Complementary and Alternative Medicine Interventions
Therapeutic massage, reflexology, spinal manipulation, and prayer are commonly used components of complementary medicine that are perceived by many to be helpful in asthma management [40,41]. However, the published data supporting these techniques is limited. In 2005, Hondras et al performed a Cochrane database review of RCTs evaluating manual therapy, including therapeutic massage, in asthma. Variations in measured outcomes, study design, and reporting made the evidence presented in the review difficult to interpret. Methodologically sound RCTs are needed before any inferences as to relative efficacy of these techniques can be drawn [42]. Since 2005, there have been no significant RCTs reported that would change this conclusion. Data on prayer, religious beliefs, and how these affect asthma and stress control are scarce. One nonrandomized patient reporting survey analysis to evaluate the presence of a high power in life and asthma medication adherence was reported by Ahmedani and colleagues. Results showed that overall medication adherence was low, particularly among those who believed a higher power was in control of their health [43].
Other relaxation methods for managing stress in asthma include music therapy [44] and art therapy [45,46]. Music therapy has had varying reported therapeutic success in other medical settings, such as cardiac rehabilitation [47] and prior to endoscopy [48]. Several studies have evaluated passive or active music therapy in various stages of asthma management with variable results reported. One RCT of patients admitted for asthma exacerbation evaluated the effectiveness of standard pulmonary rehabilitation for asthma with or without concomitant music therapy. Measured outcomes included lung function parameters (PEF and FEV 1/FVC) and self-reported anxiety scales. There was a small improvement in PEF in women in the music therapy group. Secondary statistical analysis showed lung function improvements with music therapy only in the patients with mild asthma [44]. Art therapy, the opportunity to share feelings through the use of art materials and expressions, has been used effectively to reduce psychological distress in pediatric chronic disease. One RCT of 23 children examined the potential utility of art therapy in pediatric asthma management. While it did not affect number of exacerbations, art therapy dramatically improved quality of life in children with asthma by decreasing worry and anxiety. The effect persisted for at least 6 months after the intervention was completed [46].
Pharmacotherapy Interventions
Given that anxiety and depression are commonly reported in patients with asthma, particularly in severe and difficult to control disease [49], traditional pharmacologic treatment of anxiety and depression is often attempted. Both depression and anxiety in patients with asthma has been associated with poor asthma-related QOL, but depressive disorders were more commonly associated with poorer levels of asthma control [50]. The use of antidepressant medications, especially selective serotonin reuptake inhibitors (SSRIs), in this patient population has had varying success reported. One randomized placebo-controlled trial evaluated the use of citalopram in 90 adults with asthma and major depressive disorder. Not surprisingly, there was a positive effect on the primary outcome measuring depression using the Hamilton Rating Scale for Depression. Secondary outcome analysis also showed a decrease in oral corticosteroid use in the group treated with citalopram; however, no difference in asthma symptoms between groups was observed [51]. A similar but smaller RCT evaluated the use of escitalopram in major depression and severe asthma. The escitalopram group failed to show a statistical difference in depressive symptoms, asthma control, or oral prednisone use when compared with placebo [52].