Asthma: Behavioral Treatment

Asthma is a chronic respiratory disease that is marked by intermittent and variable periods of breathing difficulty. Individuals with asthma demonstrate hypersensitivity to a range of triggers (e.g., allergens, pollutants, infections, stress) that results in swelling, obstruction, and mucus in the airways. Typical symptoms involve wheezing, shortness of breath, chest tightness, and coughing. In recent years, the prevalence, morbidity, and mortality associated with asthma have increased substantially. This rise has been particularly pronounced among ethnic minorities, inner-city communities, and low-income populations. Despite considerable medical advances that have improved the understanding of asthma and enhanced the ability to effectively treat this chronic condition, asthma remains a leading cause of health care utilization and costs.

One explanation for the persistent morbidity associated with asthma involves the behavioral challenges inherent in effectively managing the chronic condition. For instance, widespread nonadherence to asthma medications has been documented among adult and pediatric patients, with patients taking, on average, only about half of their regularly prescribed medications.

Effective asthma management typically requires a combined approach that integrates behavioral strategies (e.g., symptom monitoring) within the context of medical treatment. An integrated approach incorporates three basic behavioral recommendations. First, avoiding triggers is emphasized in order to prevent symptoms and limit the severity of asthma episodes. Avoiding triggers includes staying away from irritants (e.g., tobacco smoke, cold dry air) and allergens (e.g., animal dander, dust, mold). Second, given that medical treatment often involves use of multiple medications over time, treatment plans should be constructed to maximize patient adherence. Prescribing medications that are more convenient to use, require less frequent dosing, and have minimal side effects is more likely to facilitate adherence. Third, ongoing symptom monitoring through the use of a peak flow meter, symptom records, and regular feedback to a physician is critical to determine if adjustments in treatment approach are necessary. An additional component of symptom monitoring involves seeking appropriate health care services (e.g., physician “sick visit,” emergency department visit) if indicated.

When children and adults continue to have difficulty with asthma despite an integrated approach, supplemental psychosocial interventions are often recommended. Specialized behavioral interventions have been applied to assist patients with poorly managed asthma, and include educational efforts, cognitive-behavioral therapy, and family therapy to supplement medical interventions.

Providing asthma education as a route to promoting appropriate management behaviors is the most common strategy. Results from studies examining the effectiveness of asthma education have been mixed. A meta-analysis of asthma education programs for children concluded that these programs had limited effects on morbidity (Bernard-Bonnin, Stachenko, Bonnin, Charette, & Rousseau, 1995). Helping patients to better understand their disease and the importance of effective asthma management appears to be a valuable stepping-stone, but educational efforts in the absence of behavioral strategies typically do not result in sustainable improvements in morbidity and adherence. As a result, intervention efforts that combine education with behavioral techniques, such as cognitive-behavioral skills, stress management, and family therapy, are the most promising approaches.

Cognitive-behavioral interventions include a range of strategies aimed to maximize the frequency and effectiveness of self-management behaviors, such as medication adherence and trigger avoidance. Problem-solving therapy has been identified as a tool that can be used effectively by children, families, and adults to identify barriers to mismanagement (e.g., forgetting to take medications) and adopt strategies to circumvent barriers (e.g., using a daily calendar to monitor medication use). Cognitive-behavioral techniques can also be used to help patients recognize early signs of breathing difficulty and respond appropriately according to a predetermined action plan. As emotions have been shown to trigger asthma exacerbations for a portion of individuals, specific techniques to decrease anxiety and tension, such as relaxation training and biofeedback, have also been investigated. Generally, these programs have been found to be useful adjuncts in improving pulmonary function for individuals who have emotionally triggered asthma. Their efficacy to prevent asthma episodes, however, has not been demonstrated.

...