Anxiety and depression in adult patients with asthma: the role of asthma control, obesity and allergic sensitization

Abstract

Objective: To determine the frequency of anxiety and depression in adult patients with asthma and to identify factors associated with them.
Methods: This cross-sectional study included 164 consecutively recruited patients with asthma aged ≥ 18 years. Participants were clinically assessed and the mental state was analyzed through of the Beck Anxiety Inventory (BAI), the Beck Depression Inventory II (BDI-II); the Asthma Control Test (ACT) was measured, and allergic sensitization and respiratory function were also evaluated. Binary logistic regression models to identify the factors related to anxiety or depression were carried out. Complementary, 95% confidence intervals (CI) were estimated.
Results: Anxiety was present in 54.3% of patients (95% CI: 46.6%–61.7%) while depression was found in 50.6% (95% CI: 43.0%–58.2%). Depression increased the odds of anxiety in patients with asthma (OR: 26.00, p < 0.0001), whereas an ACT score ≥ 20 points and allergic asthma were associated with a lower odds than the reference group (OR: 0.29; p = 0.007 and OR: 0.29; p = 0.024, respectively). Depression was associated with anxiety and obesity (OR: 25.33, p < 0.0001 and OR: 3.66; p = 0.014, respectively).
Conclusions: Overall, more than half of all asthmatic patients suffer from anxiety and depression. Well-controlled asthma and allergic sensitization decreased the likelihood of anxiety, while depression was associated with both obesity and anxiety.

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Journal of Asthma
ISSN: 0277-0903 (Print) 1532-4303 (Online) Journal homepage: https://www.tandfonline.com/loi/ijas20
Anxiety and depression in adult patients with
asthma: the role of asthma control, obesity and
allergic sensitization
Martín Bedolla-Barajas, Jaime Morales-Romero, Juan Carlos Fonseca-López,
Norma Angélica Pulido-Guillén, Désireé Larenas-Linnemann & Dante Daniel
Hernández-Colín
To cite this article: Martín Bedolla-Barajas, Jaime Morales-Romero, Juan Carlos Fonseca-López,
Norma Angélica Pulido-Guillén, Désireé Larenas-Linnemann & Dante Daniel Hernández-Colín
(2020): Anxiety and depression in adult patients with asthma: the role of asthma control, obesity
and allergic sensitization, Journal of Asthma, DOI: 10.1080/02770903.2020.1759087
To link to this article: https://doi.org/10.1080/02770903.2020.1759087
Accepted author version posted online: 21
Apr 2020.
Published online: 02 May 2020.
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Anxiety and depression in adult patients with asthma: the role of asthma
control, obesity and allergic sensitization
Mart
!
ın Bedolla-Barajas, MD, MSc
a
, Jaime Morales-Romero, MD, PhD
b
, Juan Carlos Fonseca-L!
opez, MD
c
,
Norma Ang!
elica Pulido-Guill!
en, PsyD
d
,D
!
esire!
e Larenas-Linnemann, MD
e
, and
Dante Daniel Hern!
andez-Col
!
ın, MD, MSc
a
a
Servicio de Alergia e Inmunolog
!
ıa Cl
!
ınica, Nuevo Hospital Civil de Guadalajara “Dr. Juan I. Menchaca”, Jalisco, M!
exico;
b
Instituto de
Salud P!
ublica, Universidad Veracruzana, Veracruz, M!
exico;
c
Servicio de Urgencias Adultos, Nuevo Hospital Civil de Guadalajara “Dr.
Juan I. Menchaca”, Jalisco, M!
exico;
d
Centro Universitario de Ciencias de la Salud, Maestr
!
ıa en Ciencias de la Salud de la Adolescencia
y la Juventud, Universidad de Guadalajara, Guadalajara, Mexico;
e
Unidad de Investigaci!
on, Hospital M!
edica Sur, Ciudad de
M!
exico, M!
exico
ABSTRACT
Objective: To determine the frequency of anxiety and depression in adult patients with
asthma and to identify factors associated with them.
Methods: This cross-sectional study included 164 consecutively recruited patients with
asthma aged !18 years. Participants were clinically assessed and the mental state was ana-
lyzed through of the Beck Anxiety Inventory (BAI), the Beck Depression Inventory II (BDI-II);
the Asthma Control Test (ACT) was measured, and allergic sensitization and respiratory func-
tion were also evaluated. Binary logistic regression models to identify the factors related to
anxiety or depression were carried out. Complementary, 95% confidence intervals (CI)
were estimated.
Results: Anxiety was present in 54.3% of patients (95% CI: 46.6%–61.7%) while depression
was found in 50.6% (95% CI: 43.0%–58.2%). Depression increased the odds of anxiety in
patients with asthma (OR: 26.00, p<0.0001), whereas an ACT score !20 points and allergic
asthma were associated with a lower odds than the reference group (OR: 0.29; p¼0.007
and OR: 0.29; p¼0.024, respectively). Depression was associated with anxiety and obesity
(OR: 25.33, p<0.0001 and OR: 3.66; p¼0.014, respectively).
Conclusions: Overall, more than half of all asthmatic patients suffer from anxiety and
depression. Well-controlled asthma and allergic sensitization decreased the likelihood of
anxiety, while depression was associated with both obesity and anxiety.
ARTICLE HISTORY
Received 16 September 2019
Revised 30 March 2020
Accepted 18 April 2020
KEYWORDS
Asthma; adult;
anxiety; depression
Introduction
Recently, The Global Asthma Report highlighted that
asthma is a major disease burden, which has been
linked to more premature deaths and lower quality of
life; in the same report, it is noted that worldwide
almost 340 million people have asthma (1). In
Mexico, the prevalence of asthma in the adult popula-
tion is 5% (2). Like in other regions of the world, in
our country asthma prevalence has been growing;
when comparing the prevalence of asthma in late ado-
lescence in two different periods of time, the fre-
quency rose from 7.8% to 12.7% in a period of only
seven years (3).
According to the World Health Survey (WHS) the
prevalence of asthma-related depression and anxiety
can reach values higher than 50% and up to 80%,
respectively (4). Nonetheless, these values can vary
greatly in developing countries owing to social, cul-
tural, and economic inequalities (5–7).
These mental disorders have been associated with
poor asthma control and lower treatment adherence
and quality of life (8–10) although obesity (11–13),
allergic sensitization (14,15), and the sex of individuals
(16), also plays an important role in this association.
On the other hand, several studies have shown that
the presence of anxiety or depression in asthma is
associated with lower quality of life and lower prod-
uctivity. In Canada, patients with asthma combined
with psychological disorders generate higher costs
compared to those with asthma alone, in amounts
similar to those seen in those with cardiovascular
CONTACT Mart
!
ın Bedolla Barajas drmbedbar@gmail.com Servicio de Alergia e Inmunolog
!
ıa Cl
!
ınica, Divisi!
on de Medicina Interna, Nuevo Hospital
Civil de Guadalajara “Dr. Juan I. Menchaca”, 740 Salvador Quevedo y Zubieta, La Perla, Guadalajara, Jalisco 44340, M!
exico.
!2020 Taylor & Francis Group, LLC
JOURNAL OF ASTHMA
https://doi.org/10.1080/02770903.2020.1759087

disease or diabetes (17). In terms of quality of life, the
presence of anxiety or depression in asthma is one
factor more that notoriously deteriorates it (18).
Current asthma management guidelines recom-
mend avoiding factors that increase the risk of exacer-
bations (19,20). Studies that evaluate the relationship
between asthma with depression or anxiety in Latin
America are scarce; therefore the main goal of our
study was to determine the prevalence of anxiety and
depression in adults with asthma receiving medical
attention in a teaching hospital in Mexico. A second
objective was to test the hypothesis that there exists
an association between these mental disorders and
obesity, sex, allergic sensitization, and asthma control
and severity.
Methods
Study design and patients
In this cross-sectional study we analyzed the data of
164 patients with newly diagnosed asthma aged !
18 years who were consecutively recruited from an aller-
gology department of a teaching hospital. Patients were
recruited between October 2014 and January 2016.
We excluded patients who were pregnant or breast-
feeding at the time of the study or who had a clinical
background of diabetes mellitus, arterial hypertension,
rheumatoid arthritis, hives, kidney disease, neoplasia,
systemic steroids usage within the previous month, exa-
cerbated asthma in the previous month or death of a
family member 6 months prior to the study. Data about
alcohol consumption, tobacco usage, and comorbid dis-
eases such as allergic rhinitis, atopic dermatitis or food
allergy were also recorded.
The diagnosis of asthma was established if two or
more of the following symptoms were present: wheez-
ing, cough (especially if paroxysmal and nocturnal),
chest tightness or dyspnea (19,20), along with
the presence of reversible airflow obstruction on spir-
ometry after the administration of a short acting
bronchodilator.
Asthmatic patients were classified as allergic if they
had a positive skin-prick test result for one or more
of the aeroallergens included in the panel used.
The Asthma Control Test (ACT) was used to deter-
mine the level of asthma control. Controlled asthma
was defined as a score !20 points whereas uncon-
trolled asthma as a score <20 points (21). Each of
the ACT items were read to the patients by a phys-
ician and their answers were recorded. Afterwards, the
final score was calculated.
The frequency of asthma-related hospitalizations !
1 in the previous year was used as a marker of
asthma severity.
The body mass index (BMI) was obtained by divid-
ing the patients’weight in kg by their height in meters
squared. A BMI of 18.5 to 25 kg/m
2
was defined as
normal weight, >25 to <30 kg/m
2
as overweight, and
!30 kg/m
2
as obesity.
Psychological evaluation
Depression and anxiety were assessed using the Beck
Depression Inventory-II (BDI-II) and the Beck Anxiety
Inventory (BAI), respectively, in their Spanish versions
(22,23). They consist of 21 items and the final score is
obtained by adding up the values assigned to each
item. A diagnosis of anxiety or depression was made
when the final score was >13 points. These instru-
ments were applied as self-administered questionnaires
in a private area, separate from the rest of the patients,
and special care was taken to avoid response bias. At
the same time, each of the patients was ascertained the
information would be kept confidential.
Pulmonary function tests
Pulmonary function tests (PFT’s) were performed on a
MasterScreenV
RPFT system (JaegerV
R,CareFusion,
Baesweiler, Germany). Patients were instructed not to
use short acting or long acting bronchodilators for at
least 8 and 12 h prior to testing respectively. PFT’swere
performed during the morning with patients in a sitting
position and their noses occluded with a clip, the tests
were stopped once three maneuvers which met the
acceptability and repeatability criteria were obtained or
amaximumofeightattemptshadbeenmade.
Airflow obstruction reversibility was assessed by
repeating the PFT’s 15 min after the administration of
a dose of Salbutamol (400 mcg) delivered via a
metered-dose-inhaler attached to a spacer. The pres-
ence of reversibility was defined as a Forced Expiratory
Volume (FEV1) increase !12% and !200 ml (24).
Skin-prick test
As previously mentioned, asthmatic patients were clas-
sified as allergic if they had a positive skin-prick test
result for one or more of the aeroallergens included
in a panel consisting of 40 different non-standardized
glycerinated allergen extracts in a 1:20 weight/volume
concentration (Allergomex, Mexico) which included
pollens coming from weeds, grasses and trees, indoor
2 M. BEDOLLA-BARAJAS ET AL.

allergens (dust mites, cockroach mix, feather mix, dog
and cat epithelia). All tests were performed and inter-
preted following international standards by the same
allergologist (25).
Procedure
Outpatient patients were included. Initially, a com-
plete medical history was taken of each participant; if
it was compatible with asthma, then on the same day
or any other following day, respiratory function tests
(pre and post bronchodilator forced spirometry) were
carried out. If the findings were compatible with a
reversible, obstructive pattern, at that time, inventories
of anxiety, depression, and the asthma control test,
respectively, were applied. Finally, when the patient’
condition was adequate, skin testing was carried out.
Statistical analysis
Data analysis was conducted using IBM SPSS 20.0 for
Windows (IBM Co., Armonk, NY, USA). According
to their distribution continuous variables were com-
pared using Student’s t tests or Mann-Whitney U tests
and qualitative variables were compared using Chi-
square tests or Fisher’s exact tests as appropriate. We
used binary logistic regression models to identify the
factors related to anxiety or depression. The inde-
pendent covariates used in these models were sex,
ACT score !20, BMI category, and allergic asthma.
The strength of association between variables was cal-
culated using odd ratios (OR) and 95% confidence
intervals (CI), the level of alpha was 0.05.
Ethics
Approval to conduct the study was obtained from the
research ethics committee. All patients included in the
study signed a written consent and those in which
anxiety or depression were detected were referred to a
psychologist. None of the selected patients received
any incentive to participate in the study.
Results
A total of 164 patients with asthma were included,
131/164 (80%) of them were women. The mean age
was 39.0 ± 14.0 years. The prevalence of anxiety was
89/164 (54.3%; 95% CI: 46.6%–61.7%).
The mean age did not differ significantly between
the anxiety and non-anxiety groups (p¼0.127),
Table 1. However, there was a significant higher
number of women in the group with anxiety
(p¼0.002). In both groups allergic rhinitis was the
most frequent comorbid disease with no significant
difference between them (p¼0.065). In comparison
with the group of anxious patients, the non-anxious
group had a better asthma control (p<0.05).
Respiratory function tests did not show a significant
difference between the anxiety and non-anxiety
groups. Finally, the proportion of patients with
depression was higher among those with anxiety (80%
vs 16%, p<0.0001).
The prevalence of depression was 83/164 (50.6%;
95% CI: 43.0%–58.2%). Table 2 shows that the pro-
portion of women (p¼0.009) as well as the mean
BMI (p¼0.012) was significantly higher in the group
of patients with depression. However, when patients
were classified according to their nutritional status no
difference was seen between the depression and non-
depression groups (p¼0.208). In both groups the
most frequent comorbid atopic disease was allergic
rhinitis. In comparison to patients without depression
patients with asthma and depression had a signifi-
cantly lower level of asthma control (p<0.05)
although respiratory function tests did not differ
between them. Finally, the frequency of anxiety was
significantly higher in the group of patients with
depression (p<0.0001).
Table 3 shows the factors associated with anxiety in
patients with asthma. Among these factors depression
was the most important (OR: 26.00, p<0.0001)
whereas an ACT score !20 diminished this risk by
approximately 70% (OR: 0.29; p¼0.007); allergic
asthma also diminished the risk by an equal extent
(OR: 0.29; p¼0.024). Regarding the factors associated
to depression we found that, besides anxiety, (OR:
25.33, p<0.0001) obesity was an independent risk
factor associated with depression in patients with
asthma (OR: 3.66; p¼0.014) Table 4.
Discussion
Our study found a high prevalence of anxiety and
depression (>50%) in patients with asthma. It also
shows that patients with controlled asthma and aller-
gic sensitization have a lower risk of anxiety whereas
depression was associated with obesity and anxiety.
The association between anxiety or depression and
poorly controlled asthma could be the result of diverse
mechanisms such as unhealthy lifestyle or lack of self-
care, a diminished ability of patients to accurately
describe their symptoms to their treating physician, or
JOURNAL OF ASTHMA 3

through the direct effects these disorders have on the
immune and autonomic nervous systems (8).
In this study the patients with anxiety had a lower
level of asthma control compared to the non-anxious
group. However, due to the characteristics of our study
design we couldn’t stablish the direction of the rela-
tionship between anxiety and the level of asthma con-
trol. Nonetheless, a bidirectional association, i.e.,
patients with asthma and anxiety are more likely to
perceive their symptoms as being more severe and con-
versely patients whose asthma is poorly controlled have
an increased risk of anxiety due to the fear of having
an exacerbation, between these variables was recently
documented in another study (9). The high proportion
of patients whose asthma wasn’t under control seen in
our study could be attributed, at least in part, to the
characteristics of our population since it was comprised
of first-time patients and many of them were newly
diagnosed and hadn’t received proper education about
their disease, also some patients didn’t have healthcare
access and had to buy their treatment themselves
resulting in lower treatment adherence.
An interesting finding of our study is that allergic
asthma was associated with a lower risk of anxiety. To
the best of our knowledge we are not aware of studies
that have reported similar results, although the role of
allergy on anxiety has been previously
described (14,15).
Similar to the direction of the association between
asthma control and anxiety explained above, a bidirec-
tional relationship between obesity and depression has
also been reported as possible (11,12). It has been
observed that anxiety and depression in the presence
of obesity can increase the risk of developing asthma
(13). This risk also increases with age as patients with
asthma who are overweight and !65 years have a
higher risk of depression (26). In Italy, patients with
asthma and depression had a higher BMI in compari-
son to patients who did not suffer from depression
(27). Conversely, the first Israel National Health
Survey failed to show an association between obesity
and depression in patients with asthma (28). In Latin
America the prevalence of obesity and overweight has
increased significantly in recent years. Consequently,
Table 1. Clinical characteristics of patients in the anxiety and non-anxiety groups.
Anxiety
Yes
n¼89
No
n¼75 p
Age, years, mean ± SD 40.6 ± 14.5 37.2 ± 13.4 0.127
Female, n (%) 79 (88.8) 52 (69.3) 0.002
Current smokers, n (%) 5 (5.6) 5 (6.7) 0.780
Current drinkers, n (%) 14 (15.7) 19 (25.3) 0.126
BMI, Kg/m
2
, mean ± SD 29.6 ± 6.7 28.8 ± 4.8 0.348
BMI, n (%) 0.935
Normal 26 (29.2) 20 (26.7)
Overweight 26 (29.2) 23 (30.7)
Obesity 37 (41.6) 32 (42.7)
Comorbid atopic diseases, n (%)
Allergic rhinitis 64 (71.9) 63 (84.0) 0.065
Food allergy 12 (13.5) 13 (17.3) 0.494
Atopic dermatitis 6 (6.7) 4 (5.3) 0.756
ACT
Mean ± SD 15.0 ± 4.9 17.3 ± 5.4 0.004
Median (P
25
-P
75
) 15 (11 to 18) 18 (14 to 22) 0.004
Minimum-Maximum 6 to 24 5 to 25
!20, n(%) 19 (21.3) 33 (44.0) 0.002
Pulmonary function, % of predicted
Pre-bronchodilator, mean ± SD
FVC 88.2 ± 14.7 90.8 ± 20.6 0.348
FEV
1
72.3 ± 16.3 75.3 ± 20.4 0.307
FEV
1
/FVC 67.8 ± 10.4 68.6 ± 10.2 0.618
Post-bronchodilatador, mean ± SD
FVC 95.8 ± 18.2 98.4 ± 17.6 0.361
FEV
1
86.8 ± 16.3 87.9 ± 20.4 0.690
FEV
1
/FVC 73.5 ± 9.2 74.6 ± 9.7 0.480
Allergic asthma, n (%) 69 (77.5) 63 (84.0) 0.297
Hospitalizations in the previous year, n (%) 30 (33.7) 21 (28.0) 0.431
Depression, n (%) 71 (79.8) 12 (16.0) <0.0001
pvalues were obtained using Student’s t tests, Chi square tests, Fisher’s exact tests or Mann-Whitney U tests as appropriate.
SD: Standard deviation.
BMI: Body mass index.
ACT: Asthma control test.
FVC: Forced vital capacity.
FEV
1
: Forced expiratory volume in 1 s.
4 M. BEDOLLA-BARAJAS ET AL.

an increase in the number of patients with depression
is expected to occur, especially if asthma is present as
a comorbid disease. Therefore, therapeutic
interventions directed not only to achieve asthma con-
trol but also weight loss could lead to a decrease in
the frequency of depression in patients with asthma.
Table 2. Clinical characteristics of patients in the depression and non-depression groups.
Depression
Yes
n¼83
No
n¼81 p
Age, years, mean ± SD 40.3 ± 13.7 37.8 ± 14.3 0.253
Female, n (%) 73 (88.0) 58 (71.6) 0.009
Current smokers, n (%) 4 (4.8) 6 (7.4) 0.532
Current drinkers, n (%) 16 (19.3) 17 (21.0) 0.785
BMI, Kg/m
2
, mean ± SD 30.4 ± 6.5 28.1 ± 5.0 0.012
BMI, n (%) 0.208
Normal 19 (22.9) 27 (33.3)
Overweight 24 (28.9) 25 (30.9)
Obesity 40 (48.2) 29 (35.8)
Comorbid atopic disease, n (%)
Allergic rhinitis 64 (77.1) 63 (77.8) 0.918
Food allergy 13 (15.7) 12 (14.8) 0.880
Atopic dermatitis 7 (8.4) 3 (3.7) 0.329
ACT
Mean ± SD 15.2 ± 4.9 16.8 ± 5.5 0.045
Median (P
25
-P
75
) 15 (12 to 20) 17 (13 to 22) 0.039
Minimum-Maximum 6 to 24 5 to 25
!20, n(%) 21 (25.3) 31 (38.3) 0.074
Pulmonary function, % of predicted
Pre-Bronchodilator, mean ± SD
FVC 88.7 ± 15.0 90.1 ± 20.1 0.602
FEV
1
72.8 ± 16.3 74.6 ± 20.2 0.534
FEV
1
/FVC 67.9 ± 10.2 68.4 ± 10.4 0.715
Post-Bronchodilator, mean ± SD
FVC 96.9 ± 16.2 97.2 ± 19.6 0.918
FEV
1
87.3 ± 16.5 87.3 ± 20.1 0.918
FEV
1
/FVC 74.0 ± 9.0 74.0 ± 10.0 0.998
Allergic asthma, n (%) 69 (83.1) 63 (77.8) 0.387
Hospitalizations in the previous year, n (%) 25 (30.1) 26 (32.1) 0.784
Anxiety, n (%) 71 (85.5) 18 (22.2) <0.0001
pvalues were obtained using Student’s t tests, Chi square tests, Fisher’s exact tests or Mann-Whitney U tests as appropriate.
SD: Standard deviation.
BMI: Body mass index.
ACT: Asthma control test.
FVC: Forced vital capacity.
FEV
1
: Forced expiratory volume in 1 s.
Table 3. Factors associated with anxiety in adult asthmatic patients.
Non-adjusted model Adjusted model
OR 95% CI pOR 95% CI p
Depression
No 1 1
Yes 32.71 12.03–88.91 <0.0001 26.00 10.61–63.72 <0.0001
Sex
Female 1
Male 0.44 0.14–1.31 0.140 –– 0.121
ACT !20
No 1 1
Yes 0.26 0.10–0.67 0.006 0.29 0.12–0.71 0.007
BMI
Normal 1
Overweight 0.51 0.16–1.60 0.510 –– 0.989
Obesity 0.29 0.10–0.90 0.033 –– 0.066
Allergic asthma
No 1 1
Yes 0.27 0.08–0.86 0.027 0.29 0.10–0.85 0.024
OR were obtained using binary logistic regression. All variables were dichotomous except for age which was continuous.
95% CI: 95% Confidence interval.
GINA: Global Initiative for Asthma.
ACT: Asthma control test.
BMI: Body mass index.
JOURNAL OF ASTHMA 5

In Latin America, there are few research studies on
obesity and depression in patients with asthma, thus
our study provides valuable information about this
population by showing that patients with asthma and
obesity have an increased risk of suffering depression
by up to 4 times.
Interestingly, the variables: asthma control, allergic
sensitization, and sex were not associated with depres-
sion. From an epidemiological perspective, depressive
disorders occur more frequently in women. This trend
starts at adolescence and the highest levels of inci-
dence are reached at the age of 20–40 years (16). It is
likely that sex-specific immune mechanisms, which
are subject to hormonal and genetic influences, under-
lie the differences seen in the frequency of mood dis-
orders between men and women (29). In our study
women had a higher risk of depression in the univari-
ate model but this difference was not significant;
therefore, the variable sex was not included in the
final multivariate model, which might be explained
because depression is a disorder that occurs primarily
during reproductive years (16) and the mean age of
the women in the population we studied was in the
fifth decade.
If the relationship between asthma control and
depression is bidirectional, then depression could
modify the degree of severity with which symptoms
are perceived by patients and consequently alter the
level of asthma control, while poorly controlled
asthma could lead to depression (10). With respect to
allergic asthma and depression, it has been proposed
that these two variables are positively related to each
other. Similarly, a study conducted in patients with
allergic rhinitis found that the severity of depressive
symptoms increased during pollen season (30). We
have previously reported that allergic sensitization
wasn’t associated with depression, but was the chronic
course of the disease that did it (31).
With regard to the lack of association between the
severity of asthma with depression and anxiety could
be explained by the way in which the severity of the
disease was defined. Asthma-related hospitalizations is
a subrogated variable as an indirect measure of the
severity of the disease, so it is possible that no associ-
ation has been found where it actually exists (type II
error in the hypothesis testing).
Worldwide, diverse instruments have been used to
assess anxiety and depression in patients with asthma;
in this study a large number of patients with these
disorders were identified using the BAI and BDI-II.
However, there are studies whose results differ
importantly from ours. Also, diverse multicentric
studies that have followed the same methodology have
yielded different results on the prevalence of depres-
sion and anxiety (4,32).
Factors such as the instruments used, cultural and
socioeconomic differences, and the presence of
comorbidity (5–7) can have an important impact on
the observed prevalence of these disorders. Thus, in
order to prevent the impact of confounding variables
we decided to exclude pregnant or breastfeeding
women and patients with a background of chronic-
degenerative diseases, recent systemic steroids usage,
exacerbated asthma in the previous month or loss of a
family member. It’s likely that the high frequency of
anxiety and depression seen in this study could be
Table 4. Factors associated with depression in adult asthmatic patients.
Non-adjusted model Adjusted model
OR 95% CI pOR 95% CI p
Anxiety
No 1 1
Yes 28.67 11.18–73.52 <0.0001 25.33 10.58–60.62 <0.0001
Sex
Female 1
Male 0.59 0.19–1.76 0.341 –– 0.404
ACT !20
No 1
Yes 1.40 0.54–3.63 0.484 –– 0.531
BMI
Normal 1 1
Overweight 1.91 0.64–5.68 0.246 1.96 0.68–5.68 0.214
Obesity 3.51 1.23–9.98 0.019 3.66 1.30–10.29 0.014
Allergic asthma
No 1
Yes 2.49 0.90–6.92 0.080 –– 0.085
OR were obtained using binary logistic regression. All variables were dichotomous except for age which was continuous.
95% CI: 95% Confidence interval.
GINA: Global Initiative for Asthma.
ACT: Asthma control test.
BMI: Body mass index.
6 M. BEDOLLA-BARAJAS ET AL.

partially explained because the population was com-
prised of first-time patients and many of them did
not have an adequate level of asthma control as it has
been shown that patients experience improvement of
these mental disorders after receiving guideline-
directed medical therapy (33).
The limitations of this study include that the diag-
nosis of anxiety and depression were made through
the use of the BAI and BDI-II and not by a psych-
iatrist. Nonetheless, the BAI and BDI-II are tools that
have previously demonstrated their ability to detect
patients with these conditions. We also didn’t assess
the history of depression and anxiety episodes that
occurred >2 weeks and >1 month, respectively, prior
to the application of these instruments. Another limi-
tation is that because of the cross-sectional nature of
this study we couldn’t stablish temporal relationships
between the clinical course of asthma with anxiety
and depression. On the other hand, our results should
be interpreted in the light of the setting where our
research was carried out; it is a university hospital,
which attends a population that does not have regular
social medical care. In this study, although sex was
not associated with anxiety or depression, it should be
noted that women predominated in the sample which
could have modified the results; however, it is known
that in Mexico, women often request health services
more frequently than men, so the sample is a reflec-
tion of this. Another limitation is also noteworthy:
patients could not be categorized by the severity of
asthma according to the need for treatment; since
they were newly diagnosed asthma patients (first visit
to our clinic), most of them used only short-acting
bronchodilators as the only therapy. Finally, diagnosis
such as diabetes, hypertension, rheumatoid arthritis,
urticaria, kidney disease, or neoplasia were stablished
by means of a medical interview and weren’t con-
firmed by diagnostic tests.
Some of the strengths of this study are that the
included patients were consecutively recruited, thus
reducing the risk of selection bias. The cross-sectional
association design is ideal for identifying prevalence
and also allows exploring non-causal associations
between variables. Beck Depression Inventory-II (BDI-
II) and the Beck Anxiety Inventory (BAI) are two
instruments validated in the Mexican population. In
the pulmonary function tests, equipment, procedures,
and reference values valid worldwide were used. In
the skin-prick test were performed and interpreted
following international standards. Multivariate analysis
using binary logistic regression is the appropriate
technique to find associations between variables in
cross-sectional designs. Also, the impact of confound-
ing variables related to anxiety and depression was
minimized by the exclusion criteria, and the multi-
variate analysis allowed us to perform covari-
ate adjustment.
In summary, a large number of patients with
asthma suffer from anxiety and depression, and
according to the hypothesis, adequate asthma control
and an allergic asthma phenotype were among the
most important factors that were associated with a
lower risk of anxiety, whereas depression conferred a
higher risk. The most important factors related to
depression were anxiety and obesity.
Conflict of interests
The authors report no conflicts of interest.
Author contributions
Mart!
ın Bedolla-Barajas conceived the study design,
oversaw its conduct, did the statistical analysis, and
wrote the first draft of the article; Jaime Morales-
Romero did the statistical analysis, and wrote the first
draft of the article; D!
esir!
ee Larenas-Linnemann com-
mented on study results and wrote the first draft of
the article, Norma Ang!
elica Pulido-Guill!
en, contrib-
uted elements of the study design, collected patient
information, and helped write and revise the article;
Juan Carlos Fonseca-L!
opez, and Dante Daniel
Hern!
andez-C!
olin, helped conduct the study, collect
and interpret the data.
ORCID
Mart!
ın Bedolla-Barajas http://orcid.org/0000-0003-
4915-1582
Jaime Morales-Romero http://orcid.org/0000-0002-
1492-1797
Norma Ang!
elica Pulido-Guill!
en http://orcid.org/0000-
0001-7926-1817
D!
esire!
e Larenas-Linnemann http://orcid.org/0000-0002-
5713-5331
Dante Daniel Hern!
andez-Col!
ınhttp://orcid.org/0000-
0002-2424-9455
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