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Original Research: ASTHMA |

The Asthma/Mental Health Nexus in a Population-Based Sample of the United States FREE TO VIEW

Thomas H. Chun, MD; Sherry H. Weitzen, PhD; Gregory K. Fritz, MD
Author and Funding Information

*From the Departments of Emergency Medicine (Dr. Chun), Community Health (Dr. Weitzen), and Psychiatry and Human Behavior (Dr. Fritz), The Warren Alpert Medical School of Brown University, Providence, RI.

Correspondence to: Thomas H. Chun, MD, Department of Emergency Medicine, Potter 159, 593 Eddy Street, The Warren Alpert Medical School of Brown University, Providence, RI 02903; e-mail: Thomas_Chun@Brown.edu


The authors have no conflicts of interest to disclose.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

For editorial comment see page 1116


Chest. 2008;134(6):1176-1182. doi:10.1378/chest.08-1528
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Background:  Asthma is one of the most prevalent chronic medical conditions in the United States. The relationship of asthma with psychological factors has been known for centuries, and recently there has been a resurgence of interest in this topic. This study investigates the relationship between current asthma and poor mental health in a nationally representative sample of the US population.

Methods:  This study utilizes data from the 2006 Behavioral Risk Factor Surveillance System survey (n = 355,710). A multinomial logistic regression model was constructed to assess the relationship between current asthma and poor mental health. The relationship between formerly having asthma and poor mental health was also investigated.

Results:  Persons reporting poor mental health have increased risk of currently having asthma compared to persons reporting good mental health. Additionally, this asthma/mental health relationship has a “dose-response” relationship. For every incremental increase in days of poor mental health, there is a corresponding increase in risk of currently having asthma. Previously reported risk factors for asthma (ie, age, gender, race, marital, smoking, overall health, exercise, obesity, and socioeconomic status) were all found to be important covariates of asthma. The relationship between former asthma and poor mental health is less clear.

Conclusions:  This large, nationally representative sample confirms the relationship between asthma and mental health symptoms. Any degree of poor mental health appears to increase one's risk for asthma. Future research is needed to determine the causal and/or physiologic relationship between asthma and mental health symptoms.

The recognition of a link between asthma and mental state dates back to at least the 12th century. Moses Maimonides, a medieval rabbi, physician, and philosopher, noted in the treatment of a sultan's son, that the control of asthma required the treatment of the “total patient.”1 Prior to understanding the pathophysiology of asthma, asthma was thought to be psychogenic in origin and referred to as “asthma nervosa.”2 Psychoanalytic writers in the 1940s and 1950s labeled asthma one of seven illnesses caused by emotional conflicts,3 but subsequent investigations did not support this theory.4

In the last decade, there has been a resurgence of interest in the relationship between asthma and psychological factors. Early work included defining the prevalence of mental disorders in asthma populations5,6 and examining the relationship between asthma severity and psychological problems.7 More recent work has either included comparison groups or been population based, which has resulted in a better understanding of the true association between asthma and mental health. Studies have consistently found increased odds of having asthma in patients with anxiety disorders (range of odds ratio [OR], 1.5 to 5.5),812 mood disorders (OR range, 2.4 to 5.6),812 somatoform disorders (OR, 1.7),8 and adjustment disorder (OR, 1.4).12 Patients with more severe posttraumatic stress disorder have been found to have 2.3 times the odds of having asthma.13

Most previous studies have not investigated the asthma/mental health relationship in a population as large or diverse as that of the United States. Some previous studies1416 have used nationally representative data sets to explore this issue but have other limitations, including limiting their studies to subjects reporting ≥ 14 days of poor mental health and/or omitting important risk factors and potential confounders for asthma from their analyses.

The purpose of this study is to investigate the relationship between perceived poor mental health and the likelihood of currently having asthma in a nationally representative sample of US adults, adjusting for potential confounders and effect measure modifiers. This study investigates two specific hypotheses. First, does any level of mental health impairment affect asthma? And second, is there a “dose-response” relationship between mental health symptoms and asthma?

The Behavioral Risk Factor Surveillance System (BRFSS) is a health-monitoring survey of noninstitutionalized adults administered by telephone at the state level. It is conducted by the Centers for Disease Control and Prevention and since 1994 has been administered annually in all 50 states, Washington, DC; Puerto Rico; the US Virgin Islands; and Guam. Results are weighted accordingly to yield a nationally representative sample of the US population. This study uses data from the 2006 BRFSS survey and was Institutional Review Board exempt.

The outcome of interest for this study was current asthma prevalence in the United States. To be classified as currently having asthma, a BRFSS subject would need to have answered yes to the following two questions: “Have you ever been told by a doctor, nurse, or other health-care provider that you had asthma?” and “Do you still have asthma?” Subjects who answered yes to the first question and no to the second are coded as formerly having asthma. Subjects who answered no to both questions are coded as never having asthma.

The primary exposure of interest was perceived poor mental health. The BRFSS asks subjects: “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?” In this study, subjects were coded into one of five categories, depending on the number of days of poor mental health they reported: 0 days, 1 to 7 days, 8 to 14 days, 15 to 21 days, and 22 to 30 days. Poor mental health was divided into these five categories to determine whether different levels of mental health impairment are associated with asthma and if there is a dose-response relationship between mental health symptoms and asthma.

Other covariates included in this analysis were age, gender, race/ethnicity, marital status, smoking status, general overall health status, exercise status, obesity, socioeconomic status (SES), and proximity to an urban environment, which have all been shown to be important risk factors for asthma and/or negative health outcomes.14,1621

The entire BRFSS sample (n = 355,710) comprised the study group. Subjects with missing data for asthma (n = 2,225), poor mental health data (n = 6,141), race/ethnicity (n = 3,790), marital status (n = 1,493), smoking status (n = 1,475), general overall health status (n = 1,359), exercise status (n = 411), obesity (n = 17,484), education attainment (n = 990), and proximity to an urban environment (n = 7,920), were dropped from the analysis, resulting in a final sample of 318,151 subjects (89.4%). Because of the large number of respondents who declined to specify their income (n = 49,926), these respondents were coded as their own income category and included in the analyses.

Weighted statistical analyses were performed using Stata version 10.0 (StataCorp; College Station, TX). The “svy” command was utilized for all analyses to account for the complex survey design of the BRFSS. Reported results are thus representative of the entire US population.

Bivariate analysis between the exposure and demographic variables and other covariates was performed. To determine if poor mental health was independently associated with current asthma, a multinomial logistic regression model was constructed. This model additionally assessed the relationship between poor mental health and formerly having asthma.

Table 1 presents the results of the bivariate analysis between number of days of poor mental health and the included demographic variables and the final model covariates. Respondents in the oldest age group (> 65 years) consistently were the smallest proportion of respondents in all categories of poor mental health. Women reported significantly worse mental health across all categories. Divorced, separated, and never-married individuals were disproportionately more represented in the poorest mental health categories, where being married or an individual who is part of an unmarried couple appears to have a protective effect. Any history of smoking was associated with poorer reports of mental health. Overall general health, exercise status, and obesity were also associated with poor mental health. Both proxy variables for SES (educational attainment and income) showed that lower SES was associated with an increased reported number of days of poor mental health. Racial and ethnic groups and proximity to a metropolitan area (MA) were evenly distributed across all categories of poor mental health.

Table Graphic Jump Location
Table 1 Prevalence of Mental Health Status by Demographic Characteristics*

*Data are presented as %.

Table 2 presents the prevalence of asthma in the entire 2006 BRFSS sample and by exposure and outcome categories. After adjusting for covariates, respondents reporting poor mental health over the past 30 days had increased risk of currently having asthma (Table 3). Compared to respondents reporting no days of poor mental health, respondents reporting ≤ 1 week of poor mental health had 1.38 times the risk of having current asthma (95% confidence interval [CI], 1.09 to 1.75). Those reporting 1 to 2 weeks of poor mental health had a relative risk ratio (RRR) of 1.49 (95% CI, 1.23 to 1.81). The RRR for respondents who had 2 to 3 weeks of poor mental health was 1.67 (95% CI, 1.17 to 2.39), and those who had ≥ 3 weeks of poor mental health had an RRR of 2.75 (95% CI, 1.84 to 4.09).

Table Graphic Jump Location
Table 2 Prevalence of Asthma, 2006 BRFSS, and by Exposure Categories; Total Sample 8.0%*

*Data are presented as %.

Table Graphic Jump Location
Table 3 RRRs by Asthma and Mental Health Status and Demographics*

*Data are presented as RRR (95% CI).

In this sample, age, gender, race/ethnicity, smoking, general health status, exercise status, obesity, and SES were all found to be important covariates. The youngest age group (18 to 24 years) had the highest risk (1.43) of asthma of any age group, while the oldest group (> 65 years) had the lowest risk of asthma. Women had a greater risk of having asthma (RRR, 1.41), while Hispanics had markedly lower risk of having asthma (RRR, 0.39).

Respondents who rated their general health status as fair or poor had 1.31 times the risk of having asthma, compared to those who rated their health as good, very good, or excellent. Similarly, respondents who reported no physical activity or exercise in the last 30 days had 1.12 the risk of having asthma, compared to those who reported ≥ 1 day of physical activity or exercise. Investigation of smoking status and asthma yielded unexpected results. Those who smoked every day had an RRR of 0.94, smoking “some days” resulted in an RRR of 1.35, while former smokers had an RRR of 1.32. Both being overweight (RRR, 1.16) or obese (RRR, 1.67) increased the risk of having asthma.

Both SES proxy variables demonstrated a relationship between SES and asthma. Those who did not graduate from high school had an RRR of 1.10, compared to college or technical school graduates. Respondents in the two lowest annual income groups (< $15,000 and $15,000 to $24,999) had 2.55 and 1.75 the risk, respectively, of having asthma, compared to the highest annual income group (> $50,000). Respondents with missing income data were most similar to the highest annual income group, with an RRR of 1.01 for having asthma.

The relationship between former asthma and poor mental health is also presented in Table 3. There is an association between poor mental health and formerly having asthma, but the risk is not as great and does not follow a consistent pattern. Additionally, the relationship between the covariates (especially age, gender, race, smoking status, obesity, SES, and proximity to an MA) and former asthma are markedly different than that seen with current asthma.

There are two major findings of this study. The first is that respondents with any degree of mental health impairment, even those who reported < 14 days of poor mental health, were at increased risk of reporting current asthma. Those reporting ≤ 1 week of poor mental health had an RRR of 1.38 for having asthma, while those reporting 1 to 2 weeks of poor mental health had an RRR of 1.49. The second major finding is that the nexus between mental health impairment and current asthma appears to have a dose-response relationship. For each incremental (in this study, 1-week) increase of poor mental health that a respondent reported, there was a corresponding increase in the risk of having current asthma. The RRRs for < 1 week and 1 to 2 weeks of poor mental health are cited above. The RRR for 2 to 3 weeks of poor mental health was 1.67. The RRR for > 3 weeks of poor mental health was 2.75.

These two findings in a very large, nationally representative sample of noninstitutionalized adults in the United States add to the findings of previous studies of a robust and real relationship between asthma and mental health. Major unanswered questions are as follows: What is the exact nature of the relationship? Are the two conditions causally related to the other? If so, how?

Early work hypothesized that emotions may influence autonomic nervous function, ultimately resulting in cholinergically mediated bronchoconstriction.2224 More recent work has focused on psychoneuroimmunology. Psychological stress may affect asthma through dysregulation of the hypothalamic-pituitary-adrenal axis. Release of neuroendocrine hormones affect the immune system, which in turn affects the inflammatory and allergic response to infectious agents and/or allergens. A plethora of studies2527 have shown that stress directly or indirectly affects cortisol; epinephrine; norepinephrine; corticotrophin; corticotrophin-releasing hormone; adrenocorticotropic hormone; vasopressin; mast-cell degranulation; substance P; growth hormone; prolactin; endorphins; enkephalins; type 1 and type 2 cytokine production (including interferon-γ, interleukin [IL]-4, IL-5, IL-10, IL-12, and IL-13); IgE production; and downregulation of cellular glucocorticoid receptors.

In this study, Hispanic ethnicity had a protective effect regarding asthma. Some studies14,19,20,2830 have found higher risks of asthma among Hispanics, where others studies19,21 have found that race/ethnicity is a confounder and that factors related to poverty are more significant predictors of asthma than race/ethnicity. There are several possible explanations for this study's finding. There may be significant differences in asthma prevalence among Hispanic subgroups. Several studies31,32 have found that people of Mexican descent have markedly lower rates of asthma, compared to both non-Hispanic and other Hispanic groups. Using US census data, the Pew Hispanic Center33 estimates that persons from Mexico are the largest Hispanic subgroup, comprising nearly two thirds of all US Hispanics. This large number of Mexican Hispanics, combined with the low prevalence of asthma among people from Mexico, may account for the observed protective effect of Hispanic ethnicity. Another possible explanation is misclassification or misreporting of either asthma or ethnicity status, or both. The BRFSS is administered in Spanish in some but not all states. Administering the BRFSS in English to someone of Hispanic ethnicity might result in misclassification or misreporting.

It is not clear why persons who smoke every day have a lower risk of currently having asthma. It is possible that this may be an example of reverse causality (ie, people who currently have asthma avoid smoking every day because it exacerbates their asthma). Alternatively, people with asthma may be more successful at quitting or cutting down on their smoking, compared to people without asthma.

Former asthmatics were not the focus of this study. They appear to be quite different from current asthmatics, as evidenced by the disparate RRRs for poor mental health and many of the covariates of the model. This suggests that former asthmatics should be, and were appropriately analyzed in a multinomial model as their own separate outcome group.

There are several limitations to this study. Both poor mental health and asthma status are based on self-report. More objective measures such as physician examinations or records, pulmonary function tests, or validated psychological tests would be preferable. While the BRFSS question on poor mental health has been shown to have good construct3439 and criterion validity,40,41 and acceptable test-retest reliability,38 it has not been validated for diagnosing specific mental disorders. While self-reports of asthma have been shown to have good specificity (ie, respondents without asthma are very unlikely to report having asthma),42,43 they may be biased by disease severity. Specifically, subjects with mild asthma may be less likely to report their asthma.

The BRFSS surveys respondents who are noninstitutionalized, have a land-line telephone, and is administered only in English and Spanish. It is quite possible that these populations are underrepresented in this survey and have different risks for asthma and poor mental health than the general population. Additionally, due to the cross-sectional nature of the survey data, it is not possible to assess any temporal or cause-and-effect relationships between poor mental health and asthma. Finally, due to the limitations of the BRFSS data set, there are many important asthma risk factors that were not included in the final model (ie, history of prematurity, maternal smoking history, history of breastfeeding, lifetime medication exposures, family history asthma and allergic diseases, and allergen/environmental exposures).

To the best of our knowledge, this is the largest study to investigate the asthma/mental health nexus. Future research should address the issues of confounders that have not yet been fully investigated and to further elucidate the temporal and causal relationship between asthma and mental health. Ideally, these studies will use objective and/or well-validated measures of both asthma and mental health status/diagnoses. The burgeoning literature on the psychobiology of mental health and asthma portends a bright and fascinating future for this topic.

BRFSS

Behavioral Risk Factor Surveillance System

CI

confidence interval

IL

interleukin

MA

metropolitan area

OR

odds ratio

RRR

relative risk ratio

SES

socioeconomic status

Rosner F. Moses Maimonides' treatise on asthma. Thorax. 1981;36:245-251. [PubMed] [CrossRef]
 
Osler W. The principles and practice of medicine. 1892; Edinburgh, Scotland YJ Pentland
 
French TM AF. Psychogenic factors in bronchial asthma. 1941; Washington DC National Research Council
 
Fritz GK. Childhood asthma. Psychosomatics. 1983;24:959-967. [PubMed]
 
Bussing R, Burket RC, Kelleher ET. Prevalence of anxiety disorders in a clinic-based sample of pediatric asthma patients. Psychosomatics. 1996;37:108-115. [PubMed]
 
Ortega AN, Huertas SE, Canino G, et al. Childhood asthma, chronic illness, and psychiatric disorders. J Nerv Ment Dis. 2002;190:275-281. [PubMed]
 
Wamboldt MZ, Fritz G, Mansell A, et al. Relationship of asthma severity and psychological problems in children. J Am Acad Child Adolesc Psychiatry. 1998;37:943-950. [PubMed]
 
Goodwin RD, Jacobi F, Thefeld W. Mental disorders and asthma in the community. Arch Gen Psychiatry. 2003;60:1125-1130. [PubMed]
 
Richardson LP, Lozano P, Russo J, et al. Asthma symptom burden: relationship to asthma severity and anxiety and depression symptoms. Pediatrics. 2006;118:1042-1051. [PubMed]
 
Wainwright NW, Surtees PG, Wareham NJ, et al. Psychosocial factors and asthma in a community sample of older adults. J Psychosom Res. 2007;62:357-361. [PubMed]
 
Scott KM, Von Korff M, Ormel J, et al. Mental disorders among adults with asthma: results from the World Mental Health Survey. Gen Hosp Psychiatry. 2007;29:123-133. [PubMed]
 
Lev-Tzion R, Friedman T, Shochat T, et al. Asthma and psychiatric disorders in male army recruits and soldiers. Isr Med Assoc J. 2007;9:361-364. [PubMed]
 
Goodwin RD, Fischer ME, Goldberg J. A twin study of post-traumatic stress disorder symptoms and asthma. Am J Respir Crit Care Med. 2007;176:983-987. [PubMed]
 
Bandiera FC, Pereira DB, Arif AA, et al. Race/ethnicity, income, chronic asthma, and mental health: a cross-sectional study using the behavioral risk factor surveillance system. Psychosom Med. 2008;70:77-84. [PubMed]
 
Ford ES, Mannino DM, Homa DM, et al. Self-reported asthma and health-related quality of life: findings from the behavioral risk factor surveillance system. Chest. 2003;123:119-127. [PubMed]
 
Strine TW, Ford ES, Balluz L, et al. Risk behaviors and health-related quality of life among adults with asthma: the role of mental health status. Chest. 2004;126:1849-1854. [PubMed]
 
Gwynn RC. Risk factors for asthma in US adults: results from the 2000 Behavioral Risk Factor Surveillance System. J Asthma. 2004;41:91-98. [PubMed]
 
Litonjua AA, Weiss ST. Risk factors for asthma. UpToDate On-Line 16.1. 2008;
 
Aligne CA, Auinger P, Byrd RS, et al. Risk factors for pediatric asthma: contributions of poverty, race, and urban residence. Am J Respir Crit Care Med. 2000;162:873-877. [PubMed]
 
Beckett WS, Belanger K, Gent JF, et al. Asthma among Puerto Rican Hispanics: a multi-ethnic comparison study of risk factors. Am J Respir Crit Care Med. 1996;154:894-899. [PubMed]
 
Rosenstreich DL, Eggleston P, Kattan M, et al. The role of cockroach allergy and exposure to cockroach allergen in causing morbidity among inner-city children with asthma. N Engl J Med. 1997;336:1356-1363. [PubMed]
 
Miller BD, Wood BL. Influence of specific emotional states on autonomic reactivity and pulmonary function in asthmatic children. J Am Acad Child Adolesc Psychiatry. 1997;36:669-677. [PubMed]
 
Miller BD, Wood BL. Emotions and family factors in childhood asthma: psychobiologic mechanisms and pathways of effect. Adv Psychosom Med. 2003;24:131-160. [PubMed]
 
Wright RJ, Rodriguez M, Cohen S. Review of psychosocial stress and asthma: an integrated biopsychosocial approach. Thorax. 1998;53:1066-1074. [PubMed]
 
Marshall GD. Neuroendocrine mechanisms of immune dysregulation: applications to allergy and asthma. Ann Allergy Asthma Immunol. 2004;93:S11-S17. [PubMed]
 
Wright RJ. Alternative modalities for asthma that reduce stress and modify mood states: evidence for underlying psychobiologic mechanisms. Ann Allergy Asthma Immunol. 2004;93:S18-S23. [PubMed]
 
Wright RJ. Stress and atopic disorders. J Allergy Clin Immunol. 2005;116:1301-1306. [PubMed]
 
Lieu TA, Lozano P, Finkelstein JA, et al. Racial/ethnic variation in asthma status and management practices among children in managed Medicaid. Pediatrics. 2002;109:857-865. [PubMed]
 
Litonjua AA, Carey VJ, Weiss ST, et al. Race, socioeconomic factors, and area of residence are associated with asthma prevalence. Pediatr Pulmonol. 1999;28:394-401. [PubMed]
 
Miller JE. The effects of race/ethnicity and income on early childhood asthma prevalence and health care use. Am J Public Health. 2000;90:428-430. [PubMed]
 
Lara M, Akinbami L, Flores G, et al. Heterogeneity of childhood asthma among Hispanic children: Puerto Rican children bear a disproportionate burden. Pediatrics. 2006;117:43-53. [PubMed]
 
Moorman JE, Rudd RA, Johnson CA, et al. National surveillance for asthma–United States, 1980–2004. MMWR Surveill Summ. 2007;56:1-54. [PubMed]
 
Pew Hispanic Center Statistical portrait of Hispanics in the United States, 2008, Table 5. Detailed Hispanic origin.Accessed June 12, 2008 Available at:http://pewhispanic.org/factsheets/factsheet.php?FactsheetID=35.
 
Health-related quality of life and activity limitation–eight states, 1995. MMWR Morb Mortal Wkly Rep. 1998;47:134-140. [PubMed]
 
Health-related quality of life–Puerto Rico, 1996–2000. MMWR Morb Mortal Wkly Rep. 2002;51:166-168. [PubMed]
 
Hennessy CH, Moriarty DG, Zack MM, et al. Measuring health-related quality of life for public health surveillance. Public Health Rep. 1994;109:665-672. [PubMed]
 
Ounpuu S, Krueger P, Vermeulen M, et al. Using the U.S: behavior Risk Factor Surveillance System's health related quality of life survey tool in a Canadian city. Can J Public Health. 2000;91:67-72. [PubMed]
 
Andresen EM, Catlin TK, Wyrwich KW, et al. Retest reliability of surveillance questions on health related quality of life. J Epidemiol Community Health. 2003;57:339-343. [PubMed]
 
Ounpuu S, Chambers LW, Chan D, et al. Validity of the US Behavioral Risk Factor Surveillance System's health related quality of life survey tool in a group of older Canadians. Chronic Dis Can. 2001;22:93-101. [PubMed]
 
Andresen EM, Fouts BS, Romeis JC, et al. Performance of health-related quality-of-life instruments in a spinal cord injured population. Arch Phys Med Rehabil. 1999;80:877-884. [PubMed]
 
Newschaffer C. Validation of Behavioral Risk Factor Surveillance System (BRFSS) HRQOL measures in a statewide sample. 1998; Atlanta, GA U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion
 
de Marco R, Cerveri I, Bugiani M, et al. An undetected burden of asthma in Italy: the relationship between clinical and epidemiological diagnosis of asthma. Eur Respir J. 1998;11:599-605. [PubMed]
 
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Figures

Tables

Table Graphic Jump Location
Table 1 Prevalence of Mental Health Status by Demographic Characteristics*

*Data are presented as %.

Table Graphic Jump Location
Table 2 Prevalence of Asthma, 2006 BRFSS, and by Exposure Categories; Total Sample 8.0%*

*Data are presented as %.

Table Graphic Jump Location
Table 3 RRRs by Asthma and Mental Health Status and Demographics*

*Data are presented as RRR (95% CI).

References

Rosner F. Moses Maimonides' treatise on asthma. Thorax. 1981;36:245-251. [PubMed] [CrossRef]
 
Osler W. The principles and practice of medicine. 1892; Edinburgh, Scotland YJ Pentland
 
French TM AF. Psychogenic factors in bronchial asthma. 1941; Washington DC National Research Council
 
Fritz GK. Childhood asthma. Psychosomatics. 1983;24:959-967. [PubMed]
 
Bussing R, Burket RC, Kelleher ET. Prevalence of anxiety disorders in a clinic-based sample of pediatric asthma patients. Psychosomatics. 1996;37:108-115. [PubMed]
 
Ortega AN, Huertas SE, Canino G, et al. Childhood asthma, chronic illness, and psychiatric disorders. J Nerv Ment Dis. 2002;190:275-281. [PubMed]
 
Wamboldt MZ, Fritz G, Mansell A, et al. Relationship of asthma severity and psychological problems in children. J Am Acad Child Adolesc Psychiatry. 1998;37:943-950. [PubMed]
 
Goodwin RD, Jacobi F, Thefeld W. Mental disorders and asthma in the community. Arch Gen Psychiatry. 2003;60:1125-1130. [PubMed]
 
Richardson LP, Lozano P, Russo J, et al. Asthma symptom burden: relationship to asthma severity and anxiety and depression symptoms. Pediatrics. 2006;118:1042-1051. [PubMed]
 
Wainwright NW, Surtees PG, Wareham NJ, et al. Psychosocial factors and asthma in a community sample of older adults. J Psychosom Res. 2007;62:357-361. [PubMed]
 
Scott KM, Von Korff M, Ormel J, et al. Mental disorders among adults with asthma: results from the World Mental Health Survey. Gen Hosp Psychiatry. 2007;29:123-133. [PubMed]
 
Lev-Tzion R, Friedman T, Shochat T, et al. Asthma and psychiatric disorders in male army recruits and soldiers. Isr Med Assoc J. 2007;9:361-364. [PubMed]
 
Goodwin RD, Fischer ME, Goldberg J. A twin study of post-traumatic stress disorder symptoms and asthma. Am J Respir Crit Care Med. 2007;176:983-987. [PubMed]
 
Bandiera FC, Pereira DB, Arif AA, et al. Race/ethnicity, income, chronic asthma, and mental health: a cross-sectional study using the behavioral risk factor surveillance system. Psychosom Med. 2008;70:77-84. [PubMed]
 
Ford ES, Mannino DM, Homa DM, et al. Self-reported asthma and health-related quality of life: findings from the behavioral risk factor surveillance system. Chest. 2003;123:119-127. [PubMed]
 
Strine TW, Ford ES, Balluz L, et al. Risk behaviors and health-related quality of life among adults with asthma: the role of mental health status. Chest. 2004;126:1849-1854. [PubMed]
 
Gwynn RC. Risk factors for asthma in US adults: results from the 2000 Behavioral Risk Factor Surveillance System. J Asthma. 2004;41:91-98. [PubMed]
 
Litonjua AA, Weiss ST. Risk factors for asthma. UpToDate On-Line 16.1. 2008;
 
Aligne CA, Auinger P, Byrd RS, et al. Risk factors for pediatric asthma: contributions of poverty, race, and urban residence. Am J Respir Crit Care Med. 2000;162:873-877. [PubMed]
 
Beckett WS, Belanger K, Gent JF, et al. Asthma among Puerto Rican Hispanics: a multi-ethnic comparison study of risk factors. Am J Respir Crit Care Med. 1996;154:894-899. [PubMed]
 
Rosenstreich DL, Eggleston P, Kattan M, et al. The role of cockroach allergy and exposure to cockroach allergen in causing morbidity among inner-city children with asthma. N Engl J Med. 1997;336:1356-1363. [PubMed]
 
Miller BD, Wood BL. Influence of specific emotional states on autonomic reactivity and pulmonary function in asthmatic children. J Am Acad Child Adolesc Psychiatry. 1997;36:669-677. [PubMed]
 
Miller BD, Wood BL. Emotions and family factors in childhood asthma: psychobiologic mechanisms and pathways of effect. Adv Psychosom Med. 2003;24:131-160. [PubMed]
 
Wright RJ, Rodriguez M, Cohen S. Review of psychosocial stress and asthma: an integrated biopsychosocial approach. Thorax. 1998;53:1066-1074. [PubMed]
 
Marshall GD. Neuroendocrine mechanisms of immune dysregulation: applications to allergy and asthma. Ann Allergy Asthma Immunol. 2004;93:S11-S17. [PubMed]
 
Wright RJ. Alternative modalities for asthma that reduce stress and modify mood states: evidence for underlying psychobiologic mechanisms. Ann Allergy Asthma Immunol. 2004;93:S18-S23. [PubMed]
 
Wright RJ. Stress and atopic disorders. J Allergy Clin Immunol. 2005;116:1301-1306. [PubMed]
 
Lieu TA, Lozano P, Finkelstein JA, et al. Racial/ethnic variation in asthma status and management practices among children in managed Medicaid. Pediatrics. 2002;109:857-865. [PubMed]
 
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