Study links rescue inhaler overuse to depression

A new research study reveals that "overuse of rescue inhaler in chronic asthmatics linked to depression." While the researchers were not conclusive on how to interpret these results, they seem to be leaning towards blame the asthmatic.

The study was conducted by the University of Arizona and involved 416 patients.  The results were as follows:

• About half of all participants used albuterol as expected, while 27 percent of participants overused albuterol and 22 percent underused albuterol.
• 45 percent of over-users used albuterol on a daily basis.
• Participants across the board used albuterol on symptom-free days about 20 percent of the time.
• Eighty-eight percent of daily users were over-users of albuterol.
• Over-users had more days in which they had symptoms and scored worse on the asthma control questionnaire, the shortness of breath questionnaire and the asthma symptom utility index.
• Over-users of albuterol had worse mental functioning when compared to expected users of albuterol.

So that was the first part of the study.  The participants were also studied to see how they scored on a depression test, with the following results. 

• 19% of those who underused albuterol had a depression score of 16 or more
• 17% of those who used albuterol as expected had a depression score of 16 or more
• 32% of those who used albuterol too much had a depression score of 16 or more

Researchers who interpret studies concluded the following: 

What isn’t clear is whether depression leads to worsened asthma symptoms and an increase in albuterol use or whether albuterol use contributes to the development of depression. Asthma has a significant relationship with one’s mental status, and emotional states like anxiety can contribute to asthma exacerbations, leading to the need for a rescue inhaler.

It also isn’t clear whether or not albuterol over-users were more or less compliant with the chronic medications asthmatics take on a regular basis in order to avoid exacerbations of their disease process. If this is the case, doctors need to educate patients — depressed or not — on the use of chronic asthma medications so rescue inhalers like albuterol are less necessary.

My problem with these results is this: Why do they always blame the asthmatic?  If I don't have good asthma control, it's because I don't take my asthma controller medicines.  Plus, how do you define albuterol overuse? I mean, I know they define it as using it more frequently than a doctor prescribes for, but how do they know the doctor is right.

Let me put it this way, many recent studies have confirmed that corticosteroids, a top line medicine used to reduce inflammation in asthmatic lungs to make them less sensitive to asthma triggers, does not work on those with severe asthma. Inhaled corticosteroids do not help those with severe asthma gain good asthma control.  So these patients, by default, will need to use their rescue medicine more frequently.

Likewise, most asthmatics do not have pure asthma, or asthma by itself.  Like myself, most asthmatics have something else with it, like allergies.  Actually, studies show that 75% of asthmatics also have allergies, and this is a double whammy.  My point here is that, even if you have good control, you can still have trouble breathing on a regular basis.  You may still need to use your rescue inhaler daily.

Yes, if you have pure asthma you shouldn't need your rescue inhaler more than 2-3 times in a 2 week period. There are many asthmatics who would fall into this category.  Still, there are likewise many asthmatics who do not qualify for this method of defining control because they do not have pure asthma.

I describe what real asthma control is in my post"What is good asthma control?"  I wrote:

The National Heart Lung and Blood Institutes (NHLBI) Asthma Guidelines define control pretty much the same as the GINA guidelines: Control is the degree the above guidelines are met plus the degree YOUR goals of therapy are met.

Your goals may be:

• I just want to be able to walk
• I want to be able to exercise
• I don't want to miss any more school or work due to my asthma

Another means to monitor control is your own personal satisfaction. Are you satisfied with your life given your asthma severity?

Plus this notion of monitoring control by how often you use your rescue inhaler doesn't work if you don't have pure asthma.  For instance, my current doctor ordered my rescue inhaler to be used four times a day. Well, how does he know when I'm going to be short of breath?  Sometimes I go weeks without using it. Other times, such as right now when I have a cold, I use it several times a day.

My point here is that you need to be careful when reading the results of research like this.  You have to take what you read, even in peer reviewed journals, with a grain of salt. While the studies themselves come to accurate conclusions, the people who interpret the results sometimes get it wrong.  They get it wrong because they do not have asthma so they don't know what it's like.

Further reading:

• Eureka Alert: Study: Severe asthma fails to respond to mainstay treatment
• Hardluck Asthma: What's it like to have asthma?
• NHLBI: Asthma Guidelines
• RT Magazine: overuse of rescue inhaler in chronic asthmatics linked to depression
• Lung Disease News: Overuse of rescue inhalers in asthmatics linked to depression
• Healthcentral: What is good asthma control?
• Healthcentral: How to obtain good control of your asthma?