Depression and Anxiety in Patients with Asthma (Recording)

This webinar was recorded on February 19, 2026

Depression and anxiety are common in patients with asthma and are frequently overlooked contributors to poor disease control, reduced treatment adherence, and diminished quality of life. Emerging evidence highlights the complex interactions between behavioral health, immune function, and respiratory disease.

In this engaging webinar, we will delve into current evidence on the mind and its effect on the immune system, look at the association between asthma and behavioral health issues, understand that the presence of anxiety and depression in asthma is associated with negative asthma outcomes, and recognize that anxiety, depression, and asthma can be treated.

Speaker:

Todd A. Mahr, M.D., FAAP, FACAAI, FAAAAI

Todd Mahr, MD, practices Allergy/Immunology at Emplify Health by Gundersen in La Crosse, Wisconsin. He is also an adjunct clinical professor of pediatrics at the University of Wisconsin School of Medicine and Public Health in Madison.

Dr. Mahr belongs to numerous allergy societies, served on the Board of Regents of the American College of Allergy, Asthma & Immunology (ACAAI), and has received their Distinguished Service Award in 2008 and the Distinguished Fellow Award in 2014. He was President in 2018-2019 and currently serves as the Executive Medical Director of the ACAAI. He is chair emeritus of the Centers for Disease Control and Prevention-funded Wisconsin Asthma Coalition and a PI for the NIH “All of Us” research program. He is very active with the American Lung Association on a national, regional, and local level. Dr. Mahr is the recipient of the ALA’s Volunteer of the Year award for the year 2000 and the 2007 Wisconsin Department of Health and Family Services “Partners in Public Health” certificate of recognition. Dr. Mahr is the current Chair of the Partnership for a Tobacco Free Wisconsin. Dr. Mahr is also very engaged with the American Academy of Pediatrics, having served on PREP, the NCE Planning Group, as PPC Chair, and on the SOAI Executive Committee and Chair, as well as being a recipient of the CATCH planning and implementation grant. Dr Mahr has been active in the local mental health awareness community with his wife and son for the past 17 years in memory of his daughter Kaitlin, who suffered from depression and bipolar disorder. He helped co-create “Kaitlin’s Table” for local adolescent mental health.

This Advances webinar is in partnership with the American College of Allergy, Asthma & Immunology. ACAAI offers CMEs for physicians for this webinar. If you are a member of ACAAI, you can obtain CME through the member portal for the Advances webinars.

All attendees will be offered a certificate of attendance. No other continuing education credit is provided.

CME is available through ACAAI for this webinar.

Sponsored by the American College of Allergy, Asthma and Immunology

Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.

Ruthie: Good afternoon. Thank you, everyone, for joining us. We have a lot of people in the waiting room. I’m going to let some people file in before we get started. All right. We will kick it off. Hello, everyone. Thank you for joining us. I am the education program manager at the Allergy & Asthma Network. I’m delighted to welcome you to this afternoon’s webinar. We have a special presentation today focusing on mental health and how it plays a role in asthma management. Before we start today’s program I would like to cover a few housekeeping details. Everyone will remain on mute during the webinar to minimize any distractions. We will record the session today and uploaded to our website. You can watch all of our recorded webinars at allergyasthmanetwork.org. There will be time at the end for question and answer, so feel free to submit those through the Q&A box located at the bottom of your screen. One of our teenage — team members will be monitoring for any help you might need and we will do our best to answer questions at the end before we wrap up. This webinar is brought to you in collaboration with the American College of allergy, asthma, and immunology. College offers continuing credits for physicians and attendance credits for others. You can create a free account to earn CME or attendance credits for all of our advances webinars through their member portal. All attendees will receive a certificate of attendance. No additional continuing education credits will be provided. A few days after the webinar you will receive an email from Zoom with supplemental resources that mirror the content we talked about today, and also to download your certificate of attendance. Today’s presentation is titled ” depression and anxiety in patients with asthma.” As clinicians we know asthma management goes beyond inhalers and action plans. Mental health, particularly depression and anxiety, can significantly influence asthma control, adherence, outcomes, and our patient’s quality of life. Today’s presentation recognizes that treating asthma effectively means caring for the whole patient. With us today is Dr. Todd Mahr, an allergist and immunologist at Emplify Health by Gunderson in La Crosse, Wisconsin and serves as a clinical professor of pediatrics at the University of Wisconsin school of medicine and public health. He is the past president and current executive medical director of the American College of allergy, asthma, and immunology. He has received multiple distinguished service awards and has held leadership roles — roles with the asthma coalition, the NIH all of us research program, and the American Lung Association and American Academy of Pediatrics. In addition to his or roles Dr. Mahr has been active in the mental health awareness community with his wife and SON the past 17 years in memory of his daughter Kaitlyn, who suffered from depression and bipolar disorder. He helped co-create “Kaitlin’s Table” for local adolescent mental health locally. Thank you for being here, Dr. Mahr. I will turn it over to you.

Dr. Mahr: Thank you. I want to thank everyone for being online. We will go ahead and start here with disclosures. A sickly, I do have some conflicts here, but none of these are going to impact whatsoever on what we are going to talk about at all. That being said, here is our learning objectives. We are going to understand the association between asthma and behavioral health issues. We will talk about the presence of anxiety and asthma and how it is associated with outcomes and recognize that anxiety, depression, and asthma can be treated. That being said, I got active and more involved in this from the mental health standpoint with Kaitlin’s passing. This is a reprint from our local article, and talks about Kalin. You can look at this while I talk a little bit. Kaitlin passed away on November 19, 2000 seven. She had depression and she died of prescription drug overdose while at college. She was only 20, and this really impacted her life, to say the least. We kind of dug ourselves out from the grief and basically looked at what we could do next. In her obituary we put that Kaitlin lost her battle with depression and died of an accidental overdose. The process of doing that brought so many people out of the word work to talk to us and say, thank you for bringing this out into the light of day. It was our first step of many to help many others in telling Kaitlin’s story. And we wanted to help. I wrote a grant for a catch planning grant and an implementation grant for moving mental health out of, basically, the clinic and into the community. 

We help to support our local teen Center, getting it up and running, and Kaitlin was at launch University when she passed away. We have supported behavioral health programs there for adolescents and young adults attending college. Oakley I was involved with change direction and the national launch of that with Michelle Obama in Washington. I told Kaitlin’s story there. That led us down the path of having Kaitlin’s Table, which we have been down here locally and we support adolescent and young adult mental health. With that, that leads me into asthma. Katie did not have bad asthma. She had mild asthma. The rest of us have asthma and allergies, but overall what is health? Health is really a state of complete physical, mental, and social well-being. It is not just the absence of disease. That is the World Health Organization. You cannot obtain it by procedures. It really is an initiation and maintenance of this homeostasis that we need to look at. There are a lot of non-physical components. Our outlook on life. There is the physician-patient relationship. That is the entire health care team. And also relationships between our spirituality and health you’re going to be talking about anxiety and depression. Anxiety is characterized by his nothingness — apprehensive notes about real or perceived threats. But will not want to acquire in public. 

They will want to avoid certain instances where they might be placed into conflict. They will obtain lack of comfort by having increased heart rate and muscle tension. There is three main characteristics. There is the emotional. There is the physiologic, such as the muscle tension, the sweating, fast beating, or feeling that chest tightness that people have. And there is this impairment or cognitive. People talking — people talk about having brain fog and disordered thinking. Depression is a little more intense. Major depressive disorder is common. It is a serious mental disorder how you think, act, and feel. And how you perceive the whole world. Almost one third of all adults have been diagnosed with depression at some point in their lives. About 18% are currently experiencing depression. That is a 2023 survey. Women are more likely than men and younger adults are more likely than older adults to experience depression. What are the symptoms we see of depression? They can vary from mild to severe depression and be different in each person and in each person in stages, but generally we think of it as feeling sad, your double, empty, hopeless. Losing interest or pleasure in activities that people have enjoyed in the past. They can have a significant change in appetite. They can eat much less or more than usual. They could have weight loss or weight gain. They could sleep too little or too much. You can see it is not one thing. They generally have decreased energy or increased tiredness and fatigue. They don’t generally have increased energy and rambunctious nest. 

There is an increase in purposeless physical activity. The inability to sit still. They are going to be pacing, handwringing, or slowed movements and speech. Generally when it gets worse they get this feeling of worthlessness. Of excessive guilt. They have difficulty thinking or concentrating and have increased forgetfulness. Then, to the extreme, thoughts of death or suicidal ideation or suicide attempts can be part of depression symptoms. Where are we in Western society? The major health challenges we have here, we talk about chronic diseases. They have doubled between 1985 in 2005. Hypertension, cardiovascular disease, and allergy and asthma. But all most all chronic diseases have an inflammatory component. We are going to talk about that today. We are an increasingly obese and sedentary society, unfortunately. And there is an increasing level of societal stress. We are seeing that right now, both from the economic standpoint, the environmental standpoint, the COVID pandemic, and right now the winter with all of the COVID and flu and RSP and everything going around. And a huge philosophical adversarial stressor. Basically, we no longer agree to disagree. We take sides. That has definitely had an impact. At least here in the United States. Western medicine is increasingly technologically-driven. Psychosomatic illness is often trivialized or ignored. And we minimize the whole person and we want to treat individual systems rather than the body and mind and spirit. 

Does the mind affect our immune system is a question that has been asked for a long time. And, indeed, it does. Going forward we are going to talk about the hypothalamic -pituitary-adrenal system. This is between the pituitary gland and the organ systems that have this ender consistent feedback. That is a loop of hormones that enact and regulate your body’s stress. It is the neural ender consistent. The autonomic nervous system has two components, which is the sympathetic nervous system and the parasympathetic nervous system. The sympathetic nervous system functions like a gas pedal. It triggers flight or — fight or flight response, providing the body with energy so I can avoid and respond to perceived dangers. So, a stress response is not just an event, it is a stress response. The event is the stressor. The response is something different. Psychological response can be acute. That can be the fight or flight response. It is a combination of the HPA axis and the autonomic nervous system with rapid resolution. Usually is helpful. It is exercise. It is emotional excitement. But excessive or chronic type of stress can lead to anxiety and depression and over-worrying. This is this endocrine/immune exhaustion some people think of that is maladaptive. There is major factors that can impact us. Both impact how it presents, how strong it is, and how long it lasts. What is the outlook? Our optimism, perspective — versus pessimism. Other impacts are our social support system. Having a nuclear family, having a fraternal organization, having a community. And then our belief system, our spirituality. Personally, and we went through this in 2007 with Katie’s passing I had my family. I have four brothers. I have mom and dad. I had a very close family that helped. They also had my community and the College of allergy. I was basically coming off of being on the board from the college at the time. And I was involved in a lot of other organizations. Just seeing the support I got from those friends, which really became a strong community for me and my work here at the health system I work in. 

They gave me great assistance and help. Some people just don’t have that, and I was lucky to have it. Our neuro-immune-endocrine interactions are schematically drawn out here. And we will slip — show this in another slide better. There is the stressor and the perception of the stress, and then that pituitary, adrenal Access that kicks in. That can produce epinephrine and cortisol and norepinephrine, and in that sensory nervous system impacts on it. Cells can get stimulated through the use of cytokines and chemo kinds and cell activation. These immune cells have increased immune exhaustion and increased inflammatory response. Another way of looking at it is on this slide. You can have a short term stressor. That could be protective here. Is this vaccination? Infections could be beneficial. It could increase the effectiveness of vaccinations and wound healing and increased resistance. If it is an inky — acute stress that is more intense, there may be some harmful or pro-inflammatory or autoimmune disease that comes from that similarly with a chronic or long-term stress. That can be increased dysregulation. Type two cytokine responses. We see that. Then there is the depression that can come with this chronic stress. It suppresses leukocyte functioning and immobilizes immunosuppressive mechanisms. That can lead to decreased efficacy of vaccination, decrease wound healing, increase resistance — decrease resistance to infection and cancer, and some increase in autoimmune disease, but that is a side effect for that. I’m going to go through other slides that talk about other studies. I’m not going to get into all of the studies and what they did. I just want to kind of laid the groundwork for you of how all of this kind of works from that standpoint. In this study they investigated how anxiety and stressors might modulate skin pretty test responses. It is a study looking at a simple skin protest, which we do all the time in allergy, looking for responses in people with allergic rhinitis. They had 28 men and women with allergic rhinitis. They had skin test responses. They studied them in a crossover design and looked at the allergen panels that were assessed before and then after a social stress test. Then the next morning they look at them. They looked at the wheal diameters minus the saline pricked skin test. And they averaged them. What they found was that anxiety heightened the magnitude of the allergen-induced wheals. The diameters increased after the stressor compared to a slight decrease following the control task. And that anxiety also substantially enhanced the effects of the stress on the late phase response. Even skin tests performed the day after the stressor reflected the continued impact of that speech stressor used to make those people anxious. A very interesting study looking at what effect that can have. Can stress worsen existing mast cells? 

There has been studies out there. This is titled the psychological distress and maladaptive coping styles in patients with severe versus moderate asthma. They looked at 84 patients. Half of them are women, about age 80 — 846 on average. About half were severe. They looked at this using the American thoracic Society criteria. They did reviews and behavioral medicine diagnostic that looked at stress and coping factors and all that stuff. Not meant to be looked at intensely, but what you can see is highlighted those who had a positive value — P value. The second column is moderate asthma, and you can see they showed a significant difference in the severe versus moderate in anxiety and tension, cognitive dysfunction, in illness apprehension and pain sensitivity, and future pessimism from the skill they used. In spiritual absence, went down, and interventional fragility. And they found behavioral coping styles that these patients with severe asthma had a significantly-greater functional deficit and problematic compliance. Intriguing that both sets of patients had asthma, but the severity versus moderate, there were differences. We know that Ace’s and chronic and toxic stress play a role. Cortisol is increased. There is a Th1/Th2 imbalance. There is alteration in Google corduroy receptor expression, and that can lead to an altered response to inhaled steroids or anti-inflammatory agents and an auto response to Ronco dilator agents. — bronchodilator agents. We look to bring-drive neurotrophic factor levels in patients who had asthma. Levels are positively associated with both depressive symptoms and asthma severity in patients with asthma. This was published just last year. They have speculated these findings suggested that the mechanisms underlying depressive symptoms in patients with asthma may differ from those of major depression, in the effect of this — in respect to the serum brain-derived neurotrophic factor. They suggest that biological mechanisms underlying depressive symptoms and asthma may be different than those in major depressive disorder. So, it may not all be the same thing. In another study in 2018 they look that allergic disorders and a risk of depression. This was a large meta-analysis of 51 studies. 

They reviewed all of them and did a forced plot. The conclusion was that the result of the study showed allergic disorders significantly increase the risk of depression. Patients with allergic disorders are 1.5 times more likely to have a comorbidity of depression compared to controls without allergic disorders. All of these are individual studies and those to the right were more likely to show there was an influence on it. The association between asthma and depression is well described, but we are just beginning to understand a little bit. Another study, they showed that one third of the adults diagnosed with asthma also experienced signs of depression. The presence was linked with adverse outcomes, which was manifested with increased visits to ED and urgent care facilities. In a world health survey they reported that the occurrence of depression associated with asthma can exceed 50%. As clinicians and health care providers, we need to be aware of this when we are talking with our patients with asthma. There was a report from cross-sectional data that linked depression but not anxiety with a reduced bronchodilator response in adults with asthma. Which is what we just talked about. A few more studies. This is a comprehensive review of the intersection between asthma and depression that was published a couple of years ago. This was a rigorous pub med search. Papers were screened by the authors, and what they found was that there was a correlation between the conditions. They presented a preclinical and clinical research data and the evidence presented supports the existence of a correlation between asthma and depression. But I cannot — by acknowledging these shared trends we can formulate more efficacious strategies for addressing the dual-impact of asthma and depression. So again, leading us down that path that we need to be thinking about this when we are seeing patients and treating patients. This was another recent study just last year that looked at 31,000 participants. About 17,000 from the English equivalent. This is observational research. 

Patients who had depression had a significant increase in the risk of asthma in comparison to participants without depression. These further substantiate that genetically-predicted causality of depression on asthma, while the reverse causality does not stand. So, asthma doesn’t really cause depression. These findings indicate that depression make play a contributory role in the development of asthma, underscoring the potential benefit of unflinching prevention strategies in mitigating — implementing prevention steady gait — strategies in mitigating risk. This is a study that basically looked at using the all of us research program. I have a vested interest in this. I am one of the PI’s on this in Wisconsin. It is a large database that was set up to try to get one million people to lender their EMR data and do some baseline history and intake through questionnaires, and then give samples for genome analysis. They looked at a section of these, and they had 88,000 patients with asthma and about 450,000 controls. They had 400 12 — 412,000 with depression and 1.5 million controls in this cross-sectional analysis. They looked at the disposition and showed it added to asthma comorbidity through pathogenic processes. They developed a — developed targeted interventions. So, something again we should be on the lookout for. So, what do we know about it and what are we doing about it? Well, there has been some publications out there. This was published in 2019 and 2020 with an editorial, looking at the comorbidity of asthma and depression. It is not a product of vulnerable personality. It is something you should be aware of. What they looked at was the prevalence of multiple morbidities increasing significantly from 1985 to 2005, which we talked about at the beginning. The prevalence of individuals with 2, 3, or four or diseases rising by 20%, 60%, and 300% respectively. We are struggling with a lot more comorbidities. 2010 31% of all Americans had multiple chronic conditions. The presence of depression appears to increase as the number of medical morbidities increases. From 2001 to 2003 the National comorbidity survey, we had 34 million American adults and about 17% of the adult population had a comorbid medical — mental and medical condition. Specifically, asthma patients have a higher prevalence of anxiety and depression than does the general population. Compared to those without asthma, individuals with asthma are approximately twice as likely to suffer from depressive disorders, and three times more likely to suffer from anxiety disorders. This increases the risk. One of the things we are always battling in asthma management, lifestyle changes, allergen avoidance, impairing functioning , and increasing health care utilization, which can further worsen asthma control. Again, in Jackie 2018 this was anxiety, depression, and asthma control. They enrolled over 3000 patients with moderate and severe asthma. They looked at the control test. 

They did Hospital anxiety and depression scale. The treatments were decided by specialists and they wanted to examine the association of asthma diagnosis and symptoms of depression and anxiety in the asthma control. Not just a baseline, but over a six-month period. What they showed was at Ace line 22.4% and 12% of patients were diagnosed with anxiety. After six months anxiety and depression improved, and it went down to 15%, and then 12% to 8%. FEV1 one and asthma control improved. That was significant. Patients with anxiety and depression you significantly more health care resources and had more exacerbations. They showed that patients with anxiety, depression, and the lower FEV1 were independently associated with poor asthma control. We could probably guess that. It showed that there was a fourfold greater influence over asthma control and depression. Standardized asthma care after specific visits with a specialist, patients present significant improvement, at least in psychological disorders, and exhibit are asthma control and functional parameters. So, we need to treat the whole person. Need to do more than just giving them their asthma medicine. This is something very similar done. This was in 2020 one, looking at multivariate Association of Child depression and anxiety. These results suggest that psychiatric symptoms are associated with poor asthma-related related quality of life, have a more negative perception of asthma control in girls compared with boys. Clinicians should consider incorporating questions about psychiatric symptoms as part of their routine asthma management and focus patient education on the unique differences in boys and girls. In this childhood population. This is published in annals, and looked at the impact of anxiety and depression on patients with asthma. Anxiety and depression, as we talked about our patients with asthma, but a lot of findings conflict at times. They wanted to investigate the anxiety and depression in a group of patients without asthma. They did a clinical exam, lung function. Asthma control test, control grade, perception of symptoms, and Hospital anxiety and depression. They found that locally 36.9% of patients had anxiety and 11% had depression. 71 headache combined — had a combined anxiety and depression. Patients with depression had higher body mass indices. So, eating more and had higher body mass indexes. And anxiety and depression were associated with lower ACT scores.

Relevant: Abilities in asthmatic outpatients, we are going to see and can be associated with uncontrolled asthma and lower ACT scores. If we see patients back in clinic and we are following an ACT score and looking at their overall asthma control, if there asthma control is not great we really sued should be thinking about comorbid mental health disorders and be looking at those. This is followed up with a presentation in 2044 about these traits in asthma. The current excellent article published and lifted a variety of different treatable traits. One of those was anxiety and depression. They looked at prevalence of anxiety and depression in people with asthma and showed anxiety, again, 24% to 38%. What were the adverse clinical consequences? Poor asthma control, reduced health care-related quality of life. And frequent asthma exacerbations. They also looked at how to recognize anxiety and depression, and they found that the best thing you can do is questionnaires. Should have treatment options. You should be looking at, what should we do to look at these identification markers and traits? They did come up with asthma and depression and a severe asthma poster you can download. This was from Australia. I will highlight some areas in this, because this might be hard for you to read. Talks about, what is anxiety? I’m going to have a disproportionately high fear. What is depression? Ongoing symptoms of sadness, emptiness, irritability. Talk about anxiety and depression and how it can impair a person’s ability. That anxiety is 1.4 times depression, 3.1 times more common in people severe asthma. And that them — they are more common in people with asthma and that can lead to reduced asthma control, impaired quality of life, reduced lung function, and increased health care utilization. The bottom half of the poster talks about the percentages of severe asthma population. But there are some screening and referrals. Questionnaires. There is the Kessler psychological stress. There is the questionnaire. Asthma and depression score you can use. Excluding dysfunctional grading. Air referral for Acer colleges or psychiatrist. And then management options. Mental health options are — problems are undertreated. Some pharmacologic interventions. Some psychologic interventions. 

Counseling, CBT, and social support. This is from severeasthma.org in Australia. Basically, this was a scoping review in 2022 that examined existing interventional therapies a — examining depression and anxiety in people with asthma. They looked at pharmacologic interventions. They looked at psychological and lifestyle, and they came up with some highlights of the paucity of the randomized trials to treat all of this. He came up with an info graphic summarizing anxiety and depression. You can maybe have this in your clinic. This is blowing up here. Just to see you can see it better. Biologically they talk about selective serotonin reuptake inhibitors. And tricyclic or other antidepressants can be used. Benzodiazepines short-term. Magnetic stimulation is becoming more popular. Psychologically, cognitive behavioral therapy. Interpersonal therapy. Acceptance and commitment therapy. Mindfulness, relaxation therapy, and exposure therapy. Socially, gain support from family and friends. Having family education and caregiver support is important. He involved in support groups. Being involved in employment and housing. And then the lifestyle changes you can make. Exercising, eating more healthy, weight loss, good sleep hygiene, trying to maximize that sleep and make it be good sleep. Then, decreased other substance abuse, like smoking, alcohol, and other drug, sensation management. What we have to look at is other things that can be seen as other impacts. When we look at this, signs of depression linked to monoclonal antibody therapy, this is a small study from Germany. They used questionnaire screening. They found that patients that respond to monoclonal antibody therapy displayed lower levels of major depressive disorders or general anxiety disorders related symptoms. The prevalence and probable decreased significantly after initiation of the therapy. So, improving their asthma helped their major depressive disorders and general anxiety. Analysis revealed pre-existing symptoms, and were a major predictor for non-responsive they were producing significant. We have to keep that in mind. Maybe we need to improve their depressive symptoms and anxiety symptoms before we expect monoclonal antibodies to work in patients with severe asthma. What can we do in an allergist’s office? This was published in 2020. Keynotes of behavioral health symptoms. What can we do? Oh, evaluate behavioral symptoms. Due to limited time commitments we have to have these be brief, reliable, and valid questionnaires. There is a number of them out there. There is the 21-item depression and anxiety stress scale. 

There is assessing severity within the past two weeks. This measure has a strong psychometric property. It takes only a few minutes to complete and it is at the third grade reading level. It provides clinical kernels, allows providers to classify patients as normal, mild, moderate, extremely severe, and then suggests the presence of a mood or anxiety disorder. A simple tool that can be used. You can also — results can be helpful given the stigma associated with behavioral health issues. Patients may be more willing to disclose their ascent — their symptoms to a questionnaire. A number of studies have looked at that, where patients filling out a questionnaire were more likely to be honest then with you asking them direct questions. The questionnaire opens the door for you to probe further. The items on the questionnaire offers the health care provider a starting point to discuss the psychiatric symptoms and allows for proactive planning of treatment regimens. For example, a patient with severe depression has a greater likelihood of not adhering to treatment or may be more likely to miss appointments in the future. Knowing that allows you to do some problem-solving with the patient. To identify ways to approve — improve that adherence. Setting reminders on their phone, increasing the frequency of our report — our appointment reminders. Using telehealth to facilitate contact with a patient. For initiating a referral to behavioral health for evaluation and treatment in conjunction with your treatment of their asthma. With that, I went through this quite rapidly and I apologize for that, but I want to get through all of it. There are various factors that contribute to the connection between asthma, depression, and anxiety, and these are genetics — you can fix that too well yet. Cannot pick your parents — development — we are working on that, but, you know, not the easiest thing to have an impact on, but be aware of it is important as we counsel patients with younger families. 

Basically, inflammation we talked about, and then medication effects. The main implications arise from immunomodulatory effects on the body that contribute to an increase in inflammation and the lungs — in the lungs. In conjunction with genetics that influences the immune system. It can suppress the body’s ability to regulate an appropriate defense response, causing illnesses concurrently. Depending on the timing of the diagnosis of asthma, the severity, their lifestyle all of that correlates with increased likelihood of developing depression. Lifestyle changes, balanced diet, regular exercise, stress management can improve both conditions. Integrating depression screening into patient visits is needed. Finding out what your system has and what you can use is important. Some of the depression screens are copywritten and cannot be used, but a lot of them out there are basically available to all this. And then precision medicine holds promise for customized treatment plans based on genetics, lifestyle, and environment. With that — hang on a minute — I want to leave you with something totally non-stressful, and that is my dog, who basically should call me you all right now and allow you to take a breath and relax and realize that, yes, anxiety and depression impact asthma. Asthma can impact anxiety and depression. And we should be looking for this in our practices. With that, I’m going to turn it back toRuthie and see if we have questions.

Ruthie: We do have lots of questions coming in. Thank you for that recitation. Truly a topic that needs to be spoken about. In every field, but especially for our asthmatic patients. We will start off with a question we have related to medications. Similar to cardiac and blood pressure medications, are there any concerns you have with your patients about psychiatric medications affecting asthma symptoms or vice versa?

Dr. Mahr: That is a great question. Most of the psychiatric medications don’t have a negative effect on asthma control. Some of the asthma medicines can have an effect on people with anxiety. The short acting bronchodilators. And having people be aware that if they happen to be somebody who is more sensitive to those, if they have the beginning of a flare and they may overuse that they may have more issues. Prednisone for some people can have an impact. Most of the anti-depressive type medications, whether it is SSRIs, etc., most of them don’t have too many interactions with asthma. It is a great question but I would be careful on the flipside.

Ruthie: Awesome. Before in your practice should mental health evaluations be part of the work before you start escalating into advanced therapies for severe asthmatics?

Ruthie: That is a wonderful question. Should we be looking at patients who have moderate to severe asthma? And we are thinking about the next step should be a monoclonal antibody. Or should we really take a step back and think, am I doing everything else I can for that patient from the standpoint of mental health? A lot of times we have not looked at that. We do get silos in our care and as an allergist I find that in myself a lot. We may deferred this to primary care, but they may not be seeing their primary care provider that often. It behooves us as specialists to be thinking about it. A B do one of these screening tools. Maybe say, your asthma is not controlled, but before we take the next step on that let’s start the process of getting it approved. Let’s see if we can get your mental health under better stability and see if that helps. So, it is a good question and I agree.

Ruthie: We have a couple of questions regarding those screening tools. One being, which seemed most practical ? Validation tools to assess for anxiety and depression? The two part two that is, when our allergists going to be implementing those, or is it just your practice?

Dr. Mahr: I think there is a fair number of allergists and primary care providers that are doing that. It depends on your system. I am at a large medical practice. It is built into EPIC. Depression screening as part of population health and is built into it. Who does it? Sometimes it is a battle of whether the inmate does it, there’s somebody else should do it. Do they get it sent at home? That is the logistics of finding out where you practice. If you are on your own this is something you could easily implement. Sometimes there is a two questionnaire that, have you been feeling depressed, down, or have you had any thoughts of harming yourself in any way? There is a number of them out there who have good validation behind them. Find when you feel comfortable using that you have the time to consistently use in your practice. Some people say, I don’t want to use a validated measure. I’m just going to ask the patients. What the study shows is that patients are going to be more comfortable answering a questionnaire like that and it opens the door for you to act quicker — not act quicker, but open the door to ask more about that. Just like the asthma control test. It really opens the door if I walk in the room and their score is 17 and they tell me that they are doing great and they have no problems whatsoever, I can say your ACT is 17. It helps flag me that I need to ask more questions.

Ruthie: We have one question regarding monolucast. Can you speak to the side effects on your patients and the moon?

Dr. Mahr: It does have a blackbox warning. The studies have shown we are talking single digits. As its effect. However, I will tell you that since that warning came out and with the advancements we have in other therapies, I am more likely to not initiate it for patients who have mild asthma and if somebody is on it I’m going to consider that is going to be the first drug I’m probably going to take them off of if they have other therapies controlling inflammation and everything else. I’m upfront with patients. I let them know if I’m initiating that there is a black box warning on this drug. If you see any effects which might occur within the first month or two you need to be aware of it and let us know. Not seeing somebody who has been on it for years. It is seen initially with the initiation of therapy. Keep that in mind. But if I’m taking care of a teenager it is the primary place I would see it, who basically is in that rough time period where you begin to see more of the behavioral health and mental health effects of life in general, I’m going to be more likely to discontinue that than I am something else, and I hope that helps.

Ruthie: That is a great response to that. We have another question regarding differentiating between asthma and anxiety. The question is, how do you evaluate and assess what clinical cues differentiate anxiety-related dyspnea versus asthma-related dyspnea?

Ruthie: That’s another good question. I could even go down to vocal cord dysfunction as something else these patients might have. Doing a PFT. If we — if we have someone who has a normal PFT, then the question is usually, do they have mild intermittent asthma or anxiety? Then it is getting into the historical picture of, tell me when you have had your asthma. What has precipitated it? What is going on? So, somebody where you can go back in the history and be able to tease out the fact that, wow, this sounds like more of an anxiety, same way with anaphylaxis. This vasovagal effect some people could have. Then that is a little bit more likely with the vocal cord dysfunction in some teenagers. You see that on the basketball court they are running up and down and dropped to their knees and they are having problems and people think it is asthma. It is really vocal cord dysfunction. Dealing with that instead of being treated with asthma. The simplest thing that urgent care’s do is treat them for asthma. They are not going to deal with anxiety. They are going to treat them. That sounds bad, but that is the model of an urgent care. I think it behooves us as specialists to be on our guard to look at, is it anxiety or not? I think doing an anxiety scale, having a tool available that you could have that to find out if they are anxious, do more history. Have you ever had anxiety attacks? Tell me where the trouble is. Asking them where there is difficulty breathing. Usually anxiety is, I’m having trouble breathing in. And they will point to write here. Asthma is an obstructive phenomenon. It is difficult getting air out. We may perceive it as getting air in, but it is getting it out and wheezing occurs. When is the noise being made? Those of the questions you go through. If they have an otherwise-normal PFT.

Ruthie: I know it is reassuring and feels good that in our virtual asthma-coaching program we do talk about, we have a whole section when we talk about how to manage our asthma and how it relates to other comorbid conditions, but also anxiety and depression. All of what you are saying is great and makes me feel good as we continue to educate our participants. We have a couple more questions. One is, likely from a community health worker or as an educator, but the question is, is there a place for community health workers and asthma navigators in addressing anxiety and depression in children?

Dr. Mahr: That’s interesting. I’m going to put Angus back up. That is a fascinating question. I think there is. I think as a community health worker if you are doing home visits, looking at the aspects of the home, looking at other stressful situations that are occurring at the home, dealing with keying in on, what can I do to help this child, and depending on the age of the child you can work with distraction, breathing techniques, relaxation techniques, mindfulness. Although those are simple things you can talk to that child about and help them center themselves and ground themselves rather than spinning, sometimes with these kids do is start having a mild asthma attack and unfortunately there anxiety starts feeding back in on it. Helping pick up on that can be great. Then looking at their environment. You are already well-educated on what to do with smoking in the environment. But I think looking at the stressful situation, looking at the mental health of the child is something you can do and would be extremely valuable.

Ruthie: Thank you for that. Anyone in any capacity can ask those questions you said. Are you feeling like you are feeling down or do you feel like you are in a position to harm yourself? I think those are two great tools that you do not have to be credentialed. You have to be — you could be an everyday person. Awesome. One more question before we wrap up. What strategies have you seen help adolescents who are-report symptoms due to the stigma or denial?

Dr. Mahr: Part of it is normalizing as much as you can. With me it is telling my personal story, my family story. Because we have been very upfront in our community. A fair number of people know about Kaitlyn, but being upfront and honest about her issues and what we as a family went through, sometimes it breaks down the wall. But, you know, it doesn’t have to be that tornadic. For teens it is normalizing the fact that a lot of people have this. The fact that one third of the population can feel that they have problems. Unfortunately there is just a study came out today showing that about 30% of pediatric patients have untreated behavioral health issues. And a lot of it is the fact that they are not recognized or the parents cannot access proper health care. They don’t have the finances to do the next steps that need to be done. So, I think trying — when you are seeing those patients, do what you can to decrease that stigma, normalize it more, and that may help them recognize, I do have a problem and I’m going to work on that, or take the steps I need to do to get that under control, and knowing that if they do that your asthma is going to be easier to treat and would not be likely to have exacerbations.

Ruthie: Thank you for that. There he engaged group. Thank you so much. Thank you, Dr. Mahr, again, for this very engaging presentation. Thank you offer joining us today. Help this session has provided you valuable tools, strategies, but also awareness and information to support your practice and management and treatment of anxiety and depression in your asthmatic patients. In a few days Zoom will email you a link to the recording and a post-webinar evaluation. Your feedback is important to us and helps us shape future programs. Please join us next month for another advances webinar on March 18 at 1:00 p.m. With Dr. Leonard, presenting severe uncontrolled asthma, tailoring therapies for complex patients. With that, on behalf of the Allergy & Asthma Network, thank you for your participation. We look forward to seeing you in our upcoming webinars. Have a great afternoon, everyone. Thank you, Dr. Mahr. Dr. Mahr: Thanks, everybody.

Ruthie: Bye-bye.