Where Are the Guidelines for the Treatment of Asthma with Panic Spectrum Symptoms?

To the Editor.

Dr. Hasler and colleagues (1) have recently presented the first long-term follow-up study on asthma and panic disorder (PD). They showed dose-response-type relationships between PD and asthma, and bidirectional longitudinal associations between the two conditions. Earlier, Goodwin and colleagues (2) provided information on the association between physician-diagnosed asthma and DSM-IV mental disorders in a representative population sample of adults. Current severe asthma was associated with a significantly increased likelihood of any anxiety disorder, including PD and panic attacks. In patients with asthma, an early identification of PD without restricting the diagnosis to the classification's criteria, allowing a clinical judgment based on symptoms, criteria, and the spectrum concept, could lead to appropriate use of drugs in the absence of any precise psychiatric diagnosis and thus lead to better treatment, improving their health and quality of life (3).

We should now start clinical trials with antipanic medication alone and in association with asthma medications, describing the influence of such treatment on respiratory function and daily activities. Nascimento and coworkers (4) evaluated lung function in asymptomatic PD patients without asthma with the goal of investigating the effects of taking antipanic drugs (serotonin selective reuptake inhibitor antidepressants). Lung function evaluation was performed on two different days (taking antipanic drugs and in the washout phase), and included spirometric evaluation and a bronchodilatation test (salbutamol inhalation). Before the bronchodilatation test, forced expiratory volume in 1 second (FEV^sub 1^) and forced expiratory flow between 25% and 75% of forced vital capacity (FEF^sub 25-75^) were significantly higher in patients taking antipanic drugs than in the washout period. After salbutamol inhalation, only FEV^sub 1^ was significantly higher in patients treated with antipanic drugs than when measured during the washout period. A significant increase in FEV^sub 1^ and FEF^sub 25-75^ after salbutamol inhalation was observed during a 2-wk drug-free period in PD patients.

Follow-up studies with samples of PD patients with asthma may also show the impact of PD treatment on respiratory symptoms. Obstructive pulmonary diseases could trigger panic attacks in predisposed individuals by the stimulation of the central chemoreceptors hypersensitive to PCO2 and/or the locus coeruleus. This hypothesis is reinforced by the hypersensitivity to CO2 false suffocation alarm theory (5). Studies with an enhanced methodology-including laboratory measures relating to asthma-are important to find out if the improvement in lung function in asymptomatic PD patients is due to the antipanic effects in controlling bronchial tone or by decreasing anxiety sensitivity and panic-related cognition.

Conflict of Interest Statement: A.E.N. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

ANTONIO E. NARDI

Federal University of Rio de Janeiro

Rio de Janeiro, Brazil

References

1. Hasler O, Gergen PJ, Kleinbaum DG, Ajdacic V, Gamma A, Eich D, Rosslcr W, Angst J. Asthma and panic in young adults: a 20-year prospective community study. Am J Respir Crit Care Med 2005;171:1224-1230.

2. Goodwill RD, Jacobi F, Thefeld W. Mental disorders and asthma in the community. Arch Gen Psychiatry 2003;60:1125-1130.