Food Allergy in Patients Seeking Mental Health Care: What the Practicing Psychiatrist Should Know

Food Allergy and Mental Health in Children and Adolescents-The Role of Shared Familial Environment

BACKGROUND

Evidence suggests a link between food allergy and poor mental health, however, this may be explained by shared genetic and environmental factors. We aimed to investigate the association between food allergy of different severity and mental health in children, and the role of familial factors.

METHODS

This population-based, longitudinal cohort study is based on the Child and Adolescent Twin Study in Sweden with questionnaire data reported by parents and/or children. Food allergy 'ever' and doctor's diagnosis were reported at age 9-12 years, and ≥ 1 recent dispensation of adrenaline was used as a marker for current severe food allergy. Outcomes were identified using validated questionnaires for anxiety; Screen for Child Anxiety Related Disorders (SCARED); Strength and Difficulties Questionnaire (SDQ) and depression; Short Mood and Feelings Questionnaire (SMFQ), Center for Epidemiological Studies Depression Scale (CES-D) and Diagnostic and Statistical manual of Mental Disorders (DSM-IV-MDE) and reported at 9-12, 15 and 18 years of age. Multivariate linear and logistic modelling was applied to the whole cohort and a co-twin control approach to remove confounding by familial factors.

RESULTS

In total, 3039 (8.9%) children had a parent-reported food allergy. Among these, 1292 (43.5%) had non-severe food allergy without diagnosis, 1490 (49%) had non-severe food allergy with diagnosis and 257 (8.5%) had severe food allergy. Compared to children with no food allergy, non-severe food allergy with diagnosis by 9-12 years was associated with parent-reported anxiety/depression; SCARED (adjOR 2.10, 95% CI 1.48-2.98), SMFQ (adjOR 1.92, 95% CI 1.19-3.10) at 9-12 years and SDQ (adjβ 0.2, 95% CI 0.0-0.4) at 15 years. All other associations were null including for those with severe food allergy. All positive estimates in the full cohort were attenuated using co-twin controls.

CONCLUSION

Evidence associating paediatric food allergy severity and poor mental health was weak, and positive associations observed were likely due to familial confounding.

The mental health burden of food allergies: Insights from patients and their caregivers from the Food Allergy Research & Education (FARE) Patient Registry

Background

Food allergies impose a large psychosocial burden, including mental, emotional, and social aspects, on both patients and their caregivers. Patients, caregivers, and their families often experience anxiety, isolation, and fear around food allergies.

Objective

To assess the real-world mental health burden of food allergies, using the Food Allergy Research & Education (FARE) Patient Registry (NCT04653324).

Methods

Self-reported data from patients with food allergies, and their caregivers, were analyzed from the FARE Food Allergy History and Mental Health Concerns surveys. Odds ratios were also calculated as a measure of association between patient food allergy characteristics and the likelihood of having mental health concerns or a formal mental health diagnosis.

Results

The FARE Patient Registry included 1680 patients/caregivers. Anxiety (54%) and panic (32%) were the most common emotions that patients reported as a result of eating the food that produced an allergic reaction. About two-thirds of patients reported mental health concerns related to food allergies (62%), including anxiety after an allergic reaction, anxiety about living with food allergies, and concerns about food avoidance. Caregivers also experienced fear for the safety of their children, and often sought mental health care to cope with worry related to caring for patients with food allergies. The likelihood of having food allergy-related mental health concerns was increased for patients experiencing more than 1 reaction per year (OR 1.68-1.90) and was lowered for patients having a formal mental health diagnosis (OR 0.43). Caregivers filling out the FARE survey for pediatric patients (OR 4.03) and experiencing food allergy-related mental health concerns (OR 2.36) were both significant predictors for having a formal mental health diagnosis.

Conclusion

Our study highlights a continuing unmet need for mental health screening and support as part of the management of patients with food allergies.

Validated anxiety assessments among pediatric patients with peanut allergy on oral immunotherapy

BACKGROUND

Although efficacy, safety, and quality of life measures associated with peanut oral immunotherapy (OIT) have been studied, the relationship between peanut OIT and clinical anxiety has not yet been evaluated. The latter is important to help providers and families have an improved shared medical decision discussion around the benefits of initiating OIT.

OBJECTIVE

To investigate the relationship between undergoing OIT and anxiety in patients with peanut allergy.

METHODS

In this prospective cross-sectional cohort study, using validated and age-appropriate anxiety scales administered with electronic survey questionnaires, we used generalized linear regressions to compare anxiety between patients undergoing OIT and similar patients with peanut allergy but not on OIT (controls).

RESULTS

In the younger cohort (<7 years, n = 80), there was generally a low prevalence of diagnosable anxiety across patients on OIT and controls. In the older cohort (>7 years, n = 125), there was a higher prevalence of anxiety but no clinically meaningful difference between anxiety scores of patients on OIT and controls. In the older cohort, patients with asthma were more likely to have higher mean anxiety scores (P = .04), as were female patients compared with male patients (P = .004). A subanalysis of separation anxiety scores in the older cohort revealed that younger age (7-12 years vs >12 years, P < .001), non-White race (P = .04), and eczema (P = .02) were found to be meaningful predictors of higher scores. A subanalysis of social anxiety on the older cohort pointed toward non-White race as a meaningful predictor of higher scores (P < .02).

CONCLUSION

The clinical implications of these findings suggest that allergists should particularly consider screening children with food allergy for anxiety and anxiety subtypes among patients who are non-White, female, or have asthma.

Evaluation of emotional, Behavioral, and clinical characteristics of children aged 1-5 with a history of food-related anaphylaxis

BACKGROUND

Our study aimed to investigate emotional, behavioral, and social characteristics assessed with internationally validated psychometric scales and their relationship with demographic, clinical, and laboratory data in children with a history of food-related anaphylaxis.

METHOD

The study included patients aged 1-5 who were followed up in the pediatric allergy outpatient clinic with a diagnosis of food-related anaphylaxis. All participants were evaluated during admission to the clinic using a study questionnaire, which was prepared by the authors, consisting of three parts: a sociodemographic information form, a clinical evaluation form, and the Aberrant Behavior Checklist (ABC) for psychiatric evaluation. Parents answered the questionnaires regarding the patients' emotional and behavioral health.

RESULTS

Thirty patients aged between 12 and 62 months were included in the study. The data were compared with 30 healthy controls with similar age and gender distribution. The total ABC score (p = 0.015), and the stereotypic behavior (p = 0.003) and hyperactivity (p = 0.002) subscale scores were significantly higher in patients with anaphylaxis history compared to the controls.

CONCLUSION

Emotional and behavioral status assessments and the clinical follow-up of food allergies of patients who experienced anaphylaxis in early childhood are useful for the holistic management and early recognition of possible pathologies.

The relationship between dietary elimination and maternal psychopathology in breastfeeding mothers of infants with food allergy

BACKGROUND

There has been no study evaluating the psychopathology in breastfeeding mothers of infants with food allergy (FA).

OBJECTIVE

The aim of the study was to investigate the relationship between dietary elimination and maternal psychopathology, specifically anxiety, depression, and mother-to-infant bonding, in breastfeeding mothers of infants with food allergy.

METHODS

Breastfeeding mothers following an elimination diet due to FA in their children aged 1-to-12 months were compared with the healthy controls. The physician-diagnosed FA group was divided into IgE-, non-IgE-mediated, and infants with some minor symptoms which were not enough to make the diagnosis of FA were classified as Indecisive symptoms for FA group. Mothers completed standardized questionnaires including Symptom Checklist 90R, Beck Depression/Anxiety Inventories (BDI/BAI), Postpartum Bonding Questionnaire (Bonding).

RESULTS

Of 179 mother and infants, 64 were healthy, 89 were FA, 16 were indecisive symptoms for FA. The mean age of the mothers and infants were 31.1 ± 4.7 years and 6.3 ± 3.6 months, respectively. The physician-diagnosed FA groups had higher scores for anxiety (p = .008), anger (p = .042), depression (p < .001), obsession (p = .002), phobia (p = .008), somatization (p = .002), general symptom index (GSI) (p = .001), BDI (p < .001), BAI (p = .008), and Bonding (attachment [p = .001], anger [p = .019], and total [p = .036]) than the healthy ones. The indecisive symptoms for FA group had a similar score pattern to physician-diagnosed FA, except interpersonal sensitivity, BDI, and attachment.

CONCLUSION

Breastfeeding mothers of infants with FA were more anxious, with higher depression scores than controls, and had many psychopathologies which affected bonding. Interventions targeting negativity in caregivers' social relationships are urgently needed.

Prevalence of anxiety and its associated factors among infertile patients after 'two-child' policy in Chongqing, China: a cross-sectional study

BACKGROUND

With the prevalence of infertility increasing every year around the world, it has seriously impacted the individual quality of family and social life. Anxiety is one of the most prevalent anxiety disorders among infertile patients. After the two-child policy, whether it affected the prevalence of anxiety is controversial. This study aimed to determine the prevalence of anxiety and its potential risk factors among Chinese infertile women after the enforcement of 'two-child policy'.

METHODS

This cross-sectional study included 693 infertile patients in a reproductive medical center in Chongqing, China, between February 2016 and December 2018. Data was collected by Self-filling questionnaires including basic demographic information and the Generalized Anxiety Disorder-7 (GAD-7). SPSS statistical software (IBM SPSS version 25) was used to analyse the obtained data. Descriptive analysis was used to describe basic information and anxiety scores, the chi-square test and binary logistic regression were used to analyse the relationship between anxiety and other variables.

RESULTS

The prevalence of anxiety among total infertile patients was 21.8%, and its 23.5% among first-child infertile patients (FI), and 18.4% among second-child infertile patients (SI) respectively (P > 0.05). Binary logistic regression showed that patients with lower education levels were more likely to have anxiety (P < 0.01). Patients with middle salary incomes were more likely to have anxiety (OR = 1.860, 95% CI: 1.068-3.238). Oral contraception taking history (OR = 1.778, 95% CI: 1.186-2.667), and history of allergy (OR = 2.098, 95% CI: 1.219-3.612) were associated with anxiety.

CONCLUSIONS

Under the full liberalization of the "two-child policy", the total prevalence of anxiety among Chinese infertile female is comparatively high. Low education levels, middle incomes, oral contraception taking and allergy history can be the related risk factors of anxiety. We promote that all infertile patients should be evaluated for the prevalence of anxiety, especially those with potential risks, and receive consultant or targeted treatment when needed.

Living with Food Hypersensitivity as an Adolescent Impairs Health Related Quality of Life Irrespective of Disease Severity: Results from a Population-Based Birth Cohort

Food hypersensitivity (FHS) refers to food-related symptoms, with or without concurrent Immunoglobulin E (IgE) antibodies related to food(s). It remains unclear how different FHS phenotypes affect health-related quality of life (HRQoL). We examined self-reported HRQoL (with the generic instrument EQ-5D (dimensions and a Visual Analogue Scale (VAS), range 0–100) in association with phenotypes of FHS, and food-specific symptoms among adolescents (n = 2990) from a population-based birth cohort. Overall, 22% of the adolescents had FHS. Compared to adolescents without FHS, those with FHS reported more problems in the dimensions of pain/discomfort (p < 0.001), and anxiety/depression (p = 0.007). Females with FHS reported more problems than males in these dimensions (p < 0.001). Different FHS phenotypes (IgE-sensitization, allergic co-morbidity, and severity of symptoms) were not associated with differences in HRQoL. EQ-VAS scores were lowest for adolescents with symptoms for wheat vs. no wheat, median 80 vs. 89, p = 0.04) and milk vs. no milk (median 85 vs. 90, p = 0.03). Physician-diagnosed lactose intolerance median EQ-VAS was 80 vs. 90, p = 0.03 and also associated with more problems in the dimension of anxious/depression. In conclusion, FHS is associated with lower HRQoL in adolescence, irrespective of phenotypes, but differentially affects females vs. males, and those with vs. without symptoms for milk or wheat.

Psychosocial issues and quality of life associated with food allergy

The day-to-day challenges involved in caring for a child with food allergies can be a significant stress within a family. As the child with a food allergy grows up, developmental changes as well as external influences such as bullying and peer pressure can further influence these stressors. When the child with a food allergy is young, the family may be limited on where they can vacation or go out to restaurants, which can cause tension and frustration within the family. Hypervigilance and fear of accidental exposure to the allergen takes an emotional and physical toll on the child with a food allergy and the child's family. Socially, children with a food allergy may have to limit participation in school events, parties, or camps. These limitations can cause feelings of isolation for the child and feelings of guilt for the parents. As the child becomes an adolescent and young adult (AYA), increased autonomy of dining options and a desire to fit in with peers can trigger higher risk-taking behavior, which can be a source of anxiety for the AYA as well as the caregivers. The aim of this review was to describe potential negative psychosocial impacts of having a food allergy for the family. Data were reviewed from a literature search of medical literature data bases between 2010 and 2020 by using the search terms "food allergy," "psychosocial," "anxiety," and" quality of life." As we better recognize the psychosocial issues associated with food allergies, we will have a better ability to develop effective interventions to improve the quality of life for these families.

Likely questionnaire-diagnosed food allergy in 78, 890 adults from the northern Netherlands

BACKGROUND

It is challenging to define likely food allergy (FA) in large populations which limited the number of large studies regarding risk factors for FA.

OBJECTIVE

We studied the prevalence and characteristics of self-reported FA (s-rFA) in the large, population-based Dutch Lifelines cohort and identified associated risk factors.

METHODS

Likely food allergic cases (LikelyFA) were classified based on questionnaire reported characteristics consistent with FA. Subjects with atypical characteristics were classified as Indeterminate. We investigated 13 potential risk factors for LikelyFA such as birth mode and living on a farm and addressed health-related quality of life (H-RQOL).

RESULTS

Of the 78, 890 subjects, 12.1% had s-rFA of which 4.0% and 8.1% were classified as LikelyFA and Indeterminate, respectively. Younger age, female sex, asthma, eczema and nasal allergy increased the risk of LikelyFA (p-value range <1.00*10-250-1.29*10-7). Living in a small city/large village or suburb during childhood was associated with a higher risk of LikelyFA than living on a farm (p-value = 7.81*10-4 and p = 4.84*10-4, respectively). Subjects classified as Indeterminate more often reported depression and burn-out compared to those without FA (p-value = 1.46*10-4 and p = 8.39*10-13, respectively). No association was found with ethnicity, (duration of) breastfeeding, birth mode and reported eating disorder. Mental and physical component scores measuring H-RQOL were lower in both those classified as LikelyFA and Indeterminate compared to those without FA.

CONCLUSION

The prevalence of s-rFA among adults is considerable and one-third reports characteristics consistent with LikelyFA. Living on a farm decreased the risk of LikelyFA. The association of poorer H-RQOL as well as depression and burn-out with questionable self-perceived FA is striking and a priority for future study.