Background
Asthma is a common medical condition with an increased prevalence, morbidity, and mortality over the past two decades. There are numerous risk factors for asthma patients has been identified. With the ever-increasing elderly population worldwide in general and in Taiwan particular, the detection and proper management of the disease in old age may have a great impact from the public health perspective. Whether asthma in the elderly (40 to 64 and above 65 years) maintains the same characteristics as in young populations is an interesting matter. The management of asthma in advanced age is complicated by the comorbidities and polypharmacotherapy, which advocate for a comprehensive approach with a multidimensional assessment. Therefore, it is essential to look into asthma patients aged above 40 years. The key treatments for asthma patients are steroids and other anti-inflammatory drugs. These drugs both help to control asthma and prevent asthma attacks. Corticosteroids effectively work by reducing inflammation, swelling, and mucus production in the airways of patients with asthma. Asthma, anxiety, depression, and bipolar disorder are common health problems in primary care. The association between allergy and mood disorders has been proposed for a long time, some previous studies reported that subjects with a history of any allergy were more likely to be diagnosed with major depressive disorder (MDD). In recent years, evidence of a relationship between asthma and anxiety, depression, bipolar disorder is conflicting. A number of considerable data have emerged that major anxiety, depressive, and bipolar disorder is caused by corticosteroids. However, the implications of this correlation are still poorly understood. Furthermore, patient frequently use medications simultaneously for the different complaints, without being aware of the interactions these products may have. Although corticosteroids is a risk factor for MDD in the general population, its association with MDD among patients with asthma has not been well studied. In our current research, we will focus on relationship between anxiety, depression, and bipolar disorder in patients with asthma to determine whether use inhaled corticosteroids in patients with asthma increases the risk of MDD and anxiety disorder.

Methods
First, we used the patients who received a major diagnosis of asthma (ICD-9-CM codes 493) given by pulmonologists or rheumatologists in ambulatory visits or during hospitalization from year 2000 to 2011 were included. Next, each individual was followed to evaluate until 2013. Asthma was defined on the basis of at least 2 National Health Insurance ambulatory-claim records or 1 inpatient record. The study cohort will consist of all new users of inhaled corticosteroids, who were more than 40 years of age and had received their first prescription of inhaled corticosteroids drugs during the follow-up years. Finally, the comparison cohort was randomly selected from the remaining age and sex matched insured and year of receiving medical service for each patient with asthma, who had an index use of health service in the same year.
We clarified the asthma patients use ICS base on different durations of inhaled corticosteroids use to 2 groups: the asthma patients take ICS continuously for three months or more, and the asthma patients used ICS less than three months.
Results
The result investigating from a total number of 298,309 participants (includes 74,578 patients with asthma and 223,734 comparison patients) showed that: First of all, there were consistently increased risks across psychiatric disorders among patients with asthma. Compared with patients without asthma, those with asthma were at higher risk for anxiety disorder (adjusted HR = 2.58), depression disorder (adjusted HR = 1.55) and bipolar disorder than other psychiatric disorders in patients without asthma. Secondly, compared with asthma patients without ICS, those asthma patients with ICS were at higher risk for anxiety disorder, depression disorder, and bipolar disorder and other psychiatric disorders than in patients without ICS. Finally, compared with asthma patients without ICS as well as with ICS use < 3 months, those asthma patients with ICS use ≥ 3 months were at highest risk for anxiety disorder, depression disorder, and bipolar disorder.
Conclusions
We conducted a large-scale, retrospective cohort study using a nationwide database to examine the correlation between asthma with depression and anxiety disorder caused by corticosteroids. Our results showed that corticosteroids use is associated with the increase risk of depression and anxiety disorder in patients with asthma. Moreover, depression and anxiety disorder occur at higher rates in individuals in asthma patients using ICS use ≥ 3 months compared to those asthma patients in ICS use < 3 months as well as in non-ICS.

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