Key takeaways:

• 57% of patients with multi-food allergies and 46% of those with one food allergy reported anxiety.
• 8.7% of patients were screened for mental health during their food allergy appointment.

SAN ANTONIO — Mental health concerns present a burden for patients with food allergies, especially those with multiple food allergies, according to data presented at the American Academy of Allergy, Asthma & Immunology Annual Meeting.

“Unfortunately, in the folks dealing with multiple food allergies, every single one of their articulated mental health concerns was more likely to be reported,” Christopher M. Warren, PhD, director of population research at the Center for Food Allergy & Asthma Research, Northwestern University Feinberg School of Medicine, told Healio.

Study population, results

The researchers examined data from the Food Allergy Research & Education (FARE) Patient Registry database, including responses from 1,680 participants to a survey assessing their mental health concerns as well as their levels of mental health screening and care.

Christopher M. Warren

This cohort included 276 respondents involved with one food allergy (64% female; 83% white; 57% aged < 18 years) and 1,404 respondents involved with multiple food allergies (60% female; 78% white; 55% aged < 18 years). Single food allergy respondents included 105 patients and 171 caregivers, whereas multiple food allergy respondents included 595 patients and 809 caregivers.

Peanuts (64%), tree nuts (62%), egg (41%) and milk (37%) were the most common allergens. Also, 62% of respondents reported an average of one food-allergic reaction or more, with 53% occurring away from home, 51% happening within 5 minutes of exposure, and 31% categorized as recent and severe or very severe.

Exposures were attributed to accidents (78%) and ingestion (86%), with 9% of reactions occurring when the patient was alone.

“Folks with multi-food allergy are more likely to have atopic comorbidities,” Warren added.

For example, 34% of patients with one food allergy and 53% of those with multiple food allergies had atopic dermatitis. Asthma was reported by 36% of those with one food allergy and 53% of those with multiple food allergies. Additionally, 30% of those with one food allergy and 46% of those with multiple food allergies had allergic rhinitis.

Among patients, the most common emotional reactions to consuming an allergen included anxiety (54%), panic (32%), fatigue (25%), irritability (25%) and impending doom (22%).

While 62% of patients reported mental health concerns related to food allergies, these concerns were more prevalent among patients with multiple food allergies, the researchers said. Also, there were differences in the prevalence of these concerns between those with single food allergies and those with multi-food allergies.

For example, 57% of the multi-allergy patients and 46% of the single-allergy patients felt anxiety living with disease. Also, 47% of the multi-allergy patients and 41% of the single-allergy patients felt anxiety about allergic reactions.

Concerns about social isolation were reported by 29% of the multi-allergy patients and 20% of the single-allergy patients, whereas 27% of the multi-allergy patients and 13% of the single-allergy patients were anxious about oral food challenges.

Plus, 25% of the multi-allergy patients and 16% of the single-allergy patients were concerned about bullying, in addition to 29% of the multi-allergy patients and 21% of the single-allergy patients avoiding foods.

Among caregivers of patients with food allergies, the most common concerns included fear of trusting others with their child (33%), fear for their child’s safety (32%) and struggling with stress (23%).

These concerns were more prevalent among the caregivers of children with multiple food allergies as well. Specifically, 34% of caregivers of children with multiple food allergies and 29% of caregivers of children with single food allergies reported fear of trusting others with their child.

“Fear of trusting others with your child is always a concern in any context, but for food allergic patients it’s greater. For food allergic patients who are having to manage more food allergies, it’s even greater,” Warren said.

Similarly, 33% of the multi-allergy caregivers and 30% of the single-allergy caregivers feared for their child’s safety, and 25% of the multi-allergy caregivers and 17% of the single-allergy caregivers struggled with stress.

Accessing mental health care

These concerns represent a lot of unmet needs, Warren said, especially among patients with multiple food allergies.

“But most importantly,” Warren continued, “they’re also more likely to endorse being diagnosed with a mental health disorder generally not related to food allergies.”

According to the FARE survey, 24% of patients with a single food allergy and 32% of patients with multiple food allergies received a mental health disorder diagnosis.

Also, 13% of caregivers of patients with food allergy sought mental health care to cope with their worry about their caregiving, including 14% of those taking care of patients with multiple food allergies and 8% of those taking care of patients with single food allergies.

“It’s disheartening to me that such a small percentage of all these folks are actually seeking and receiving mental health services to help deal with that,” Warren said.

But even though 38% of patients had mental health concerns that carried over to problems that were not related to their food allergies, only 8.7% of patients were screened for mental health disorders during their food allergy appointment.

Screenings remain a challenge, Warren said.

“It’s such early days in understanding what the population level ‘normal’ burden is,” Warren said, noting that the six-item Food Allergy Independent Measure is one option for these screenings.

“It’s a patient report. It comes in all different flavors of parents reporting on kids and adults reporting on themselves,” Warren said. “That could actually be a nice clinical screener, because that’s the one instrument where we know what the population-level norms are.”

Beyond that, Warren said, there is no toolkit that is ready to hand off to providers for screening, but work is being done. Still, he encouraged allergists to conduct mental health screenings with their patients and refer them to specialists when indicated.

“We know that’s not really happening to a meaningful degree at this point,” he said.

Warren additionally noted the need for more research.

“There’s so much more work that needs to be done in understanding multiple food allergy,” he said.

Perspective

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Tamara Hubbard, LCPC

As a family therapy-trained behavioral health care provider working with allergic families in private practice, the findings in this study were not surprising.

I routinely see the reported caregiver mental health concerns, which were primarily centered around fear, lack of trust and stress management, in my patients. It is not uncommon for these concerns to lead to avoidance behaviors, such as reluctance to delegate food allergy management responsibilities, hire babysitters and engage in a variety of life experiences as a family system. Unfortunately, these behaviors typically exacerbate caregiver stress and anxiety levels, and they can impede the food allergic child’s development.

Additionally, it makes sense that more caregivers with children managing multiple food allergies sought out mental health care than those managing a single food allergy, as these caregivers likely experience even greater elevated levels of stress due to the added complexity and, therefore, might find it more difficult to effectively manage stress.

With 62% of patients reporting food allergy-related mental health concerns, and more than one-third reporting that these concerns carried over to nonfood allergy-related problems, it is disappointing that only 8.7% reported that they were screened for mental health disorders during their appointments. Not screening food allergic patients for mental health concerns limits opportunities to proactively intervene with psychoeducation and behavioral health care recommendations that have the potential to increase patients’ quality of life and teach them crucial anxiety and stress management skills.

While patients may want to completely extinguish anxiety, that is not a realistic therapeutic goal. Rather, anxiety management goals include the development of distress tolerance skills, or the ability to manage actual and perceived emotional and physical distress. With food allergic patients and caregivers, especially those with pre-existing mental health disorders, providing education leading to the development of these skills is key, and screening these patients and caregivers is the starting point for that process.

With increasingly persuasive evidence that managing food allergy impacts mental health and emotional well-being, it is imperative that these patients and caregivers are routinely asked about psychosocial impacts. I am hopeful that studies such as this one are encouraging health care providers to identify ways to incorporate mental health assessment into their existing patient care routines, which can be accomplished through open-ended questions and brief, validated screening tools, food allergy-specific and otherwise.

Tamara Hubbard, LCPC

Owner of Tamara Hubbard, LCPC, LLC

Founder and CEO of The Food Allergy Counselor Inc.

Disclosures: Hubbard reports receiving honorariums and project payments from FARE and payments from Allergy Insider (ThermoFisher) for webinars.

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American Academy of Allergy, Asthma & Immunology Annual Meeting