Asthma associated with increased risk for suicide
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Key takeaways:
- Patients with asthma were 26% more likely to die by suicide.
- Rates were higher for patients with asthma and schizophrenia, depression anxiety.
- Risk factors also included hospitalization and COPD.
Patients with asthma in South Korea faced increased risk for suicide compared with those who did not have asthma, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
The risk increased patients were prone to hospitalization, did not have obesity and also had COPD, Sang Hyuk Kim, MD, division of pulmonary, allergy and critical care medicine, Dongguk University Gyeongju Hospital, and colleagues wrote.
Study design, results
The study used data from the Korean National Health Insurance Service, which is a mandatory, single-payer, universal insurance system that covers nearly 97% of the citizens of South Korea.
The cohort of 3,914,041 individuals aged 20 years and older who had a health examination in 2009 included 290,623 with asthma, defined as three or more outpatient department visits or one hospitalization within a previous 5-year period of enrollment.
Median ages included 55.9 years for the asthma group and 46.7 years for the non-asthma group (P < .001). Also, 40.5% of the asthma group and 55.3% of the non-asthma group were men (P < .001). Median BMI included 24.1 kg/m2 for the asthma group and 23.7 kg/m2 for the non-asthma group (P < .001).
Additionally, 18.7% of the asthma group and 17.9% of the non-asthma group regularly performed physical activity (P < .001), and 20.7% of the asthma group and 19.5% of the non-asthma group had low income (P < .001).
Proportions of never smokers included 71% in the asthma group and 59.5% in the non-asthma group (P < .001). Proportions of heavy drinkers included 4.9% for the asthma group and 8.1% of the non-asthma group (P < .001).
Patients in the asthma group were less likely to reside in urban areas as well (43.8% vs. 45.7%; P < .001). Also, all the comorbidities that the researchers assessed were more prevalent in the asthma non-asthma group (P < .001).
With a median follow-up period of 12.3 years, 1,383 patients in the asthma group (0.48%) and 11,658 patients in the non-asthma group (0.32%) suicide (P < .01) for rates per 1,000 personyears of 0.41 and 0.27, respectively.
In the fully adjusted model, patients in the asthma group had a hazard ratio of 1.26 (95% CI, 1.19-1.33) for suicide.
Adjusted hazard ratios for suicide also included 1.61 (95% CI, 1.4-1.84) for patients with asthma who were prone to hospitalization, 1.37 (95% CI, 1.27-1.64) for those with asthma who did not have obesity, and 1.47 (95% CI, 1.22-1.76) for those with asthma and COPD.
Patients with asthma and schizophrenia had a rate of 2.49 suicides per 1,000 person-years and an adjusted hazard ratio of 3.38 (95% CI, 2.28-5.02).
Adjusted hazard ratios for suicide among patients with asthma further included 3.24 (95% CI, 2.85-3.68) for those who also had depression, 2.54 (95% CI, 2.05-3.16) for those who also had underweight, 2.47 (95% CI, 2-3.05) for those with anxiety disorder, and 2.22 (95% CI, 1.73-2.84) for those with cancer.
Additional adjusted hazard ratios for suicide among patients with asthma included 1.39 (95% CI, 1.28-1.51) for age 65 years and older, 1.33 (95% CI, 1.24-1.42) for never smokers, 1.29 (95% CI, 1.22-1.37) for non-heavy alcohol drinkers, 1.34 (95% CI, 1.24-1.26) for hypertension and 1.27 (95% CI, 1.2-1.35) for no substance use disorder.
Conclusions, next steps
The researchers offered several explanations for why risks for suicide are higher among patients with asthma.
First, the researchers suggested that patients with asthma may have depression that is underdiagnosed and undertreated.
Next, they said that the physical deconditioning that asthma imposes on patients, especially because of their respiratory symptoms, may be a factor.
The researchers additionally said that the isolation and increased dependence among patients with asthma may contribute to suicide.
South Korea also has the highest rate of suicide among Organization for Economic Co-operation and Development nations, the researchers said.
Suicide in South Korea is particularly prevalent among the elderly, often driven by financial difficulties and social isolation, the researchers said, noting the association between older age and risk for suicide among patients with asthma seen in this study.
As a result, clinicians need to consider underlying biological mechanisms as well as cultural factors in reducing suicide among patients with asthma, the researchers said, adding that the Global Initiative for Asthma guidelines do not address these risks.
Modifying these risk factors may mitigate the risk for suicide among patients with asthma, the researchers said, and members of the family and community as well as physicians should pay attention to patients with these risk factors.
The researchers further called for guidelines that highlight these risks in addition to research in this area so these rates can be reduced, although they cautioned that strategies should be tailored based on cultural backgrounds.
Perspective
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I don't think the findings are very surprising. As the authors pointed out, suicide has been associated with various chronic diseases, and prior studies have suggested this association already.
While the risk was significant, it was not that much higher than the control population overall. In addition, their findings that it was most associated with psychiatric comorbidities, such as schizophrenia and depression, make it not too surprising.
Given the low overall incidence of suicide in the population, I don’t think these associations are something that would be picked up on an individual provider level. Rather, it is a finding on a population level.
That being said, I think anyone who cares for asthma sees depression and anxiety in their patients with asthma, especially severe or uncontrolled asthma, and this is something we should all pay attention to and strive to address as best we can.
I think those providers who treat patients with asthma could attempt to identify depression and anxiety in these patients. Using simple screening tools in clinic can help. Most asthma specialists are probably not going to be adept at treating these comorbidities. But if we can help to identify them, perhaps we can attempt to refer patients to resources or practitioners that can help address these issues.
Studies that integrate psychosocial treatment plans in patient with asthma have been conducted, and they are probably next step in this research as well. If you can treat the underlying psychiatric comorbidity, can you impact the rate of suicide in these patients?
Some final comments:
One issue is finding appropriate resources for these patients. Neuropsychiatric care is difficult to find and often under-reimbursed, so, in my experience, it is hard to find for patients in this country on federal insurance such as Medicaid or Medicare.
The second issue is that this study was conducted in Korea, and there are likely very specific issues that differ from issues in other countries, the United States.
Third is the issue of not including medications in the analysis, which the authors point out. Systemic steroids and likely leukotriene modifiers montelukast have neuropsychiatric effects, and these were not accounted for in the analysis.
Collapse
Kim SH, et al. J Allergy Clin Immunol Pract. 2024;doi:10.1016/j.jaip.2024.11.013.
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