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1 pissn: eissn: (3): , May ORIGINAL ARTICLE 성인천식과우울증과의관계에관한연구 김여진 1, 김정은 2, 이주석 1 성균관대학교의과대학삼성창원병원 1 소아청소년과, 2 내과 Association between asthma and depression in Korean adults Yeo Jin Kim 1, Jeoung Eun Kim 2, Ju Suk Lee 1 Departments of 1 Pediatrics and 2 Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea Purpose: is one of the most common allergic diseases in which depression is an important comorbidity. However, little is known about the prevalence of depression in Korean adult asthmatics. This study was performed to evaluate the association between asthma and depression and to investigate the clinical characteristics of Korean adult asthmatics with depression. Methods: Data were acquired from 18,066 men and women, aged older than 19 years who participated in the Fifth Korea National Health and Nutrition Examination Surveys, which was conducted from 2010 to The presence of asthma was based on self-reported physician diagnosis of asthma in the Health Interview Surveys. Results: The prevalence of asthma was 3.2%, and that of depression was 4.2%. In univariate analysis, adults with asthma were old age, marital status, unemployment, low education, low monthly family income, low number of household members, obesity (P< 0.05) were significantly associated with asthma, but sex, residence area, and smoking status were not associated with asthma. The prevalence of hypertension and depression were higher in asthmatics (P< 0.05), while diabetes mellitus was not associated with asthma. After adjustment for age, marital status, number of household members, monthly family income, body mass index, hypertension, unemployment, low educated status, and depression were associated with the higher prevalence of asthma (P< 0.01). Depression was associated with female sex, unemployment, while it was not associated with lung function in asthmatics. Conclusion: The results of this study show that depression may be an important risk factor for asthma in Korean adults. Further studies are needed to explore mechanisms responsible for the association between depression and asthma. (Allergy Respir Dis 2015;3: ) Keywords:, Depression, Respiratory function tests 서론천식은가장흔한만성호흡기질환의하나로전세계적으로유병률증가를보이며 1,2) 국내에서도지속적인증가추세를보인다. 3,4) 천식의유병률이증가하는이유로는생활습관의변화, 대기오염, 위생가설등이제안되고있으며 5-7) 최근에는천식과정서적인문제와의연관성에대한보고도이루어지고있다. 8) 이중우울증과의연관성에대해서는천식환자에서일반인보다우울증의빈도가높고우울증이천식조절에악영향을미치는것으로알려져있다. 9,10) 천식과우울증의관계에대한최근국내보고에의하면우울증을동반한성인천식환자에서우울증을동반하지않은경우에비해짧은유병기간을가지고천식증상이잘조절되지않는다고보고 하였다. 11) 그러나천식환자들의우울증유병률에대한국내연구는없어이에본저자들은천식환자에서정상인에비해우울증유병률이높은지를알아보고자하였고또한우울증을동반한천식환자에서우울증을동반하지않은경우에비해나이, 성별, 흡연, 체질량지수등의임상적인자와폐기능검사수치의차이가있는지를알아보고자후향적단면연구를실시하였다. 대상및방법 1. 연구대상본연구는 5차국민건강영양조사 (Korea National Health and Nutrition Examination Surveys) 의자료를이용하여실시하였다. 국 Correspondence to: Ju Suk Lee Department of Pediatrics, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, 158 Paryong-ro, Masanhoewon-gu, Changwon , Korea Tel: , Fax: , ljs @lycos.co.kr Received: January 16, 2015 Revised: March 28, 2015 Accepted: March 30, The Korean Academy of Pediatric Allergy and Respiratory Disease The Korean Academy of, Allergy and Clinical Immunology This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (

2 Kim YJ, et al. Association between asthma and depression in Korean adults 민건강영양조사의세부적인조사내용과방법은질병관리본부연구윤리심의위원회 (Institutional Review Board) 의승인을받아수행되고있다. 5차국민건강영양조사는 2010년부터 2012년까지 3년동안의조사이며총 25,534명이참여하였다. 본연구는 25,534명중 19세이상의성인을대상으로실시하였으며 18세이하 5,935명을제외하였다. 19,599명중에서천식의유무를응답하지않은 1,533 명은연구에서제외하여 18,066명을대상으로연구를실시하였다. 2. 연구방법본연구는 5차국민건강영양조사를이용하여실시한인구기반후향적설문조사연구이며국민건강영양조사자료는국민건강영양조사홈페이지 ( 에서제공받았다. 연구에사용되었던각변수의정의는체질량지수의경우 <23, 23 25, >25 kg/m 2 을기준으로세군으로나누었고이는정상, 과체중, 비만을의미한다. 결혼상태는결혼생활을유지하고있는경우, 사별또는이혼후독신인경우, 결혼한적없는경우로나누었고직업군은현재직업에종사하고있는경우와, 무직으로나누었다. 흡연의경우는흡연을한번도하지않았던군, 이전에흡연을하였지만현재금연을한군, 현재도흡연을하고있는군으로나누었으며금연군은금연시행후흡연을한번도하지않은군으로정의하였고간헐적흡연이있었던군은흡연군으로분류하였다. 거주지역은도시와농촌으로나누었으며시, 동은도시로읍, 면은농촌으로분류하였다. 한달가족수입은 5차국민건강영양조사에서분류한 4분위수를이용하였고교육수준은중학교졸업미만, 중학교졸업, 고등학교졸업, 대학졸업이상으로나누었다. 당뇨, 고혈압, 천식과우울증의유무는평생의사에의해진단받은적있는경우로한정하였다. 3. 통계분석자료분석은 PASW Statistics ver (SPSS Inc., Chicago, IL, USA) 프로그램을사용하였고 2군에서빈도비교는 chi-square 를사용하였고천식과우울증과의연관성을알아보기위해 logistic regression analysis를사용하였으며 P 값이 0.05 미만인경우를통계적으로의미있다고판단하였다. 결과 1. 대상자들의특징총 18,066명의연구대상자들중천식으로진단된경우는 587명 (3.2%) 이었고우울증으로진단된경우는 758명 (4.2%) 이었다. 교육수준은고졸이상인경우 (63.3%) 가많았으며가족구성원의수는 2 4인가정인경우 (79.8%) 가대부분을차지하였다. 도시지역거주자의빈도 (79.2%) 가높았으며대상자들의현재흡연율은 20.3% 였 Table 1. Demographic characteristics of subjects (n= 18,066) No. (%) Sex Male 7,632 (42.3) Female 10,434 (57.8) Age (yr) ,359 (13.1) ,448 (19.1) ,156 (17.5) ,434 (19.0) ,082 (17.1) > 70 2,587 (14.3) Marital status, n= 18,065 Married 13,394 (74.1) Single (separated or divorced) 2,183 (12.1) Never-married 2,488 (13.8) Employment status, n= 17,821 Employed 10,480 (58.8) Unemployed 7,341 (41.2) Education, n= 17,860 < Middle school 4,606 (25.8) Middle school 1,948 (10.9) High school 5,939 (33.3) > High school 5,367 (30.0) Monthly family income (quartile), n= 17, ,538 (19.8) 2 4,597 (25.7) 3 4,841 (27.1) 4 4,880 (27.3) No. of household members 1 1,368 (7.6) 2 4,741 (26.2) 3 4,461 (24.7) 4 5,040 (27.9) >5 2,456 (13.6) Residence area Urban 14,315 (79.2) Rural 3,751 (20.8) Smoking status Current 3,673 (20.3) Ex-smoker 3,632 (20.1) None 10,761 (59.6) Body mass index (kg/m 2 ), n= 17,961 < 23 8,074 (45.0) ,187 (23.3) > 25 5,700 (31.7) Hypertension Yes 4,117 (22.8) No 13,949 (77.2) Diabetes mellitus Yes 1,506 (8.3) No 16,560 (91.7) (Continued to the next page) 174

3 김여진외 성인천식과우울증과의관계에관한연구 Table 1. Continued No. (%) Depression Yes 758 (4.2) No 17,308 (95.8) Yes 587 (3.2) No 17,479 (96.8) Table 2. Demographic characteristics according to the presence of asthma (n= 18,066) (n= 587) Nonasthma (n= 17,479) Sex 0.16 Male 231 (39.4) 7401 (42.3) Female 356 (60.6) 10,078 (57.7) Age (yr) < (11.1) 2,294 (13.1) (13.3) 3,370 (19.3) (10.7) 3,093 (17.7) (16.2) 3,339 (19.1) (22.1) 2,952 (16.9) > (26.6) 2,431 (13.9) Marital status, n= 18,065 < 0.01 Married 385 (65.6) 13,009 (74.4) Single (separated or divorced) 129 (22.0) 2,054 (11.8) Never-married 73 (12.4) 2,415 (13.8) Employment status, n= 17,821 < 0.01 Employed 258 (44.3) 10,222 (59.3) Unemployed 324 (55.7) 7,017 (40.7) Education, n= 17,860 < 0.01 < Middle school 245 (42.0) 4,361 (25.2) Middle school 70 (12.0) 1,878 (10.9) High school 155 (26.6) 5,784 (33.5) > High school 113 (19.4) 5,254 (30.4) Monthly family income (quartile), < 0.01 n= 17, (33.0) 3,347 (19.4) (24.0) 4,458 (25.8) (21.4) 4,717 (27.4) (21.6) 4,755 (27.5) No. of household members < (11.9) 1,298 (7.4) (32.2) 4,552 (26.0) (23.9) 4,321 (24.7) (21.1) 4,916 (28.1) >5 64 (10.9) 2,392 (13.7) Residence area 0.47 Urban 458 (78.0) 13,857 (79.3) Rural 129 (22.0) 3,622 (20.7) (Continued to the next) Table 2. Continued 고고혈압의빈도는 22.8% 였다. 당뇨병의빈도는 8.3% 였으며체질량 지수 25 kg/m 2 이상의비만을나타내는경우는 31.7% 였다 (Table 1). 2. 천식환자의사회경제학적특성. 본연구대상자들에서천식으로진단된경우에평균연령이높 았고 (56.2±17.9 years vs. 50.4±16.5 years, P<0.01) 또한연령이 높을수록천식으로진단되는빈도가높은경향을보였으며천식 으로진단되는경우에사별혹은이혼으로독신인경우가많았다 (P<0.01). 천식인경우에무직인경우와중학교졸업이하의학력 을가진경우가많았고소득수준이낮은경우와 2 인이하의가족 인경우에천식의빈도가높았다 (P<0.01). 비만, 고혈압있는경우 에천식의동반빈도가높았으나당뇨, 거주지, 흡연유무에따른차 이는없었다. 천식이있는경우에우울증의동반빈도는 8.0% 로천 식이없는경우에비해유의하게높았다 (8.0% vs. 4.1%, P < 0.01) (Table 2). (n= 587) Nonasthma (n= 17,479) Smoking status 0.14 Current 104 (17.7) 3,569 (20.4) Ex-smoker 133 (22.7) 3,499 (20.0) None 350 (59.6) 10,411 (59.6) Body mass index (kg/m 2 ), n= 17, < (40.2) 7,839 (45.1) (24.3) 4,045 (23.3) > (35.4) 5,493 (31.6) Hypertension < 0.01 Yes 193 (32.9) 3,924 (22.4) No 394 (67.1) 13,555 (77.6) Diabetes mellitus 0.07 Yes 61 (10.4) 1,445 (8.3) No 526 (89.6) 16,034 (91.7) Depression < 0.01 Yes 47 (8.0) 711 (4.1) No 540 (92.0) 16,768 (95.9) Values are presented as number (%). 각연령별로나누어분석한결과천식과가족구성원수, 고혈압, 비만, 당뇨, 거주지, 흡연유무와유의한관계는없었으나성별, 소 득수준, 교육수준, 결혼, 직업, 우울증과는유의한상관관계를보 이는연령군도있었다. 성별의경우에 20 대남성에서천식빈도가 높았고 (3.8% vs. 2.0%, P = 0.01) 60 대여성에서천식빈도가높았다 (2.4% vs. 3.4%, P = 0.02). 다른연령층에서는 40 대이후에여성에서 남성보다천식유병률이높은경향을보이나유의한차이는없었 다. 결혼의경우에는 20 대미혼의경우에기혼자에비해천식유병 률이높았고 (2.5% vs. 0.2%, P = 0.03) 70 대이상의경우에서는기혼 175

4 Kim YJ, et al. Association between asthma and depression in Korean adults Table 3. Adjusted odds ratio (OR) and their 95% confidence intervals (CIs) for the prevalence of asthma Adjusted* OR 95% CI Age (yr) > 70 Reference Marital status, n= 18, Married Single Never-married Reference Employment status, n= 17,821 < 0.01 Unemployed Education < 0.01 < Middle school Reference Middle school High school < 0.01 > High school < 0.01 No. of household members Reference > Monthly family income (quartile) Reference Body mass index (kg/m 2 ) 0.15 < 23 Reference > Hypertension Yes Depression Yes < 0.01 *Adjusted for age, marital status, occupation, education, number of household members, monthly family income, body mass index, hypertension, depression. 인경우에사별혹은이혼, 미혼인경우에비해천식유병률이높았다 (2.1% vs. 0.7 vs. 0.4%, P = 0.01). 직업유무에있어서는 40대이후부터무직인경우에천식유병률이유의하게높았다 (P<0.05). 소득의경우에는 50대 (P<0.01), 60대 (P<0.01) 에서소득수준이낮은경우에천식유병률이높았다. 교육수준의경우에는 40대 (P<0.01), 60대 (P = 0.02) 에서교육수준이낮은경우에천식유병률이높았다. 우울증의경우에는 30대 (7.4% vs. 2.1%, P < 0.01), 40 Table 4. Demographic characteristics of asthma with and without depression (n= 587) Depressed (n= 47) Nondepressed (n= 540) Sex < 0.01 Male 9 (3.9) 222 (41.1) Female 38 (96.1) 318 (58.9) Age (yr) (4.3) 63 (11.7) (14.9) 71 (13.1) (12.8) 57 (10.6) (14.9) 88 (16.3) (36.2) 113 (20.9) > 70 8 (17.0) 148 (27.4) Marital status 0.32 Married 31 (66.0) 354 (65.6) Single (separated or 13 (27.7) 116 (21.5) divorced) Never-married 3 (6.4) 70 (13.0) Employment status, n= 582 < 0.01 Employed 10 (21.7) 248 (46.3) Unemployed 36 (78.3) 288 (53.7) Education, n= < Middle school 21 (45.7) 224 (41.7) Middle school 7 (15.2) 63 (11.7) High school 12 (26.1) 143 (26.6) > High school 6 (13.0) 107 (19.9) Monthly family income (quartile), n= (40.9) 173 (32.3) 2 13 (29.5) 126 (23.6) 3 5 (11.4) 119 (22.2) 4 8 (18.2) 117 (21.9) No. of household members (14.9) 63 (11.7) 2 15 (31.9) 174 (32.3) 3 14 (29.8) 126 (23.3) 4 4 (8.5) 120 (22.2) >5 7 (14.9) 57 (10.6) Residence area 0.94 Urban 37 (78.7) 421 (78.0) Rural 10 (21.3) 119 (22.0) Smoking status 0.65 Current 31 (66.0) 319 (59.1) Ex-smoker 7 (14.9) 97 (18.0) None 9 (19.1) 124 (23.0) Body mass index (kg/m 2 ), n= < (42.6) 215 (40.0) (19.1) 133 (24.8) > (38.3) 189 (35.2) Values are presented as number (%)

5 김여진외 성인천식과우울증과의관계에관한연구 Table 5. Lung function of asthma with and without depression (n= 587) Depressed (n= 26) Nondepressed (n= 263) FVC (L) 2.82± ± FEV1 (% predicted) 83.9± ± FEV1/FVC (%) 0.72± ± FEF25%-75% (L/sec) 2.39± ± PEFR (L/sec) 5.22± ± Values are presented as mean± standard deviation. FVC, functional vital capacity; FEV1, forced expiratory volume in one second; FEF25%-75%, forced expiratory flow during 25% 75%; PEFR, peak expiratory flow rate. 대 (5.7% vs. 1.9%, P = 0.02), 60대 (9.3% vs. 3.9%, P<0.01) 천식환자에서우울증의동반빈도가높았고나머지연령층에서도통계적유의성은없었으나천식환자에서우울증의동반빈도가높았다. 다변량분석후무직 (odds ratio [OR], 1.429; 95% confidence interval [CI], ), 저학력 (P < 0.01), 우울증이있는경우 (OR, 1.577; 95% CI, ) 에유의하게천식의빈도가높았다 (Table 3). 3. 우울증이천식환자에미치는영향천식환자에서우울증이동반된경우에여성인경우 (96.1% vs. 89.3%, P<0.01) 가많았고무직인경우 (78.3% vs. 53.7%, P<0.01) 가많았다. 우울증의동반유무와나이, 결혼상태, 교육수준, 가구당수입, 가구당가족수, 거주지역, 흡연, 비만, 폐기능사이에유의한관계는없었다 (Tables 4, 5). 고찰 일반인에비해천식환자에서우울증의빈도가높다는결과는인종과문화가다른여러연구에서공통적으로보고되고있다 ) 국내천식유병률은 2.0% 5.8% 로보고되고있고 17) 우울증의유병률은 3.7% 17.7% 로보고되고있으며 18-20) 본연구에서천식유병률은 3.2% 였고우울증의유병률은 4.2% 였다. 천식환자에서우울증의동반빈도는미국성인을대상으로한연구에서 7.5% 로보고하였고 14) 본연구에서는 8% 의동반빈도를보여정상인에비해천식환자에서우울증의동반빈도가높았다. 본연구에서우울증이동반된천식환자의경우에무직, 여성의빈도가유의하게높았고나이, 결혼상태, 교육수준, 가구당수입, 가구당가족수, 거주지역, 흡연, 비만과유의한관계는없었다. 우울증은고령, 여성, 무직, 독신, 교육수준이낮은경우, 저소득층, 도심거주, 흡연, 비만의경우에빈도가높다고알려져있으며 21-23) 본연구에서도우울증을동반한천식환자에서무직, 여성의빈도가유의하게높았다. 독신, 교육수준이낮은경우, 저소득층, 흡연, 비만의경우에본연구에서천식환자의우울증동반빈도가다소높 게측정되었으나통계적유의성은없었다. 본연구에서 60세이상의고령연령의천식환자에서우울증의동반빈도가다소높았으나통계적유의성은발견하지못하였고 70대이상에서는우울증의동반빈도가낮게측정되었다. 국민건강영양조사보고에서는우울증상경험률이고령일수록증가하였는데 24) 이러한차이는우울증진단의차이에기인한다고생각된다. 본연구에서는우울증을의사진단에의한경우로한정하였고국민건강영양조사에서는우울증상자가보고를사용하였는데전체국민건강영양조사연구참여자에서의사의진단에의한우울증의빈도는 70대이후감소추세를보인다. 천식환자에서우울증을동반하는경우에여성의빈도가높고 25) 연령이증가할수록우울증의빈도가높다고보고하고있다. 26,27) 본연구에서도우울증을동반한천식환자에서여성의빈도가높았으며통계적유의성은없었으나 60세이상의고령인경우빈도가높은경향을보였다. 이전국내보고에서 11) 천식환자에서연령이증가할수록, 소득수준이낮을수록우울증동반빈도가높고성별, 비만, 교육수준, 무직, 흡연에따른우울증동반빈도는차이가없다고보고하였다. 본연구결과와다른국내연구와 11) 차이가발생하는이유로는연구대상자선정의차이에의해발생한다고생각된다. 본연구에서대상자는국민건강영양조사의참여자를대상으로하였고천식유무를의사에의해진단받은과거력에대한설문결과에의해결정하였으나이전국내보고의 11) 경우에는병원을내원하는천식환자중일부를대상자로선정하였고천식을 Global Initiative for National 권고안에기반을두어진단하였다. 우울증이천식조절에영향을준다고알려져있으나 28) 우울증이천식환자의폐기능에미치는영향에대해서는우울증을동반한천식환자에서폐기능이감소되었다는보고와 29,30) 우울증이천식환자의폐기능에영향을주지않는다는보고가있다. 31) 우울증을동반한천식환자에서낮게측정된폐기능은우울증으로인한천식약물순응도저하에의해발생할수있어조절상태에있는천식환자에서우울증이폐기능에미치는영향에대한향후연구가필요하다. 본연구에서우울증이천식환자의폐기능에미치는영향은없었고이는이전국내연구결과와동일하다. 11) 천식과우울증의연관성이천식과우울증의직접적인관계에의한것인지만성질환과우울증과의연관성에의한것인지는아직완전히밝혀지고있지않지만만성간염환자보다천식환자에서우울증의빈도가높다고보고되어천식과우울증사이에어느정도관계가있으리라생각된다. 32) 천식과우울증과의연관성에대한가설로는몇가지가제안되고있는데첫번째로천식이우울증을일으킨다는가설이다. 이러한기전을설명하는데는크게두가지가설이있다. 일반적으로천식이우울증과같은기분장애보다먼저발생하는데천식환자에서호흡장애와같은공포체험이심리 177

6 Kim YJ, et al. Association between asthma and depression in Korean adults 적긴장상태를야기시켜이후우울증과같은기분장애를일으킬수있다는인식가설과 33) 천식에의한저산소증, 과이산화탄소혈증증세가중추신경계의과잉반응을일으켜이후우울증을야기한다는생물학적가설이있다. 34) 그러나저산소증, 과이산화탄소혈증을겪지않은잘조절되고있는경증천식환자에서도우울증이발생하기때문에최근에는생물학적가설에대해서는널리받아들여지지않고있다. 두번째가설은우울증이천식을발생시킨다는가설로우울증과같은기분장애로인해발생한장기간의긴장상태가시상하부- 뇌하수체-부신축의하향조절과부신피질, 부신호르몬수용체의하향조절을발생시키고이로인한호르몬불균형상태가천식을발생을일으킨다고제안하고있다 ) 즉, 흡입항원에대한알레르기면역반응이긴장상태에의해증폭되며이는향후천식으로발생한다. 38) 세번째가설은천식과우울증이아직밝혀지지않은동일면역기전에의해발생한다는가설로 tumor necrosis factor-α, interleukin (IL) 1, IL-4, IL-6가두질환모두에서증가되어있어동일기전에의해발생한다고제안하고있으나이에대한연구가부족하다. 39) 본연구의단점은첫째후향적단면연구로천식과우울증사이의인과관계를밝히기어렵고둘째설문조사연구이므로대상자선정에서선택삐뚤림, 연구참여자의기억에의하므로회상삐뚤림이발생할수있다. 또한천식, 우울증등의진단이정확한진단기준없이의사의주관에의해이루어질수있어이또한본연구의단점으로생각된다. 마지막으로질병유병률에있어확률표본추출을고려하지않았으므로전국민을대표하는결과로서한계점을지닌다. 그럼에도불구하고본연구의장점은대규모설문조사내용을이용한연구이며검사에있어서동일한방법으로표준화가시행되었다. 또한대규모국내자료를이용하여정상인과천식환자에서우울증의유병률차이에대한첫보고에의의가있다. 천식과같은아토피질환과우울증과의관계에대해서는임상의학에서많은관심이있으나국내에서이에대한연구는부족하다. 본논문에서천식이있는경우에우울증의동반빈도가높았고우울증을동반한천식환자의경우에있어서여성, 무직의빈도가높았다. 이러한결과가인종, 사회적특성에기반한것인지또는연구상의오류에의한것인지에대해서는향후다른추가연구가필요하다. 본논문내용을기반으로할때저자들은성인천식환자에서여성인경우, 무직인경우에는우울증의동반유무를확인하는과정이필요하며이러한동반질환을적절히치료함으로써환자의천식치료에도어느정도도움이되리라생각된다. REFERENCES 1. Asher MI, Montefort S, Bjorksten B, Lai CK, Strachan DP, Weiland SK, et al. Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC phases one and three repeat multicountry cross-sectional surveys. Lancet 2006;368: Eder W, Ege MJ, von Mutius E. The asthma epidemic. N Engl J Med 2006; 355: Kim H, Oh SY, Kang MH, Kim KN, Kim Y, Chang N. Association between kimchi intake and asthma in Korean adults: the fourth and fifth Korea National Health and Nutrition Examination Survey ( ). J Med Food 2014;17: Kim SY, Jung JY, Park MS, Kang YA, Kim EY, Kim SK, et al. Increased prevalence of self-reported asthma among Korean adults: an analysis of KNHANES I and IV data. Lung 2013;191: Brown EM, Arrieta MC, Finlay BB. A fresh look at the hygiene hypothesis: how intestinal microbial exposure drives immune effector responses in atopic disease. Semin Immunol 2013;25: Delfino RJ. Epidemiologic evidence for asthma and exposure to air toxics: linkages between occupational, indoor, and community air pollution research. Environ Health Perspect 2002;110 Suppl 4: Pearce N, Douwes J. Lifestyle changes and childhood asthma. Indian J Pediatr 2013;80 Suppl 1:S Goodwin RD, Jacobi F, Thefeld W. Mental disorders and asthma in the community. Arch Gen Psychiatry 2003;60: Lu Y, Mak KK, van Bever HP, Ng TP, Mak A, Ho RC. Prevalence of anxiety and depressive symptoms in adolescents with asthma: a meta-analysis and meta-regression. Pediatr Allergy Immunol 2012;23: Cluley S, Cochrane GM. Psychological disorder in asthma is associated with poor control and poor adherence to inhaled steroids. Respir Med 2001;95: Choi GS, Shin YS, Kim JH, Choi SY, Lee SK, Nam YH, et al. Prevalence and risk factors for depression in Korean adult patients with asthma: is there a difference between elderly and non-elderly patients? J Korean Med Sci 2014;29: Kunik ME, Roundy K, Veazey C, Souchek J, Richardson P, Wray NP, et al. Surprisingly high prevalence of anxiety and depression in chronic breathing disorders. Chest 2005;127: Loerbroks A, Apfelbacher CJ, Bosch JA, Sturmer T. Depressive symptoms, social support, and risk of adult asthma in a population-based cohort study. Psychosom Med 2010;72: Oraka E, King ME, Callahan DB. and serious psychological distress: prevalence and risk factors among US adults, Chest 2010;137: Hasler G, Gergen PJ, Kleinbaum DG, Ajdacic V, Gamma A, Eich D, et al. and panic in young adults: a 20-year prospective community study. Am J Respir Crit Care Med 2005;171: Scott KM, Von Korff M, Ormel J, Zhang MY, Bruffaerts R, Alonso J, et al. Mental disorders among adults with asthma: results from the World Mental Health Survey. Gen Hosp Psychiatry 2007;29: Song WJ, Kang MG, Chang YS, Cho SH. Epidemiology of adult asthma in Asia: toward a better understanding. Asia Pac Allergy 2014;4: Kim KW, Kim SH, Shin JH, Choi BY, Nam JH, Park SC. Psychosocial, physical, and autonomic correlates of depression in Korean adults: results from a county-based depression screening study. Psychiatry Investig 2014; 11: Kim TS, Jeong SH, Kim JB, Lee MS, Kim JM, Yim HW, et al. The clinical research center for depression study: baseline characteristics of a Korean long-term hospital-based observational collaborative prospective cohort study. Psychiatry Investig 2011;8: Park RJ, Moon JD. Coffee and depression in Korea: the fifth Korean Na

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한국성인에서초기황반변성질환과 연관된위험요인연구

한국성인에서초기황반변성질환과 연관된위험요인연구 한국성인에서초기황반변성질환과 연관된위험요인연구 - - i - - i - - ii - - iii - - iv - χ - v - - vi - - 1 - - 2 - - 3 - - 4 - 그림 1. 연구대상자선정도표 - 5 - - 6 - - 7 - - 8 - 그림 2. 연구의틀 χ - 9 - - 10 - - 11 -