DISCUSSION
This study aimed to assess the impact anaphylaxis has on the QoL and
mental health of adults, using validated measures. A new tool developed
and validated by our group for measuring anaphylaxis specific QoL for
adults12 was employed and scores on scales to measure
general QoL and mental health were compared to relevant norm data where
available. When comparing scores with norm data, adults with anaphylaxis
reported greater stress and poorer general QoL in social and
environmental domains. It is unsurprising that adults with this
condition report high levels of stress and an impact on social and
environmental QoL, given the constant vigilance required to avoid their
respective triggers, which involves continually assessing risk in their
environment. Those with food allergy also need to assess risk every time
they eat and this type of allergy has been consistently related to
poorer social lives, impacting on activities such as eating out or going
on holiday25. On the other hand, adults with
anaphylaxis reported a better general physical QoL than norm values.
This may be due to particular characteristics of this cohort that might
be different to the norm sample. For example, the majority of the
participants in this cohort were educated up to at least high-school
level which may indicate a better socio-economic status, an established
predictor of better quality of life26 and general
health27.
Gender differences were found when exploring differences in anxiety and
depression compared to norm data, with only females scoring
significantly worse. Almost half of the present sample of female adults
also reported moderate to severe anxiety levels. Anxiety due to
anaphylaxis has been reported in younger age groups in both males and
females5,6. It is unclear why females in this sample
reported particularly high levels compared to males. It may be due to
females being more likely to report mental health
issues28 or they may simply have a greater fear of the
consequences of anaphylaxis than men. Exploration of beliefs and
understanding of anaphylaxis would be useful, particularly as illness
beliefs have been shown to be associated with mental health outcomes and
long-term management of allergic conditions such as food
allergy29 as well as other conditions such as
diabetes30. The findings regarding depression are
novel as very little research has measured this in adults with
anaphylaxis, although depression is a common co-morbidity with other
long-term health conditions31.
Poorer anaphylaxis specific QoL was significantly related to greater
stress, anxiety, depression and poorer general QoL across all domains,
which highlights the impact anaphylaxis has on day-to-day living of
adults with this condition. Important demographic and clinical variables
were also related to anaphylaxis specific QoL such as gender (with
females reporting a greater impact), younger age, other atopic
conditions and number of anaphylactic reactions. Clinicians should take
particular note of patients with these characteristics, as they may
require further support in managing their condition and/or require
psychological support to reduce mental distress.
Direct comparisons across the different causes for anaphylaxis was
possible due to the newly validated A-QoL-Adults scale. Those with
anaphylaxis to food or with spontaneous anaphylaxis reported a bigger
impact on their anaphylaxis specific QoL compared to those with
medication or venom as a cause. This may be due to the level of risk
assessment and daily effort needed to avoid allergen/s for those with
food allergy, or the extra vigilance for those who do not know what
causes their anaphylaxis. Significant differences across causes were
also seen for those with anaphylaxis to medication, who reported greater
depression and poorer overall physical QoL in comparison to those with
anaphylaxis to venom. Clinicians should therefore be aware of the
different aspects of lives that are affected, depending on the cause of
anaphylaxis, in order to ensure appropriate support is in place for
optimal allergy management.
In regression models, psychological variables explained a significant
amount of variance in QoL after demographic and clinical variables had
been controlled for. In the final model, younger age, greater number of
anaphylactic reactions experienced and greater anxiety significantly
predicted poorer anaphylaxis specific QoL. Reducing the number of
reactions people experience is therefore key to improving anaphylaxis
related QoL and it is likely that this may also reduce anxiety, which
was the strongest predictor of QoL. Those with high levels of anxiety
may benefit from psychological support.
Some limitations should be taken into account when assessing the results
of this study. First, two thirds of participants who expressed an
interest in taking part in the study did not return their study packs
and these participants may have potentially responded differently to
those who took part. Second, the sample is predominantly White British
and as mentioned previously almost 60% were educated to at least a
post-high school level (A levels in the UK education system). Third,
those with suboptimal or no proficiency in English language were
excluded as questionnaires were not available in other languages. This
may have had an impact on results although we found no differences
across ethnicity. However, group numbers for different ethnic minority
groups were relatively low and so we were not able to determine if these
results would be the same in different socio-economic strata or ethnic
groups where we know rates of anaphylaxis and allergic conditions may
vary32. Fourth, data was generated from a single
centre, although it is a major regional centre with a wide catchment
area outside Birmingham city. Nevertheless, this study reports novel
findings in a sample of well characterised adult patients with
anaphylaxis which could assist in informing
clinical and psychological support
for allergy management. Patient education and training for allergen
avoidance is needed to improve self-management of anaphylaxis. In
addition, help in recognising when anaphylaxis is having an impact on
mental wellbeing is key to timely referral to for psychological support.
In conclusion, anaphylaxis has an adverse impact on QoL and mental
health of adults across different causes. Anxiety, depression and number
of reactions seem to be important in explaining the impact on QoL. Those
with anaphylaxis to food or spontaneous anaphylaxis in particular may
benefit from support to help improve quality of life. Further
multi-centre studies including a larger sample of patients from ethnic
minority groups may help gain further insight into the impact of
anaphylaxis on QoL and facilitate development of novel supportive
interventions.