Ambient ozone concentration and emergency department visits for panic attacks
Introduction
Concern about neuropsychiatric effects of air pollution is growing. Recent epidemiological studies reported positive associations between ambient air pollution and mental health problems such as suicidal behaviour (Kim et al., 2010, Szyszkowicz et al., 2010) and depression (Cho et al., 2014, Lim et al., 2012, Szyszkowicz et al., 2009). These associations have been substantiated by numerous animal experiments showing systemic inflammation following air pollution exposure, resulting in neuroinflammation and changes in neurotransmitter levels including dopamine and serotonin (Gonzalez-Pina et al., 2008, Gonzalez-Pina and Paz, 1997, Sirivelu et al., 2006, Veronesi et al., 2005). Another animal study showed that ozone-induced lung inflammation may affect stress response-related brain regions (e.g., the amygdala) through vagal afferent nerves (Gackiere et al., 2011). Together with depression, anxiety affects the neurotransmitters and brain regions that are impacted by air pollution, and depression and anxiety share a common pathophysiology (Weiss et al., 1994). Nonetheless, ambient air pollution's effect on anxiety has been minimally investigated.
Among anxiety disorders, panic disorder is a major mental health challenge because it causes chronic psychosocial impairment and decreased quality of life (Markowitz et al., 1989). According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V), panic disorder criteria include recurrent unexpected panic attacks. A previous study reported that the lifetime panic disorder prevalence is about 2.0%, whereas panic attacks are 9.0% (Wittchen and Essau, 1993). A more recent epidemiological study revealed that the lifetime panic attack prevalence reached 22.7% in the United States (Kessler et al., 2006). A panic attack is characterized by cardiopulmonary symptoms such as shortness of breath, sudden palpitations, and chest pain and may be frequently followed by emergency department visits (Buccelletti et al., 2013). Regarding its aetiology, in addition to the genetic components, panic disorder is associated with psychological stress, but is not essentially bound to a situation compared to other anxiety disorders such as phobias (Schmidt et al., 2014).
Although little evidence exists linking environmental pollution and panic disorder, several studies reported the occurrence of anxiety disorders including panic disorder in workers exposed to organic solvents (Dager et al., 1987, Morrow et al., 2000, Visser et al., 2011). However, ambient air pollution's effect on panic disorder in the general population has not been well studied. Thus, we investigated the risks of panic disorder related to ambient air pollution using national representative data.
Section snippets
Study participants
We collected medical record data on individuals who visited the emergency department in 2005–2009 in Seoul, Republic of Korea. These data were obtained from the Health Insurance Review and Assessment Service (HIRA), a part of the National Health Insurance program of the Republic of Korea. The HIRA information included age, gender, diagnosis code, and date of the visit. The diagnosis of ‘panic disorder without agoraphobia’ (F41.0) was made according to the International Classification of
Results
The study period was 1826 days (2005–2009), and there were 2320 emergency department visits for panic attacks in Seoul, Republic of Korea (Table 1). Of all emergency department visits during the period, the proportion of those for panic attacks was 0.05%. The number of males and females was similar. Among panic attack-related emergency department visits, 37.4% of cases had a prior history of panic disorder, and 39.9% had received medical care for a depressive disorder.
Table 2 shows the average
Summary
We investigated short-term ambient air pollution effects on emergency department visits for panic attacks in Seoul, Republic of Korea. Our data showed that ambient O3 concentration was positively associated with emergency department visits for panic attacks, whereas PM10, NO2, SO2, and CO did not show any statistically significant risk.
Although only a few studies have been published on air pollution's association with panic disorders, several previous studies showed increased anxiety disorders
Conclusion
Our study suggests that ambient O3 concentration is significantly associated with emergency department visits for panic attacks. Individuals <40-years-old and women were at significantly higher risk for the visits for panic attacks. Additionally, of the four seasons, only summer showed a significantly increased risk.
Role of the funding source
This subject is supported by Korea Ministry of Environment (MOE) as “the Environmental Health Action Program” (grant number 2014001360002) and by the Yonsei University College of Medicine, Seoul, Republic of Korea (grant number 6-2014-0106). The researchers conducted this study independently from the funding sponsors. The sponsors had no involvement in the design and conduct of the study, in the collection, analysis, and interpretation of the data, or in the preparation, review, and approval of
Contributors
J Cho, C Kim, and DC Shin participated in the study design. C Kim and YJ Choi contributed to data collection. M Suh, J Sohn, SK Cho, and KH Ha were involved in the data processing, and J Cho analysed the data. J Cho and C Kim wrote the manuscript. C Kim had full access to all of the study data and takes responsibility for the data integrity and analysis accuracy.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
The authors would like to thank the Ministry of Environment, National Meteorological Office, and Health Insurance Review and Assessment Service for providing the data.
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