Psychological interventions for asthma in children and adolescents.

BACKGROUND: Rates of asthma are high in children and adolescents, and young people with asthma generally report poorer health outcomes than those without asthma. Young people with asthma experience a range of challenges that may contribute to psychological distress. This is compounded by the social, psychological, and developmental challenges experienced by all people during this life stage. Psychological interventions (such as behavioural therapies or cognitive therapies) have the potential to reduce psychological distress and thus improve behavioural outcomes such as self-efficacy and medication adherence. In turn, this may reduce medical contacts and asthma attacks. OBJECTIVES: To determine the efficacy of psychological interventions for modifying health and behavioural outcomes in children with asthma, compared with usual treatment, treatment with no psychological component, or no treatment. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register (including CENTRAL, CRS, MEDLINE, Embase, PsycINFO, CINAHL EBSCO, AMED EBSCO), proceedings of major respiratory conferences, reference lists of included studies, and online clinical databases. The most recent search was conducted on 22 August 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing psychological interventions of any duration with usual care, active controls, or a waiting-list control in male and female children and adolescents (aged five to 18 years) with asthma. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. symptoms of anxiety and depression, 2. medical contacts, and 3. asthma attacks. Our secondary outcomes were 1. self-reported asthma symptoms, 2. medication use, 3. quality of life, and 4. adverse events/side effects. MAIN RESULTS: We included 24 studies (1639 participants) published between 1978 and 2021. Eleven studies were set in the USA, five in China, two in Sweden, three in Iran, and one each in the Netherlands, UK, and Germany. Participants' asthma severity ranged from mild to severe. Three studies included primary school-aged participants (five to 12 years), two included secondary school-aged participants (13 to 18 years), and 18 included both age groups, while one study was unclear on the age ranges. Durations of interventions ranged from three days to eight months. One intervention was conducted online and the rest were face-to-face. Meta-analysis was not possible due to clinical heterogeneity (interventions, populations, outcome tools and definitions, and length of follow-up). We tabulated and summarised the results narratively with reference to direction, magnitude, and certainty of effects. The certainty of the evidence was very low for all outcomes. A lack of information about scale metrics and minimal clinically important differences for the scales used to measure anxiety, depression, asthma symptoms, medication use, and quality of life made it difficult to judge clinical significance. Primary outcomes Four studies (327 participants) reported beneficial or mixed effects of psychological interventions versus controls for symptoms of anxiety, and one found little to no difference between groups (104 participants). Two studies (166 participants) that evaluated symptoms of depression both reported benefits of psychological interventions compared to controls. Three small studies (92 participants) reported a reduction in medical contacts, but two larger studies (544 participants) found little or no difference between groups in this outcome. Two studies (107 participants) found that the intervention had an important beneficial effect on number of asthma attacks, and one small study (22 participants) found little or no effect of the intervention for this outcome. Secondary outcomes Eleven studies (720 participants) assessed asthma symptoms; four (322 participants) reported beneficial effects of the intervention compared to control, five (257 participants) reported mixed or unclear findings, and two (131 participants) found little or no difference between groups. Eight studies (822 participants) reported a variety of medication use measures; six of these studies (670 participants) found a positive effect of the intervention versus control, and the other two (152 participants) found little or no difference between the groups. Across six studies (653 participants) reporting measures of quality of life, the largest three (522 participants) found little or no difference between the groups. Where findings were positive or mixed, there was evidence of selective reporting (2 studies, 131 participants). No studies provided data related to adverse effects. AUTHORS' CONCLUSIONS: Most studies that reported symptoms of anxiety, depression, asthma attacks, asthma symptoms, and medication use found a positive effect of psychological interventions versus control on at least one measure. However, some findings were mixed, it was difficult to judge clinical significance, and the evidence for all outcomes is very uncertain due to clinical heterogeneity, small sample sizes, incomplete reporting, and risk of bias. There is limited evidence to suggest that psychological interventions can reduce the need for medical contact or improve quality of life, and no studies reported adverse events. It was not possible to identify components of effective interventions and distinguish these from interventions showing no evidence of an effect due to substantial heterogeneity. Future investigations of evidence-based psychological techniques should consider standardising outcomes to support cross-comparison and better inform patient and policymaker decision-making.

Mixed Reality Technology to Deliver Psychological Interventions to Adolescents With Asthma: Qualitative Study Using the Theoretical Framework of Acceptability.

BACKGROUND: Interactive, mixed reality technologies such as augmented reality, virtual reality, and holographic technology may provide a novel solution to fast-track the translation of evidence into practice. They may also help overcome barriers to both mental health and asthma management service uptake, such as cost, availability of appointments, fear of judgment, and quality of care. OBJECTIVE: This study aimed to investigate if mixed reality technology is an acceptable mechanism for the delivery of a component of cognitive and behavioral therapies for the management of elevated psychological distress among young people with asthma. METHODS: To explore the perceived acceptability of these technologies, mixed reality tools were evaluated via qualitative, 1-on-1 interviews with young people with asthma and symptoms of psychological distress, parents/caregivers of young people with asthma and symptoms of psychological distress, and relevant health professionals. The Theoretical Framework of Acceptability was used for the deductive coding of the recorded interview transcripts. RESULTS: This study enrolled the following participants: (1) 3 adolescents with asthma and symptoms of psychological distress with a mean age of 14 (SD 1.7) years; (2) 4 parents/caregivers of adolescents with asthma with a mean age of 55 (SD 14.6) years; and (3) 6 health professionals with a mean age of 40.8 (SD 4.3) years. A total of 4 constructs-experienced affective attitude, experienced effectiveness, self-efficacy, and intervention coherence-were coded in all participant transcripts. The most frequently coded constructs were experienced affective attitude and intervention coherence, which were reported a total of 96 times. The least frequently coded construct was anticipated opportunity cost, which was reported a total of 5 times. Participants were mostly positive about the mixed reality resources. However, some concerns were raised regarding ethicality, particularly regarding privacy, accessibility, and messaging. Participants noted the need for technology to be used in conjunction with face-to-face engagement with health professionals and that some patients would respond to this type of delivery mechanism better than others. CONCLUSIONS: These results suggest that mixed reality technology to deliver psychological interventions may be an acceptable addition to current health care practices for young people with asthma and symptoms of psychological distress. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry ACTRN12620001109998; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380427.

An Augmented Reality Technology to Provide Demonstrative Inhaler Technique Education for Patients With Asthma: Interview Study Among Patients, Health Professionals, and Key Community Stakeholders.

BACKGROUND: Many people with asthma use incorrect inhaler technique, resulting in suboptimal disease management and increased health service use. Novel ways of delivering appropriate instructions are needed. OBJECTIVE: This study explored stakeholder perspectives on the potential use of augmented reality (AR) technology to improve asthma inhaler technique education. METHODS: On the basis of existing evidence and resources, an information poster displaying the images of 22 asthma inhaler devices was developed. Using AR technology via a free smartphone app, the poster launched video demonstrations of correct inhaler technique for each device. In total, 21 semistructured, one-on-one interviews with health professionals, people with asthma, and key community stakeholders were conducted, and data were analyzed thematically using the Triandis model of interpersonal behavior. RESULTS: A total of 21 participants were recruited into the study, and data saturation was achieved. People with asthma were confident with inhaler technique (mean score 9.17, SD 1.33, out of 10). However, health professionals and key community stakeholders identified that this perception was misguided (mean 7.25, SD 1.39, and mean 4.5, SD 0.71, for health professionals and key community stakeholders, respectively) and facilitates persistent incorrect inhaler use and suboptimal disease management. Delivering inhaler technique education using AR was favored by all participants (21/21, 100%), particularly around ease of use, with the ability to visually display inhaler techniques for each device. There was a strongly held belief that the technology has the capacity for improving inhaler technique across all participant groups (mean 9.25, SD 0.89, for participants; mean 9.83, SD 0.41, for health professionals; and mean 9.5, SD 0.71, for key community stakeholders). However, all participants (21/21, 100%) identified some barriers, particularly regarding access and appropriateness of AR for older people. CONCLUSIONS: AR technology may be a novel means to address poor inhaler technique among certain cohorts of patients with asthma and serve as a prompt for health professionals to initiate review of inhaler devices. A randomized controlled trial design is needed to evaluate the efficacy of this technology for use in the clinical care setting.

The modifiable biopsychosocial drivers of psychological distress for adolescents with asthma: Implications for Clinical Care.

PURPOSE: Overwhelming distress exceeds the capacity of healthy coping strategies to feel better using healthy coping strategies alone, resulting in the use of unhealthy coping strategies. Unhealthy coping strategies may exacerbate asthma symptoms and asthma can contribute to overwhelming distress. This study aimed to review the modifiable drivers of overwhelming distress in adolescents with asthma. METHODS: The biopsychosocial drivers of psychological distress for adolescents with asthma were explored within the domains of the modifiable biopsychosocial model of health and wellbeing. RESULTS: Asthma in adolescents is associated with problems in the domains of environment, developmental outcomes, sense of belonging, health behaviours, coping, and treatment of illness. CONCLUSIONS: The relationship between asthma and psychological distress highlights the need for holistic treatment of asthma. Further research is needed to establish causation between variables and to investigate whether interventions that address either asthma symptoms or biopsychosocial drivers of distress can improve both factors.

Pharmacological interventions for the treatment of psychological distress in patients with asthma: a systematic review and meta-analysis.

Objective: To evaluate the effectiveness and safety of pharmacological interventions for the treatment of psychological distress in people with asthma.Data sources: Electronic searches were performed in Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed/Medline, Embase, PsycInfo, Health Technology Assessment Database and Web of Science (inception to April 2019).Study selections: Included studies were randomized controlled trials (RCT) or controlled clinical trials investigating the effect of pharmacological interventions for psychological distress in people with asthma. Records were screened and data extracted by two independent authors into standardized pilot-tested extraction templates. Data was analyzed according to standard Cochrane methodology and entered into Review Manager Software version 5.3.Results: From 5,689 studies, six RCTs (n = 215) met inclusion criteria and were included in the systematic review, of which four studies were included in the meta-analysis. A meta-analysis of four studies (n = 158) indicated no evidence of an effect for selective serotonin reuptake inhibitors (Citalopram or Escitalopram) on reduction of psychological distress in adult patients with asthma. Similarly, antiepileptic medication (Levetiracetam) was no better than placebo in the treatment of psychological distress in people with asthma. Adverse events were poorly reported across all studies but were slightly increased among intervention participants compared to control participants.Conclusions: There was great heterogeneity between studies and overall poor methodological quality providing insufficient evidence to make recommendations for or against the use of pharmacotherapy in asthma patients with psychological distress. Further confirmatory trials are warranted to make recommendations for clinical practice.

Community pharmacy personnel interventions for smoking cessation.

BACKGROUND: Community pharmacists could provide effective smoking cessation treatment because they offer easy access to members of the community. They are well placed to provide both advice on the correct use of smoking cessation products and behavioural support to aid smoking cessation. OBJECTIVES: To assess the effectiveness of interventions delivered by community pharmacy personnel to assist people to stop smoking, with or without concurrent use of pharmacotherapy. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialised Register, along with clinicaltrials.gov and the ICTRP, for smoking cessation studies conducted in a community pharmacy setting, using the search terms pharmacist* or pharmacy or pharmacies. Date of the most recent search: January 2019. SELECTION CRITERIA: Randomised controlled trials of interventions delivered by community pharmacy personnel to promote smoking cessation amongst their clients who were smokers, compared with usual pharmacy support or any less intensive programme. The main outcome measure was smoking cessation rates at six months or more after the start of the intervention. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane for study screening, data extraction and management. We conducted a meta-analysis using a Mantel-Haenszel random-effects model to generate risk ratios (RRs) and 95% confidence intervals (CIs). MAIN RESULTS: We identified seven studies including 1774 participants. We judged three studies to be at high risk of bias and four to be at unclear risk. Each study provided face-to-face behavioural support delivered by pharmacy staff, and required pharmacy personnel training. Typically such programmes comprised support starting before quit day and continuing with weekly appointments for several weeks afterwards. Comparators were either minimal or less intensive behavioural support for smoking cessation, typically comprising a few minutes of one-off advice on how to quit. Participants in both intervention and control arms received equivalent smoking cessation pharmacotherapy in all but one study. All studies took place in high-income countries, and recruited participants visiting pharmacies. We pooled six studies of 1614 participants and detected a benefit of more intensive behavioural smoking cessation interventions delivered by community pharmacy personnel compared with less intensive cessation interventions at longest follow-up (RR 2.30, 95% CI 1.33 to 3.97; I2 = 54%; low-certainty evidence). AUTHORS' CONCLUSIONS: Community pharmacists can provide effective behavioural support to people trying to stop smoking. However, this conclusion is based on low-certainty evidence, limited by risk of bias and imprecision. Further research could change this conclusion.