Depression Alters Asthma Interventions and Quality of Life in Urban Teens

Depressive symptoms can affect the way teens with asthma respond to interventions that are aimed at improving their asthma control and quality of life. Depression can modify the degree of improvement in emotional quality of life in response to specific interventions being done in the school setting for urban teens with asthma.

By screening for depressive symptoms in their adolescent patients, physicians can help identify and provide specific interventions for their patients. Primary care physicians can take the lead in helping address these additional comorbidities, such as depression, in their patients with asthma.

My colleagues and I discussed the effects of depressive symptoms on asthma interventions for urban teens in a recent study in the Annals of Allergy, Asthma & Immunology.

Depression as Comorbidity in Asthma
Depression has been shown to be a significant comorbidity in patients with chronic respiratory illnesses and in urban teens with asthma.^1-3 Many previous cross-sectional, community-based, epidemiological studies have highlighted the relationship between depressive symptoms and increased frequency of asthma symptoms and health care utilization rates.⁴ Also, young children with asthma whose parents are depressed are known to have higher rates of emergency department visits and health care utilization.⁵

The prevalence of depressive symptoms in our study of teenagers with asthma (Puff City II) was similar to the state of Michigan’s reported overall prevalence of depression of 27.4% for all persons in this age-group.⁶ This implies that 1 in 4 teens reports depressive symptoms, and this can have a significant impact on their quality of life. The added morbidity of a chronic illness such as asthma in these teens can add to these symptoms.

The rates of adherence to medication and treatment plans have been shown to be lower in depressed teens with asthma.⁷ Therefore, depression can have a significant impact on asthma symptoms and health care utilization rates.

Physiological measures of lung function alone may not be true indicators of functional status. Therefore, a better understanding of asthma and its associated comorbidities may help lessen the impact of the disease on patients’ lives. By addressing these aspects together, physicians can strive to develop disease management strategies that also will affect quality of life positively.

Asthma symptoms may disrupt daily activities, social interactions, and family functioning and this, in turn, affects the quality of life of urban teens. Research into the biological mechanisms of asthma and depression show that these two diseases both are associated with increased proinflammatory mediators. Interventions that target asthma symptoms alone may not be adequate to improve quality of life. Addressing these comorbidities may further enhance the effect of these interventions.

Self-Management Programs
We analyzed data from a randomized controlled trial of a Web-based, tailored asthma management intervention for urban teens to determine whether depression modulates intervention effectiveness for asthma control and quality of life outcomes. Using logistic regression analysis, we found that a lower percentage of treatment students had indicators of uncontrolled asthma compared with controls. However, for teens depressed at baseline, quality of life scores at follow-up were significantly higher in the treatment group than in the controls.

Several self-management programs have been developed for asthma and other chronic illnesses.^8-13 These measures have been reported to be effective in both school and home settings. They can help patients take ownership of their disease and participate more actively in their disease management. These are structured programs that are targeted toward providing patients with information about their illness, its causes, and its management. They also help promote the learning of coping skills, which helps reduce the psychosocial impact of the illness on the child and the entire family.

In a systematic review and meta-analysis of all self-management studies done in children and adolescents with asthma, educational programs were associated with modest to moderate improvement in lung function, self-efficacy, absenteeism from school, symptoms (number of days of restricted activity, nights disturbed by asthma), and number of visits to an emergency department.¹⁴ The educational programs included in this meta-analysis were diverse and targeted children, parents, or both groups.

Single-session educational programs had the greatest reductions in measures of illness and symptoms associated with asthma. Programs based on several sessions achieved the greatest improvement in children’s ability to cope with their asthma and reduced the number of emergency department visits.

By examining the impact of depressive symptoms on response to self-management interventions in urban teens with asthma, our study reports a significant difference in emotional quality of life that differed between the teens who reported depressive symptoms versus those who did not. Primary care physicians who take care of patients with various forms of chronic illnesses should recognize this interaction and help address the depressive symptoms in their patients. This may help make their disease-specific interventions more effective.

References
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10. Espinoza-Palma T, Zamorano A, Arancibia F, et al. Effectiveness of asthma education with and without a self-management plan in hospitalized children. J Asthma. 2009;46:906-910.
11. Chiang LC, Huang JL, Yeh KW, Lu CM. Effects of a self-management asthma educational program in Taiwan based on PRECEDE-PROCEED model for parents with asthmatic children. J Asthma. 2004;41:205-215.
12. George M, Campbell J, Rand C. Self-management of acute asthma among low-income urban adults. J Asthma. 2009;46:618-624.
13. Snyder SE, Winder JA, Creer TJ. Development and evaluation of an adult asthma self-management program: Wheezers Anonymous. J Asthma. 1987;24:153-158.
14. Guevara JP, Wolf FM, Grum CM, Clark NM. Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis. BMJ. 2003;326:1308-1309.