1. Psychological and social-economic characteristics of patients with severe asthma

2. Index Introduction Methods Database Results Discussion of the Results Limitations Gantt Chart

3. Introduction Definition No consensual definition: 1 Different disease: lack of response to usual treatment 2 : 1) resistance to corticosteroids (CS) 2) altered response to CS because of modified airways structure. Different Phenotype: heterogeneity in the severe asthma group 1) Wenzel S.E., A different disease, many diseases or mild asthma gone bad? Challenges of severe asthma, European Respiratory Journal, 2003; 22: 397-938 2) M. Gaga, N.Papageorgiou, G. Yougiotti, P. Karydi, A. Liapikou, H.Bitsakoy, E.Zervas, Risk factors and characteristics associated with severe and difficult to treat asthma phenotype: an analysis of the ENFUMOSA group of patients based on the ECRHS questionnaire, Clinical and Experimental Allergy, 2005; 35: 954-959

4. Introduction Characteristics of severe/ difficult to treat asthma patients Predominance of female 1 High level of corticosteroids use 3 Increased in healthcare utilization 1 High level of neutrophils in sputum 1 High number of activated T lymphocytes 4 1) Wenzel S.E., A different disease, many diseases or mild asthma gone bad? Challenges of severe asthma, European Respiratory Journal, 2003; 22: 397-398 3) Brinke A., Ouwerkerk M., Zwinderman A., Spinhoven P., Bel E., Psychopathology in Patients with Severe Asthma Is Associated with Increased Health Care Utilization, American Journal of Respiratory and Critical Care Medicine, 2001; Vol 163, page 1093-1096 4) Caramori G., Pandit A., Papi A., Is there a difference between chronic airway inflammation in chronic severe asthma and chronic obstructive pulmonary disease?, Current Opinion in Allergy and Clinical Immunology, February 2005; 5(1):77-83

5. Introduction Characteristics of severe/ difficult to treat asthma patients Chronic airway inflammationcentral and peripheral 5 High air-trapping and obstruction 1 Low diffusing capacity 1 Forced expiratory volume during the first second (FEV1) ≤60% of predicted 6 Peak expiratory flow (PEF) variability over 30% 6 1)Wenzel S.E., A different disease, many diseases or mild asthma gone bad? Challenges of severe asthma, European Respiratory Journal, 2003; 22: 397-398 5) Smith J. R., Mildenhall S., Noble M. J., Shepstone L., Koutantji M. Mugford M.,Harrison B. D., The Coping with Asthma Study: a randomised controlled trial of a home based, nurse led psychoeducational intervention for adults at risk of adverse adthma outcomes, Thorax, December 2005;30/12):1003-11 6) Stirling R. G., Chung K. F., Severe asthma: definition and mechanisms, Allergy, September 2001; 56(9):825-40

6. Introduction Rationale Psychological aspects of severe/ difficult to treat asthma have been insufficiently studied 7 ; Psychosocial problems are a known risk factor for dying from asthma 8 ; High costs of the severe asthma due to hospitalizations, emergency and domiciliary care 7. 7) Osborne M., Deffebach M., The Epidemiology and Natural History of Asthma Outcomes and Treatment Regimens (TENOR)Study, Annals of Allergy, Asthma and Immunology, 2004 8) Barton C.A., McKenzie D.P., Walters E.H., Abramson M.J., Interactions between psychosocial problems and management of asthma: who is at risk of dying?, The Journal of asthma, May 2005; 42(4):249-56

7. Introduction Aims of the study To compare psychological and social characteristics in adult patients with severe asthma and patients with mild to moderate asthma; Relevant Questions that may be answered in this study Is depression related to severe asthma? Is there any relation between anxiety scores and the severity of asthma? Is there any association between severe asthma and the age of severe asthma patients? Is social status related to severe asthma? Is there any relation between schooling and the severity of asthma? May factors as age and gender cause overfitting?

8. Instruments Self-Anxiety (Zung, 1975) Depression Inventory (Beck, 1961) Asthma Control Questionnaire (Juniper, 1999) Mini-Asthma Quality of Life Questionnaire (Juniper, 1998) Spirometry Peak Expiratory Flow (PEF) Forced Expiratory volume in 1st second (FEV1)

9. Flowchart Phase 2: Database analysis

10. Sample description Demographic Characteristics =>31<31 Age (years) 100 80 60 40 20 0 Percent (%) severe non-severe p<0.001 FemaleMale Gender 100 80 60 40 20 0 Percent (%) severe non-severe p=0.003

11. Sample description Social Characteristics class IV and Vclass I, II and III graffar social classification 100 80 60 40 20 0 Percent (%) severe non-severe p=0.005 Divorced or Separated WidowerSingleMarried Marital Status 80 60 40 20 0 Percent (%) severe non-severe p=0.051

12. Sample description Social Characteristics 53210 Number of children 50 40 30 20 10 0 Percent (%) severe non-severe p=0.264 >1210-125-90-4 years Education 60 50 40 30 20 10 0 Percent (%) severe non-severe p=0.003

13. Sample description Psychological Characteristics Middle or Severe DepressionNo Depression or Light Depression Depression Level 100 80 60 40 20 0 Percent (%) severe non-severe p=0.013 Pathologic AnxietyNo Pathologic Anxiety Anxiety Level 80 60 40 20 0 Percent (%) severe non-severe p=1.000

14. Multivariate Analysis Social Characteristics

17. Multivariate Analysis Psychological Characteristics

20. Discussion 9) Baumeister, H., Korinthenberg, K., Bengel, J., Ha ̈ rter, M. Bronchial asthma and mental disorders - A systematic review of empirical studies. Psychotherapie Psychosomatik Medizinische Psychologie (2005), 55 (5),Pages 247-255 10) Eisner, M.D., Katz, P.P., Lactao, G., Iribarren, C. Impact of depressive symptoms on adult asthma outcomes. Annals of Allergy, Asthma and Immunology (2005), 94 (5), Pages 566-574. Related results Gender and Age Different from other studies (9) Non related results Education Anxiety Similar to other studies (11)

21. Inconsistent results Social-economic status: Low social status may determine worse physical condition, wich explain frequent emergency care (10), but not influence severity of asthma Depression: Depressive symptoms associated with asthma severity (10) Severe asthma individuals with low levels of depression after asthma treatment (12) Depression is a heavier factor in the severity of asthma than anxiety (11) Lavoie, K.L., Cartier, A., Labrecque, M., Bacon, S.L., Lemie ̀ re, C., Malo, J.-L., Lacoste, G., (...), Ditto, B. Are psychiatric disorders associated with worse asthma control and quality of life in asthma patients? Respiratory Medicine (2005), 99 (10), Pages 1249-1257 (12) Heaney, L.G., Conway, E., Kelly, C., Gamble, J. Prevalence of psychiatric morbidity in a difficult asthma population: Relationship to asthma outcome. Respiratory Medicine (2005), 99 (9), Pages 1152-1159

22. Limitations Small Sample Nature of study Instruments

23. Mariana Cunha Mariana Koehler Mariana Taveira Marta Rodrigues Marta Tavares da Silva Marta Santos Silva Marta Alves Marta Lopes Miguel Almeida Authors Web Site Project Managers Prof. Doutor Altamiro da Costa Pereira Dr. João Fonseca

24. Gantt Chart First Phase

25. Gantt Chart Second Phase

26. Gantt Chart Third Phase