Breathless and blue: are anxiety and depression underdiagnosed in severe asthma?

Introduction: Anxiety and depression are associated with poor asthma outcomes and increased healthcare utilization in severe asthma. However, stigma is a significant obstacle to the timely diagnosis and treatment of these conditions. Aim: To evaluate the prevalence of anxiety (A) and depression (D) symptoms, and their impact on asthma-related outcomes in severe asthma (Step 4 or 5 of GINA). Methods: 113 patients on follow up with the severe asthma clinic at Singapore General Hospital were assessed with the Hospital Anxiety and Depression Scale (HADS). Sociodemographic and clinical data including asthma-related outcomes (Asthma Control Test (ACT) scores, exacerbation rates, spirometry) were collected. Results: Mean age was 49 years and 38.9% were male. The prevalence of anxiety/depression was 46.9% in this cohort, of which only 13.2% and 9.4% had been formally diagnosed with anxiety and depression respectively. Mean ACT scores were lower in patients with positive HADS scores compared to those without (15.7 ± 4.2 vs. 19.4 ± 3.2, p<0.001). There were no differences in gender, ethnicity, smoking status, exacerbation rates or lung function between patients with positive and negative HADS scores. Conclusions: These findings suggest that more emphasis should be placed on identifying obstacles to psychological assessment, one of which is social stigma. Systematic efforts are needed to engender improved access to psychological evaluation in patients with severe asthma. Reducing stigma and discrimination toward psychiatric afflictions is a first step.