician interaction, she said. A recent survey of physicians, published in Social Science & Medicine, found that doctors consistently perceived African American patients to be less pleasant, less educated, and less intelligent than whites, she noted.

Physicians need to be more aware of racial bias that may affect interactions with their patients, Dr. Apter said. Such stereotyping may be exacerbated when time pressure is high and the patient's needs are complex, she added.

To improve patient attitude, physicians should assess patients' health beliefs and take the time to correct any misperceptions, such as the idea that inhaled corticosteroids are carcinogenic, she said.

Asthma in the ER

Emergency room doctors may need to be especially aware of Dr. Apter's advice, as significant numbers of asthma patients bypass their primary care physician and go straight to the emergency room for asthma problems, said Rita K. Cydulka, M.D., of Case Western Reserve University in Cleveland. Dr. Cydulka was the third and final symposium speaker.

In 2000, there were 1.8 million emergency room visits for asthma in the United States, according to the U.S. National Health Interview Study, 1997-1999, said Dr. Cydulka.

Lack of health insurance or access to a primary care physician may not be the only reasons asthmatic patients visit the emergency room, she said. A recent study found that just one third of emergency room patients (33%) lacked insurance. Furthermore, more than half of emergency room patients (65%) could provide their primary care physician's name and phone number, the study found.

According to her own experience as an emergency room physician, Dr. Cydulka said that patients suffering from asthma symptoms likely to go straight to the emergency room because they feel they are experiencing an immediate medical emergency. They don't want to wait a week or perhaps two to see their primary care doctor, she said.

In addition, if asthma symptoms strike on an evening or a weekend, one's primary care physician is probably not available, she added.

Because emergency rooms end up being a significant source of asthma care for many patients, emergency room doctors should try to be more vigilant about making sure patients with asthma have current prescriptions for appropriate medications, rather than leaving this task to the primary care physician, Dr. Cydulka said.

The symposium was supported by a grant from AstraZeneca.