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Respiratory Symptoms and Mental Disorders Among Youth: Results From a Prospective, Longitudinal Study

From the Department of Epidemiology, Columbia University and the Oregon Research Institute.

Address correspondence and reprint requests to Renee D Goodwin, PhD, 1051 Riverside Drive, Unit 43, New York, NY 10032. E-mail: rdg66{at}columbia.edu

	ABSTRACT

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OBJECTIVE: To determine the relationship between respiratory symptoms and mental disorders among youth in the community, and to investigate possible mechanisms of these linkages.

METHODS: Data were drawn from the Oregon Adolescent Depression Project (n = 1,709), a longitudinal study of adolescents in the community. Multiple logistic regression analyses were used to examine the cross-sectional and longitudinal associations between respiratory symptoms and mental disorders at baseline, and linkages between respiratory symptoms at baseline and the onset of specific mental disorders at follow-up. Additional analyses were performed to examine the strength and specificity of the relationship between respiratory symptoms and mental disorders. The potential roles of hypochondriasis, functional impairment, and cigarette smoking in the associations between respiratory symptoms and mental disorders were investigated.

RESULTS: Respiratory symptoms were associated with a significantly increased odds of any mental disorder (odds ratio (OR) = 1.9), specifically any depressive disorder (OR = 1.9), major depression (OR = 1.9), any substance use disorders (OR = 1.6), panic attacks (OR = 3.1), and attention deficit/hyperactivity disorder (ADHD) (OR = 5.8) at baseline. Respiratory symptoms at between 1987 and 1989 (Time 1) were associated with significantly increased risk of the onset of any mental disorder a year later (Time 2) (OR = 2.1). While demographic differences, hypochondriasis, functional impairment, and cigarette smoking contributed to the relationships between respiratory symptoms and mental disorders, these associations persisted after adjusting for these factors.

CONCLUSIONS: The results suggest evidence of an association between respiratory symptoms and mental disorders among youth in the community. While demographic differences, hypochondriasis, functional impairment, and cigarette smoking may contribute to the linkage, these factors do not appear to completely explain the association. Future studies that can replicate these findings and include an examination of other possible mechanisms for these patterns of comorbidity, such as shared familial vulnerability or other environmental risk factors (e.g., childhood behavioral risk factors), are needed next.

Key Words: epidemiology, • respiratory disease, • psychopathology, • youth, • comorbidity.

Abbreviations: ADHD = attention deficit/hyperactivity disorder;; DISC = Diagnostic Interview Schedule for Children;; SES = socioeconomic status.

	INTRODUCTION

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In recent years, there has been increasing interest in the relationship between respiratory disease and anxiety and depressive disorders among youth (1–11). Evidence to date on this association has come mainly from three sources. First, data from clinical samples of pediatric asthma patients show higher levels of behavioral problems (12) and depression and anxiety symptoms in youth with moderate-severe asthma, compared with controls with other medical illnesses (13–15). There are also data to suggest higher levels of externalizing symptoms among youth with, compared with those without, asthma (12), though the support for this link is not as strong. Second, data from psychiatric samples of youth show higher than expected levels of asthma among those with anxiety disorders (16,17). For instance, Koltek et al. (17) found an elevated rate of asthma among adolescent psychiatric inpatients with post-traumatic stress disorder (PTSD) compared with a control group, yet in contrast, the prevalence of diabetes was not similarly elevated in this sample. The third line of evidence comes from epidemiologic data, which have been used to demonstrate an association between asthma and anxiety disorders among youth in community samples. Specifically, Ortega et al. (6) found a higher rate of separation anxiety disorder (SAD), overanxious disorder, and phobia among youth with asthma in a community sample compared with those with diabetes and other chronic illnesses.

Despite consistent results reflecting a link between respiratory disease and anxiety and depressive disorders among youth, several questions about these associations remain unanswered. First, previous studies in youth have used relatively vague indicators of respiratory problems, including the combined grouping of asthma, allergy, or other respiratory symptoms. Similarly, studies in adults linking lung disease with panic attacks have combined asthma, bronchitis, and emphysema in the definition of lung disease. Therefore, it is unclear to what extent there is an association between anxiety and depressive disorders and specific respiratory symptoms, or to any respiratory disease in general. Second, previous studies on respiratory problems in youth have relied on parent report of asthma or allergies. These data may therefore be influenced by parental anxiety or help-seeking behavior. For instance, parents with anxiety disorders may be more likely to bring a child with an allergic reaction or mild symptoms to a physician, compared with a non-anxious parent. As such, parental anxiety or report bias could influence or confound results. This is especially true of studies in which parental report of childhood behavior has been included in making diagnoses of mental disorders in youth, whereby there could be uncontrolled confounding with reports from one information source (i.e., parents reporting on both asthma and psychopathology in children). Third, previous investigations include parental report of a physician’s diagnosis of asthma in the analyses, which could be vulnerable to information bias by factors such as socioeconomic status (SES), health care availability, or other behavioral patterns, and therefore may confound results. Fourth, to our knowledge, with the exception of one cross-sectional sample of youth in the community (6), this association has been investigated exclusively in clinical samples. Therefore, previous results may not be generalizable to youth in the community. Finally, previous studies have not investigated possible mechanisms of the association between respiratory disease and mental disorders.

There are several possible explanations for the observed link between respiratory symptoms and mental disorders. Specifically: 1) hypochondriacal concerns; it may be that individuals with mental disorders, who are more likely to report somatic symptoms (18), compared with those without mental disorders, may over report respiratory symptoms and this may account for the observed association; 2) functional impairment; it may be that the functional impairment associated with respiratory disease or respiratory symptoms (19), which are frequently chronic, leads to demoralization and decreases in quality of life, which then increases the risk of depression or severe anxiety due to role loss; 3) cigarette smoking; mental disorders are associated with increased cigarette smoking in youth and adults (3,20–24), and cigarette smoking is associated with increased likelihood of respiratory symptoms, therefore the linkages between mental disorders and respiratory symptoms may be due to uncontrolled confounding associated with cigarette smoking.

Against this background, the goal of the current study is to investigate the relationship between symptoms of respiratory disease and mental disorders in youth, and overcome the methodological limitations of previous studies. First, the study will examine the cross-sectional relationship between respiratory symptoms (dyspnea, lung problems, cough) and mental disorders both cross-sectionally and longitudinally in youth. Second, the study will investigate possible mechanisms of these associations by examining the roles of hypochondriasis, functional impairment, and cigarette smoking in the relationship between respiratory symptoms and mental disorders.

	METHOD

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Participants
Participants were a subset of individuals from the Oregon Adolescent Depression Project. Participants were originally randomly selected from nine senior high schools in western Oregon. A total of 1,709 adolescents (ages 14–18; mean age at initial assessment = 16.6 years, SD (SD) = 1.2) completed the initial assessment, which consisted of an interview and questionnaires, between 1987 and 1989 (Time 1). Approximately 1 year later (Time 2), 1,507 participants (88.2%) participated in a reassessment that used the same interview questions and questionnaires (mean interval between Time 1 and Time 2 = 13.8 months, SD = 2.3) (additional details are provided elsewhere (23,25).

Measures
Diagnostic Interviews
Participants were interviewed at Time 1 with a version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) that combined features of the epidemiologic version (26) and the present episode version and included additional items to derive Diagnostic and Statistical Manual of Mental disorders-Version III-Revised (DSM-III-R) diagnoses. At Time 2, participants were interviewed with the Longitudinal Interval Follow-Up Evaluation (27), which elicited detailed information about the course of psychiatric symptoms and disorders since the previous interview.

Most diagnostic interviewers had an advanced degree in clinical or counseling psychology or social work, and all were extensively trained before data collection. Interviews took place in an interview room at the Oregon Research Institute (ORI) or in a private room in a community center (in rural settings). Interrater reliability for lifetime diagnoses in a randomly selected subsample at Time 1 (N = 233) was moderate to excellent: kappa = 0.86 for major depressive disorder, and kappa = 0.76 to 0.89 for non-mood disorder categories.

Symptoms of Respiratory Disease
Respiratory symptoms were assessed with three binary response (yes/no) questions measured at both Time 1 and Time 2. Respondents were asked whether they had "problems with:" "persistent cough and wheeze," "shortness of breath," and "problems with lungs or breathing."

Functional Impairment
Functional impairment was assessed using a dichotomous measure of self-reported functional limitations associated with physical health problems by each of the respondents. These questions followed the section on physical health problems and questions about the extent to which those problems impaired daily activities, school, and social activities. Functional impairment was assessed at Time 1 and Time 2. The top decile of impairment was used to dichotomize the variable for analyses.

Hypochondriasis
Hypochondriasis was measured with a sum score of 8 possible hypochondrical symptoms from the hypochondriasis scale (28). Hypochondriasis was assessed at Time 1 and Time 2, a summed score of both assessments was created, and the top decile was used as a cutoff.

Cigarette Smoking
Information on cigarette smoking (lifetime, current, and daily) was gathered at Time 1 and Time 2 from the respondent. For the purposes of these analyses, daily cigarette smoking was used in order to reduce the inclusion of youth who may have smoked once or experimentally, which may be less likely to lead to ongoing respiratory symptoms.

Analytic Strategy
Data from Time 1 and Time 2 were used in the following cross-sectional and longitudinal analyses. First, Chi-Square tests were used to determine the association between shortness of breath, lung/breathing problems, and cough and each mental disorder at Time 1 and Time 2 cross-sectionally. Next, multiple logistic regression analyses were used to determine the association between each respiratory symptom at Time 1 or Time 2 and the likelihood of each mental disorder at Time 1 or Time 2. This included any mental disorder, any depressive disorder, any substance use disorder, panic attacks, and attention deficit/hyperactivity disorder (ADHD). These analyses were then adjusted for age, sex, race, and then additionally for hypochondriasis, health-related functional impairment, and cigarette smoking. All of these factors were included in the final model in order to investigate possible mediating effects on the relationships between respiratory symptoms and mental disorders. Next, multiple logistic regression analyses were used to determine the relationship between each type of respiratory symptom at Time 1 and the risk of mental disorders (any incident anxiety disorder, any alcohol/substance use disorder, any depressive disorder, ADHD) adjusted for potential confounding factors (functional impairment, hypochondriasis, cigarette smoking).

	RESULTS

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Cross-sectional Associations Between Respiratory Symptoms and Mental Disorders
Table 1 displays the associations between any and each respiratory symptom (cough, lung problems, shortness of breath) at Time 1 and Time 2 (lifetime) and mental disorders at Time 1 and Time 2 (lifetime). Chi-square tests were used and statistical significance was set at p < .01.

Shortness of breath (dyspnea) was associated with a significantly increased likelihood of any mental disorder, any depressive disorder, major depression, dysthymia, any anxiety disorder, ADHD, and substance abuse/dependence.

Cough was associated with a significantly increased likelihood of any mental disorder, any depressive disorder, major depression, panic attacks, any substance use disorder, alcohol abuse/dependence, and substance abuse/dependence.

Associations Between Respiratory Symptoms and Potential Confounding Factors
Chi-square tests were used to determine the associations between lung/breathing problems (Time 1 or Time 2), cough, and shortness of breath and hypochondriasis (top 10%), cigarette smoking (daily at Time 2), and health-related functional impairment (top 10%), compared with those without respiratory symptoms. Each of these comparisons (data not shown) was statistically significant at the p < .0001 level, with levels of hypochondriasis, cigarette smoking, and health-related functional impairment being more common among those with, compared with those without, each type of respiratory symptoms.

Adjusted Associations Between Respiratory Symptoms and Mental Disorders
Table 2 shows the associations between respiratory symptoms and mental disorders before and after adjustment for a series of potentially confounding and mediating factors (age, gender, race, hypochondriasis, functional impairment, and cigarette smoking). Any mental disorder, any depressive disorder, any substance use disorder, ADHD, and panic attacks were included in this set of adjusted analyses since they were statistically significant in bivariate analyses. Multiple logistic regression analyses were used to calculate unadjusted and adjusted odds ratios (with 95% confidence intervals). The table shows that:

2) Shortness of Breath (Dyspnea)
Shortness of breath was associated with significantly increased likelihood of all outcomes assessed. After adjustment for demographics and potentially mediating factors, the links between shortness of breath and any mental disorder and any depressive disorder decreased slightly, but remained statistically significant, while the link with any substance use disorder was no longer statistically significant after adjustment. In contrast, the associations between shortness of breath, ADHD, and panic attacks appeared stronger after adjustment.

3) Cough
Cough was associated with significantly increased likelihood of any mental disorder, any depressive disorder, any substance use disorder, and panic attacks, but was not associated with ADHD. After adjustment, the association between cough and any mental disorder, any depressive disorder, and any substance use disorder remained statistically significant. The association between cough and panic attacks, however, was no longer significant after adjustment for differences in age, sex, and gender.

Longitudinal Association Between Respiratory Symptoms at Time 1 and Risk of Mental Disorders at Time 2
Table 3 shows the longitudinal relationships between having each type of respiratory symptom at Time 1 and the risk of any incident mental disorders at Time 2. Multiple logistic regression analyses were used to determine the odds ratios describing the strength of these associations, before and after adjustment for age, gender, and race and then hypochondriasis, functional impairment, and cigarette smoking, and then all variables were included in the final model. The table shows that having any respiratory symptom at Time 1 was associated with a significantly increased risk of any incident mental disorder at Time 2. This association appeared to be affected very little by adjustment for any of these potentially mediating factors.

	DISCUSSION

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These findings confirm and extend results from previous studies suggesting that early respiratory symptoms are associated with increased rates of mental disorders among youth (1,2,4–11). These linkages have now been demonstrated using both clinical and community-based samples, suggesting that those with higher levels of childhood respiratory symptoms and respiratory disease have odds of later mental disorders between 2 to 4 times higher than those without. An important question raised by these findings concerns the extent to which the links between early respiratory symptoms and later mental disorders are mediated by other factors. Statistical analysis in which associations between respiratory symptoms and mental disorders were adjusted for hypochondriasis, functional impairment, and cigarette smoking, however, showed that the majority of these linkages remained statistically significant and consistent even after adjustment. These findings are consistent with previous findings of linkages between allergy and shyness among youth, and between panic and asthma among youth (29,30) and adults (6,31–33), and extend this link to the community. The strength of the association between panic and dyspnea, in particular, is consistent with previous work and may be explained by respiratory abnormalities common to both respiratory illnesses and panic, an explanation which is supported by results of laboratory studies (34–36). In other words, it is also possible that this link is purely due to the overlap in symptoms between dyspnea and panic disorder—specifically that dyspnea is a symptom of panic attack makes their co-occurrence possibly partially or completely attributable to this overlap in symptoms.

Our findings show some variation in the relationship between specific respiratory symptoms and the risk of new onset of mental disorders. Specifically, the strongest association was between lung/breathing problems and the risk of onset of incident mental disorders at Time 2. Our results indicate that these associations are not attributable to cigarette smoking, functional impairment, or hypochondriasis, which are possible mechanisms that have been suggested previously. As such, alternative possible mechanisms which may need consideration include: a) a common environmental risk factor for both lung problems and mental disorders (this might include low SES, childhood trauma, or other deprivation early in life); b) a common genetic vulnerability to both lung disease and mental disorders; and c) a persistent difficulty in breathing that may lead to poorer coping styles or a negative outlook on the future and sense of self-mastery, which may lead to increased risk of onset of mental disorders when it occurs in conjunction with other factors.

The strength of the links between respiratory symptoms and depressive disorders, panic attacks, and ADHD are noteworthy in view of previous results from several studies showing familial and possibly genetic links between atopic disease and depressive symptoms and panic disorder (15,37). Specifically, Wamboldt et al. (37) showed familial and genetic linkages between atopic disease and depressive symptoms among adults in the community. Similarly, Slattery et al. (15) showed familial associations between panic disorder in parents and increased risk of atopic disease among offspring in a clinical sample. In contrast, in a clinical sample of youth, Biederman et al. (38) failed to find a familial link between ADHD and asthma, though high rates of co-occurring symptoms of the two disorders have been found, and concluded that asthma and ADHD are independently transmitted in families. Future community-based studies are needed to replicate these findings, and to examine the potential role of environmental factors in these linkages.

The present study has a number of strengths including: a) the use of a well-studied community sample; b) the prospective measurement of respiratory symptoms and mental disorders among youth, thereby reducing the potential for later mental disorders to contaminate reporting of respiratory symptoms earlier in life; and c) the use of measures of respiratory symptoms based on self-report by the child and Diagnostic Interview Schedule for Children (DISC), based on both parent and youth reports. Previous measures were largely based on parental-report of respiratory disease. Still, the data available on respiratory symptoms is extremely sparse with only a few questions used. In addition, we did not have comparable information available on other chronic physical symptoms or disease available for analysis, therefore it is not possible to comment on the specificity of this association with regard to respiratory symptoms. Also, misperception or inaccurate reporting of symptoms of a hypochondriacal nature is possible and could have affected results, despite adjustment for hypochondriasis. Therefore, this possibility should be considered when interpreting results and in planning future investigations. Additional limitations of the study include lack of data from diagnostic tests or physician diagnoses of respiratory symptoms, which should be included in replication studies.

Received for publication June 25, 2003.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Goodwin, R. D. Articles by Seeley, J. R. Search for Related Content PubMed PubMed Citation Articles by Goodwin, R. D. Articles by Seeley, J. R. Related Collections Depression Other Psychiatric Disorders Pulmonary