General Hospital Psychiatry
Volume 34, Issue 1 , Pages 17-23, January 2012

Depressive symptoms, risk factors and sleep in asthma: results from a national Israeli health survey

  • Aviva Goral, M.Sc.

      Affiliations

    • Unit of Mental Health Epidemiology and Psychosocial Aspects of Illness, Tel Hashomer 52621, Israel
    • Corresponding Author InformationCorresponding author. Mental Health Epidemiology and Psychosocial Aspects of Illness, Sheba Medical Center, Tel Hashomer 52621, Israel. Tel.: +972 3 535 4252; fax: +972 3 530 3277.
    • ,
  • Joshua D. Lipsitz, Ph.D.

      Affiliations

    • Ben Gurion University of the Negev, Beer Sheva 84105, Israel
    • ,
  • Khitam Muhsen, M.Sc.

      Affiliations

    • Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 69978, Israel
    • ,
  • Raz Gross, M.D., M.P.H.

      Affiliations

    • Unit of Mental Health Epidemiology and Psychosocial Aspects of Illness, Tel Hashomer 52621, Israel
    • Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 69978, Israel
    • Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
    • Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA

Received 24 May 2011; accepted 10 September 2011. published online 24 October 2011.

Article Outline

Abstract 

Objective

The objective was to assess the association between asthma and depressive symptoms (DS) and to evaluate the relationship between DS and risk factors [smoking, physical inactivity, body mass index (BMI) and sleep duration] in asthmatic individuals.

Methods

We analyzed data from the Israeli National Health Interview Survey, conducted among 9509 participants aged ≥21 years in 2003–2004. Data on sociodemographic factors, chronic respiratory disorders, DS and risk factors were obtained through telephone interviews. DS were measured using Short Form 36 mental health items. Analyses were performed using multivariate logistic regression models.

Results

A total of 393 participants (4.2%) reported chronic asthma in the 12 months previous to the interview. Of those, 37.4% had DS, compared with 21.8% of nonasthmatic participants [odds ratio (OR), 1.84; 95% confidence interval (CI), 1.47–2.30; P<.001]. DS in asthmatic individuals were significantly associated with physical inactivity [adjusted OR (AOR), 2.01; 95% CI, 1.12–3.61; P=.02], with smoking (AOR 1.80; 95% CI, 1.04–3.12; P=.04) and with less sleep (AOR, 1.81; 95% CI, 1.03–3.19; P=.04). DS in asthmatic participants were not associated with BMI.

Conclusions

DS are common in asthmatic individuals and are significantly associated with physical inactivity, with smoking and with less hours of sleep. Such health-related risk factors may impact on the course of asthma and on overall health.

Keywords: Asthma, Depressive symptoms, Risk factors

 

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1. Background 

Asthma is one of the most common chronic medical conditions worldwide. The prevalence of asthma is about 7%–10% in children and about 5% among adults [1], [2]. Asthma incidence, prevalence and severity have increased in recent decades in many countries throughout the world [1], [3], [4], [5]. Asthma is associated with lower health-related quality of life, high health care utilization rates and considerable social and economic burden [1], [6], [7], [8].

Adults with asthma have higher rates of mental disorders [2], [9], [10], [11], [12] which are, in turn, associated with an increased risk of health problems and the worsening of existing medical conditions, including asthma [6], [13], [14], [15]. Individuals with asthma and comorbid depression have worse medical outcomes. Poor asthma control is, in turn, associated with increased asthma-related morbidity and mortality [6], [7], [13], [14], [16], [17] and with higher psychiatric morbidity [18]. Voogd et al. [17] showed in a recent longitudinal study that depressive symptoms (DS) among patients with stable chronic obstructive pulmonary disease were associated with higher mortality rates, suggesting that even DS (as opposed to depression diagnosis) may be associated with higher mortality risk. However, most studies were conducted using clinical samples that included patients with more severe illness; therefore, the findings may not generalize to asthmatic individuals in the community.

One possible mechanism which may explain the association between asthma and depression is the link with health-related risk factors. Studies show that mentally distressed asthmatic individuals are more likely to show adverse health factors such as smoking [6], [14], [15], physical inactivity, obesity [6], [15], [19] and sleep disturbance [20]. The association between health-related risk factors and poor asthma control may clarify, at least in part, the link between mental disorders (e.g., depression and anxiety) and asthma.

Similarly, studies show significant associations between asthma course and health-related risk factors such as physical inactivity and obesity [21], [22]. Increasing body mass index (BMI) is associated with lower lung volume [22]. Obese and physically inactive asthmatic patients experience worse asthma symptoms, have sleep problems, use more medications and have higher health care utilization rates [21], [22]. It is speculated that increased systemic inflammation plays a role in the relationships between obesity, physical activity and asthma. Smoking is associated with poor asthma control and with worse asthma-related outcomes [23], [24].

Quality sleep is vital to good health, yet sleep disturbance is more common among asthmatic individuals. Asthma symptoms and use of certain asthma medications may be associated with delayed sleep onset, with insomnia and with an overall poor sleep [25], [26]. Disrupted sleep is also common among persons with psychiatric disorders and is associated with higher depression and anxiety levels and with more physical and psychological disability.

In light of the known relationships between asthma, mental disorders and health-related risk factors in asthmatic patients, it is important to understand whether these relationships hold in self-reported mental health symptoms. To date, research on the association between mental health symptoms and health-related risk factors in asthmatic individuals is scarce. In this study, we aimed to assess the relationship between asthma and DS, and the relationship between DS and health-related risk factors (smoking, physical inactivity and higher BMI levels) and hours of sleep among participants with asthma in a large community sample.

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2. Methods 

2.1. Study population, sampling and design 

We analyzed data from the first Israeli National Health Interview Survey (INHIS-1), which was conducted on a large representative sample of the adult Israeli population (ages 21 years and older) in 2003–2004. INHIS-1 is a telephone survey based on the European Health Interview Survey project led by the World Health Organization Regional Office of the European region. Telephone numbers were randomly selected from a computerized list of national telephone company subscribers (not including cellular phone numbers). At the time of the study, over 90% of Israeli households had telephone lines [27]. Exclusion of fax, disconnected or commercial numbers; numbers of households with no residents ≥21 years of age; and lost to follow-up households resulted in 21,326 eligible households. Of those, 4980 households (23.4%) could not be located, and 6837 households (32.1%) were excluded for no response. Of the remaining 16,346 contacted households, 9509 (58%) adults had a complete questionnaire (Fig. 1). Of those, almost 80% were Israeli Jews; almost 19% were Israeli Arabs. The response rate among Israeli Jews in this study was similar to that obtained in the Israel National Health Survey, a cross-sectional survey conducted between 2003 and 20004 (71% were Israeli Jews). More details on the INHIS-1 appear elsewhere [28].

The INHIS questionnaire was administered by trained interviewers in Hebrew, Arabic and Russian. The core questionnaire included socioeconomic and demographic data as well as data on chronic conditions, psychological distress and risk factors.

2.2. Parameter classification 

2.2.1. Chronic conditions 

Participants were asked about various chronic conditions using the following yes/no items: (a) “Do you have or have you ever had (index condition)?” (b) “Was this condition diagnosed by a physician?” (c) “Was this condition present in the previous 12 months?” (d) “Did you take medications or receive any form of treatment for the condition during the 12 months prior to the interview?”

Participants were classified as current asthmatic if they reported (a) asthma being diagnosed by a physician and (b) asthma being present during the year prior to the interview. In addition to asthma, the analysis controls for other current comorbid conditions. Participants were classified as having “other comorbid chronic conditions” if they reported being currently diagnosed with at least one of the remaining conditions listed in the questionnaire, including heart attack, angina pectoris, heart failure or other cardiac disorder, hypertension, allergies, cataract, high blood cholesterol level, stroke, bronchitis, rheumatic arthritis, osteoporosis, peptic or duodenal ulcer, malignant tumor, chronic pain, chronic anxiety/depression or diabetes, and if the condition was present during the year prior to the interview.

2.2.2. Depressive symptoms 

Depressive symptoms were measured using the five-item Mental Health Index (MHI-5). The MHI-5, a subscale of the Short Form 36 [29], measures current psychological distress and was shown to be effective in evaluating mental health and in depression screening and detection [30], [31], [32]. Berwick et al. [30] reported areas under the curve ranging from 0.739 (for the detection of anxiety disorders) to 0.892 (for the detection of major depression) using the MHI-5.

Participants were asked “How much of the time in the previous four weeks have you been/felt…” (a) “very nervous,” (b) “so down in the dumps that nothing could cheer you up,” (c) “calm and peaceful,” (d) “downhearted and depressed” and (e) “happy?” Response categories ranged from 1 (all of the time) to 6 (not at all). The scores were summed across the five items (reversing items three and five which ask about positive feelings) to obtain an overall score ranging from 5 to 30. Calculated scores were then transformed to a 0–100-point scale as recommended by Ware et al.[29] where lower scores indicate worse psychiatric distress. A cutoff point of 60 was used to classify respondents as having “significant depressive symptoms” (scores 0–59) and “no depressive symptoms” (scores ≥60). The cut point selected was recommended by previous research as a case identifier for depression in patients with physical symptoms [33], [34], [35].

2.2.3. Health-related risk factors 
2.2.3.1. Smoking 

Participants were defined as current smokers if they responded yes to questions about smoking cigarettes, cigars, pipe or narghile (a water pipe commonly used with tobacco in some Middle Eastern countries). Over 99.9% of participants defined as smokers smoked cigarettes; about 95% smoked on a daily basis. Past smokers were categorized as nonsmokers. Data on the number of cigarettes per day were also obtained, and participants were classified as (a) nonsmokers, (b) smokers who smoked ≤10 cigarettes per day, (c) smokers who smoked 11–20 cigarettes per day and (d) smokers who smoked >20 cigarettes per day.

2.2.3.2. Physical activity 

Physical activity measures in this study were derived from the International Physical Activity Questionnaire (IPAQ) [36]. The IPAQ was developed as an instrument for monitoring physical activity and is based on subjective reports of physical activity behavior including the type, duration and frequency of activity.

Participants were asked whether they engaged in physical activity such as walking, running, swimming, gymnastic exercise or ball games for at least 20 min. Those who responded positively to the first question were further asked about the frequency of engagement in physical activity. Participants were classified as “physically active” if they reported regular physical activity at least once a week; all others were classified as “physically inactive.” Participants were further classified according to the following physical activity levels: (a) physically inactive, (b) physically active 1–2 times a week and (c) physically active every day or almost every day.

2.2.3.3. BMI level [calculated as (weight in kg)/(height in m)2] 

Participants were grouped according to the following BMI levels: (a) underweight (BMI≤18.49), (b) normal weight (BMI level 18.5–24.9), (c) overweight (BMI level of 25–29.9) and (d) obese (BMI≥30).

2.2.3.4. Sleep duration 

Participants were asked the following questions regarding sleep: (a) “How many hours do you sleep at night?” (b) “How many hours do you sleep during the day?” Values from the two parameters were summed to create a single measure of number of sleep hours. According to Kripke et al. [37], sleep duration of ≤6 h and sleep duration of ≥8 h are associated with higher mortality risk. Participants were grouped according to the number of sleep hours: (a) short sleep duration (≤6 h), (b) sleep duration of >6–<8 h and (c) long sleep duration (≥8 h).

2.3. Statistical analyses 

2.3.1. Missing data 

About 24% of all participants (and 23% of asthmatic participants) had missing data for household income. Missing values were replaced for participants in households with two or more residents with median values obtained by cross-tabulating DS and asthma. Participants with missing values for either DS or current chronic asthma (N=237) were excluded from all analyses. The total analytic sample included 9271 participants.

2.3.2. Asthma and depressive symptoms 

The prevalence of DS in asthmatic participants was examined in stratified analysis according to various sociodemographic and health characteristics; crude odds ratios (ORs) and 95% confidence intervals (CIs) were estimated.

2.3.3. Depressive symptoms and risk factors 

Logistic regression models were used to examine the association between DS and risk factors (smoking, physical inactivity and BMI levels) and sleep duration categories among asthmatic participants. Continuous measures for BMI, number of cigarettes and hours of sleep were compared between asthmatic participants with and without DS using adjusted general linear models. Potential covariates were ascertained by assessing the relationship between selected demographic and clinical characteristics and between DS, smoking, physical activity, BMI and sleep duration in bivariate regression models. Final regression models were adjusted for all covariates significant at P<.2; these included age, sex, marital status, household income, religion and comorbid chronic conditions. Statistical analyses were conducted using SAS 9.1.

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3. Results 

The total sample consisted of 9271 participants of whom 57.6% were female; mean age was 47.2 years (median: 46 years). Overall, 393 (4.2%) were classified as having current chronic asthma, and 2085 (22.5%) were classified as having DS. DS were significantly more prevalent among asthmatic participants compared with nonasthmatic participants [37.4% vs. 21.8% respectively; AOR, 1.85; 95% CI, 1.48–2.31; P<.001).

3.1. Depressive symptoms in asthmatic participants 

Demographic and clinical characteristics of participants with current asthma are presented in Table 1. The mean age among asthmatic participants with DS was 50.7 (S.D. 16.3), compared with 48.4 (S.D. 17.3) among participants with no DS. DS were significantly more common among asthmatic participants aged 40–59 years (OR 1.70; 95% CI, 1.04–2.80; P=.04), among females (OR 1.78; 95% CI, 1.16–2.73; P≤.001) and among participants with comorbid medical conditions (OR 2.09; 95% CI, 1.36–3.22; P<.001). Compared to participants with the lowest household income level [≤5200 New Israeli Shekels (NIS)], participants with higher household income were less likely to report DS (OR 0.18; 95% CI, 0.11–0.30; P<.001 for the 5201–6500 NIS income level and OR 0.11; 95% CI, 0.05–0.27; P<.001 for the 6500 NIS and up income level). The odds of DS were higher among asthmatic Israeli Arabs than among Israeli Jews, though these differences were not statistically significant (OR 1.61; 95% CI, 0.95–2.74; P=.08).

Table 1. Prevalence of depressive symptoms among participants with asthma by demographic characteristics (N=393)
CharacteristicNDepressive symptoms
N (%)		Odds of depressive symptoms
OR (95% CI); P value
All393147 (37.4)–
Age
21–39 years13943 (30.9)Reference
40–59 years13458 (43.3)1.70 (1.04–2.80); .04
60 and older12046 (38.3)1.39 (0.83–2.32); .21
Gender
Male15646 (29.5)Reference
Female237101 (42.6)1.78 (1.16–2.73); .01
Religion
Israeli Jews321114 (35.5)Reference
Israeli Arabsa6832 (47.1)1.61 (0.95–2.74); .08
Othersb31 (33.3)–
Marital status
Married or cohabitating25894 (36.4)Reference
Otherc13453 (39.6)1.14 (0.74–1.75); .55
Household incomed
≤520015897 (61.4)Reference
5201–650016136 (22.4)0.18 (0.11–0.30); <.001
≥65015812 (20.7)0.16 (0.08–0.33); <.001
Comorbid chronic disorder
No16044 (27.5)Reference
Yes233103 (44.2)2.09 (1.36–3.22); .01

aMuslims 70.6%; Christians 16.2; Druze 13.2%.

bOthers (including Catholic Christians and undefined religion) 0.8%.

cOthers including single/divorced/widowed subjects.

dHousehold income in NIS per month.

3.2. Association of depressive symptoms with risk factors 

Depressive symptoms among asthmatic participants were significantly associated with smoking, with physical inactivity and with shorter sleep duration (Table 2). Almost one third (31.3%) of asthmatic participants with DS were smokers compared with 20.7% of those with no DS (AOR 1.80; 95% CI, 1.04–3.12; P=.04). DS among asthmatic smokers were not associated with a higher number of cigarettes smoked per day.

Table 2. Risk factors in asthmatic persons (N=393) by depressive symptoms
Risk behaviorDepressive symptomsAORa (95% CI); P value
No (N=246)
N (%)		Yes (N=147)
N (%)
Smoking
Nonsmokers195 (79.3)101 (68.7)Reference
Current smoker51 (20.7)46 (31.3)1.80 (1.04–3.12); .04
Number of cigarettes smoked per day (among smokers)
≤10 per day24 (47.1)17 (37.0)Reference
11–20 per day16 (31.4)14 (30.4)1.10 (0.30–4.03); .43
>20 per day11 (21.6)15 (32.6)1.39 (0.37–5.19); .88
Physical activity
Physically active almost every day75 (30.5)26 (17.7)Reference
Physically active 1–2 times a week48 (19.5)18 (12.2)1.14 (0.52–2.49); .75
Physically inactive123 (50.0)103 (70.1)2.01 (1.12–3.61); .02
BMI level
Mean (S.D.)26.7 (5.4)27.0 (7.3)Pb=.61
Normal weight86 (35.0)54 (36.7)Reference
Underweight9 (3.7)10 (6.8)1.49 (0.49–4.56); .49
Overweight73 (29.7)35 (23.8)0.71 (0.38–1.32); .27
Obese60 (24.4)34 (23.1)0.57 (0.30–1.09); .09
Number of sleep hours
Median (S.D.)7.00 (1.48)6.00 (1.97)Pb=.004
>6–7.584 (34.1)32 (21.8)Reference
≤693 (37.8)82 (55.8)1.81 (1.03–3.19); .04
>7.569 (28.0)33 (22.4)0.99 (0.52–1.91); .99

aOdd ratios adjusted for age, gender, marital status, household income level, religion and current comorbid chronic disorder.

bLinear regression, adjusted as above.

DS were also associated with physical inactivity (Table 2). Over 70% of asthmatic participants with DS were physically inactive (compared with only 50% of asthmatic participants with no DS) (AOR 2.01; 95% CI, 1.12–3.61; P=.02); almost 18% engaged in physical activity “almost every day” compared with over 30% of asthmatic participants with no DS.

Overall, the mean BMI among asthmatic participants with DS was similar to that in asthmatic participants with no DS (mean BMI levels were 27.0 and 26.7, respectively; P=.61). The odds of being classified as “obese” or “overweight” were lower among asthmatic participants with DS compared with asthmatic participants with no DS; differences were not statistically significant (AOR 0.57; 95% CI, 0.30–1.09; P=.09 for obese and AOR 0.71; 95% CI, 0.38–1.32; P=.27 for overweight).

The median duration of sleep was 6 h among asthmatic participants with DS and 7 h among asthmatic participants with no DS (P=.004). Asthmatic participants with DS were significantly more likely to sleep 6 h or less than asthmatic participants with no DS (AOR 1.81; 95% CI, 1.03–3.19; P=.04) (Table 2).

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4. Discussion 

We analyzed the relationship between chronic asthma and DS in a representative community sample of the adult Israeli population. Consistent with published literature, we found that DS were more common in asthmatic participants than in nonasthmatic participants. Furthermore, we found that DS were significantly more common in asthmatic participants who were female and those who had comorbid chronic conditions; this too, was consistent with previous findings [38]. DS were significantly less prevalent among asthmatic participants with higher household income.

We further analyzed the relationship between DS and health-related risk factors and sleep duration among asthmatic participants. We sought to examine whether the association between asthma, depression and risk factors would be sustained on the level of symptoms rather than diagnosis; the results of this study show that they do. Like depression diagnosis, DS are significantly more common among asthmatic participants then among nonasthmatic participants and, in asthmatic persons, are significantly associated with physical inactivity, with smoking and with less sleep.

DS among asthmatic participants were associated with a 70% increased likelihood of being a smoker (P=.04). In a review article, Williams and Ziedonis [39] concluded that there is a neurobiological link between tobacco use and mental conditions such as depression and anxiety. Smoking is associated with poor asthma control and worse symptoms [23], [24]. One could presume that cigarette smoking mediates the relationship between mental disorders and respiratory conditions; this, however, was not supported in our study. We found a significant association between DS and chronic asthma even after adjusting for smoking. Similarly, Goodwin et al. [40] showed in a recent longitudinal study that the association between respiratory symptoms and mental disorders is not mediated by cigarette smoking.

We found that DS were significantly associated with physical inactivity. Engagement in routine physical activity is an important component of optimal asthma management [41] as well as in the management of mental disorders. Major depression risk may be reduced by 25% in physically active compared with nonactive individuals [42]. Furthermore, physical inactivity is an important risk factor for obesity, and both are associated with lower spirometry values in asthmatic adults [21].

Unlike Strine et al. [15] who found increased obesity among adults with asthma and current depression, we failed to find an association between DS and obesity among asthmatic participants. While Strine et al. looked at depression diagnosis (current and lifetime), we looked at DS. In addition, “current asthma” was restricted in our study to cases in which asthma was diagnosed by a physician and was present during the year prior to the interview; the asthma classification in the study conducted by Strine et al. was different and included nondiagnosed asthma cases. This discrepancy could also be due to cultural differences related to diet and weight between Israel and the United States.

Consistent with previous findings [25], we found a significant association between depression and sleep duration among asthmatic participants. Almost 56% of asthmatic participants with DS reported sleep duration of 6 h or less compared with about 38% of asthmatic participants with no DS.

Such problematic health-related risk factors may have an adverse impact on the course of asthma. The management of both asthma and psychiatric conditions should include physical activity, smoking cessation, sufficient sleep hours and maintenance of a normal BMI level. Approaches to improving asthma-related risk factors need to address the potential complication of DS. For example, smokers with DS have been found to be more resistant to standard smoking cessation programs [43], [44]. Also, increasing physical activity is more challenging for those with DS due to physical fatigue, lack of motivation, etc. Therefore, specific strategies need to address mood and its impact, e.g., through more systematic behavioral activation used with depressed patients [45], [46]. Improvements in sleep quality are correlated with better asthma control [25]. This suggests that physicians should carefully consider existing sleep problems in the treatment of asthma, especially when comorbid with psychiatric disorders and symptoms.

4.1. Study limitations 

Data in this study were obtained through self reports; therefore, no assumptions can be made regarding the temporality of the relationships between asthma and DS or between DS and health-related risk factors. Further longitudinal research is needed to determine temporality/causality and to investigate the possible mechanism of these associations.

Inaccuracies in self-reported data may exist, and in the case of medical conditions, discrepancies may exist between self-reported and physician-confirmed diagnoses.

Measures of asthma severity or medication use were not obtained in the current study, although most asthmatic participants (87%) reported being treated for their condition during the year previous to the interview, and about 50% reported consuming prescribed asthma medications during the 2 weeks previous to the interview. The magnitude of the associations between asthma and DS as reported in our study may underestimate the association in more severe respiratory conditions. Disability and decreased quality of life due to asthma may trigger DS. We selected a limited number of risk factors which have been found to be prominent in individuals with asthma and because they were prevalent in our sample. We did not consider another important risk factor for asthma, alcohol abuse [47], since this was reported by a relatively small number of participants with asthma and because there were inconsistencies in INHIS data in this category. In addition, we did not consider other factors such as use of pain medication or history of accidents or hospitalizations which may be associated with DS. Furthermore, the association between asthma and DS may be biased by the presence of other somatic symptoms (e.g., fatigue) in asthmatic patients.

The compliance rate in the INHIS-1 survey was 58%, which is reasonable for a large survey of this kind. However, data on those who were not included in the study are lacking. The sampling frame comprised of subscribers of the national telephone company and did not include subjects who own cellular phones only; the generalizabilty of our findings may therefore be limited.

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5. Conclusions 

Depressive symptoms are common in asthmatic individuals and are significantly associated with health-related risk factors which may impact on the severity and course of asthma. Physicians' awareness of the common comorbidity between asthma and psychiatric symptoms and the potential complications associated with it is essential for an effective course of therapy. A comprehensive approach should target both asthma and mental health symptoms. However, benefits from a targeted intervention (e.g., for improving sleep or increasing activity) may impact positively on both conditions and symptoms. Future longitudinal studies could elucidate causal mechanisms which may explain the association between respiratory conditions and mental disorders.

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PII: S0163-8343(11)00296-9

doi:10.1016/j.genhosppsych.2011.09.007

General Hospital Psychiatry
Volume 34, Issue 1 , Pages 17-23, January 2012

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