Jonathan M. Feldman, Ph.D. - US grants

DESCRIPTION (provided by applicant): This application is being submitted to the NIMH DAHBR Health and Behavior Research Branch Co- Morbidity Program. This is a pilot study designed to culturally adapt for Latinos a behavioral treatment for comorbid panic disorder (PD) and asthma, and examine its efficacy versus an active placebo treatment. This R34 proposal is a follow-up to an R21 study, which developed the Panic-Asthma Treatment and showed promising results for reducing panic and asthma symptoms. There is a large degree of symptom similarity between PD and asthma. Confusion between panic and asthma symptoms can result in serious errors in self- management of both disorders. Patients with PD and asthma need a tailored intervention because what may be therapeutic for one condition can potentially exacerbate the other condition. The intervention teaches participants to differentiate between panic and asthma symptoms, and how to apply self-management strategies for each. The treatment also includes elements of cognitive behavioral therapy for PD that are safe for patients with asthma, and combines it with asthma education and heart rate variability biofeedback therapy. The research plan will involve two aims: 1) Cultural adaptation of the Panic-Asthma Treatment and 2) a randomized, placebo-controlled pilot study. Participants will be primarily recruited from two major, inner-city hospitals in the Bronx, NY. Diagnosis of PD will be based on the Structured Clinical Interview for DSM-IV. Diagnosis of asthma will be based on national guidelines. The first year of the project will be devoted to approximately 5 focus groups with Latino (primarily Puerto Rican) participants, pilot treatment and participant feedback. The protocol will be adapted based on key cultural issues that are systematically observed during Phase 1. During Years 2-3, 40 participants with PD and asthma will be randomized into two treatment arms: Panic-Asthma Treatment and an active placebo condition involving music therapy and paced breathing at resting respiration rates. Each treatment will involve 8 weekly sessions. An interviewer, who will be blind to treatment condition, will conduct assessments at pre-treatment, mid-treatment, post-treatment, and 3-month follow-up. The primary hypotheses are that participants in the Panic-Asthma treatment group will have greater decreases than subjects in the placebo condition on the PD severity scale and albuterol use (i.e., rescue asthma medication) from pre-test to post-test and across 3-month follow-up. Albuterol use is important to examine because it may be an indicator of confusion between panic and asthma symptoms. Reductions in albuterol use may lead to improvements in panic symptoms due to fewer side effects. The goals of this study are highly relevant to the mission of NIMH to develop efficacious, culturally relevant behavioral treatments of co-occurring mental and physical disorders. This R34 study will generate feasibility data (e.g., initial effect sizes, recruitment and retention rates, treatment credibility, etc.) to design a future full- scale randomized, placebo-controlled trial via an R01 grant. PUBLIC HEALTH RELEVANCE: The development of a behavioral treatment for Latinos with comorbid panic disorder and asthma has great potential to reduce the immense public health costs of both disorders. Panic disorder is over-represented in patients with asthma, and asthma disproportionately affects Puerto Rican individuals. The Panic-Asthma treatment will be adapted to incorporate the specific, cultural issues relevant to Latinos.

The overall objective of this study is to investigate the biological and behavioral pathways linking depression with asthma outcomes in older adults. Major depression (MD) is highly prevalent among older asthmatics, particularly in minorities, and is associated with increased asthma morbidity. MD leads to enhanced systemic inflammation (increased levels of interleukin [IL]-1?, IL-2, IL-6, and tumor necrosis factor-?). Some of these pro-inflammatory cytokines have been linked to more severe asthma phenotypes, potentially explaining the relationship between MD and worse asthma outcomes. However, biological pathways are likely only part of the drivers of asthma morbidity. Prior studies show that depression is consistently linked with low medication adherence in other chronic diseases. Additionally, theory and limited empirical evidence suggest that cognitive and emotional illness representations in depressed patients may lead to maladaptive coping strategies that result in low adherence to asthma self-management behaviors (SMB) and poorer outcomes in older adults. This proposal brings together a multidisciplinary team of investigators to expand understanding of the pathways through which MD is associated with increased asthma morbidity. The Specific Aims are to: 1) Determine the relationship of MD with airway and systemic inflammation in older asthma patients and evaluate the longitudinal association with outcomes and 2) Establish the longitudinal association between MD and adherence to asthma SMB (medication adherence, trigger avoidance, and inhaler technique) among older adults and identify the behavioral pathways linking them. We will use structural equation modeling to assess an integrated model of the direct and indirect causal inflammatory and behavioral pathways, explore the directionality of relationships in this biobehavioral model, and evaluate the contributions of specific pathways to asthma outcomes in older patients with MD. We will conduct a longitudinal study of 400 English and Spanish- speaking older adults (?60 years) with persistent asthma (~50% with MD) recruited from 3 racially diverse practices in New York City. Study subjects will undergo a comprehensive in-person baseline evaluation of their asthma and will be assessed for current MD disorder using the gold standard for psychiatric interviews. We will also collect peripheral blood and induced sputum for airway cytokine and cellular expression assessments. Participants will be monitored for 4 weeks to obtain objective assessment of asthma medication adherence using an electronic device. Subjects will be followed prospectively at 6, 12 and 18 months with repeated assessments of MD, systemic inflammatory markers, SMB, illness and medication beliefs, and asthma outcomes. Using these data, we will evaluate the interplay of biological and behavioral pathways underlying the relationship of MD with increases in asthma morbidity in older adults. The clinical implications of this study include potentially identifying older patients with asthma who may benefit from different anti-inflammatory treatments, and targeting modifiable beliefs that predict asthma SMB in older adults.