Depression in the patient with COPD
Many of depression's symptoms can overlap with those of COPD. feelings and mental state can help you and your doctor tell the difference. It is not surprising that COPD significantly affects the sufferer's mental health. The association between COPD and anxiety and depression is well recognized. In a recent review on the presence of depression in patients with COPD, it was concluded that no final conclusion could be drawn on the association between.
This argument assumes that the depression is caused by the COPD see below. All of the above prevalence rates were determined by diagnostic instruments. Whether screening for depression should be undertaken in patients with COPD also depends on the impact of the disease, its ease of treatment, and the impact of the treatment.
As demonstrated below, the recognition and treatment of depression should lead to significant improvements in quality of life. In the same study, patients requiring readmission had higher scores on the Hospital Anxiety and Depression HAD scale than patients not requiring readmission. In an outpatient population, the presence of depression or anxiety led to a doubling of the number of days admitted to hospital Mikkelsen et al Depression was a better predictor of reduction in activities of daily living than forced expiratory volume in 1 second FEV1 Yohannes et al In some studies, depression, among other factors, has been associated with higher mortality Almagro et albut this has not been found in all studies Yohannes et al A small study in the elderly demonstrated that the reduction in FEV1 had the biggest impact on QOL, but mood was also important Peruzza et al Depression also has other impacts on patients with COPD.
The depression did not have any effect on the preference for mechanical ventilation. Pulmonary rehabilitation programs can result in improvement of depression Kozora et al ; Garuti et al ; Goldberg et al Whether this is due to improved physical wellbeing, involvement in group activities, or improvement in oxygenation is unknown.
In the literature on asthma, there is evidence that QOL in patients with asthma and depression is worse than in those patients suffering either alone Goldney et al There is also evidence in this literature that symptoms may reflect depression severity rather than asthma severity Rimington et al Whether these findings also apply to COPD has not been studied.
Because of the side effects of TCA there has been a reticence to use them Clary et al The advent of selective serotonin reuptake inhibitors SSRIs may change this, but so far the studies have been very limited Clary et al Several reviews of cognitive behavioral therapy CBT Clary et al ; de Godoy DV and de Godoy RF ; Mikkelsen et al have demonstrated its effectiveness in improving physical as well as psychological wellbeing.
These reviews have supported the use of CBT as an adjunct to pulmonary rehabilitation. The positive impact of improving mood in response to rehabilitation suggests that the diminished mood may be secondary to COPD.
A difficulty arises in that at least some of the symptoms of depression, as measured in depression rating instruments, may arise from the COPD itself. Tiredness, lack of energy, weight loss, and disturbed sleep are symptoms of both conditions.
The diminished cognition and mental slowing may be attributable to hypoxia Clary et al ; Mikkelsen et aland depression itself may be secondary to corticosteroid administration Mikkelsen et al Treatment of COPD may improve the hypoxia and lead to a reduction in corticosteroid administration.
The association of mood with corticosteroid administration is complex, with several possible outcomes. Clinical experience suggests that a significant number of people taking corticosteroids have an improvement in their mood, yet drug-induced psychosis is also seen.
Depression and anxiety in patients with COPD
People who are on reducing doses of corticosteroid medication may develop tiredness and joint pains. The impact of corticosteroids in the individual patient is idiosyncratic.
Cause and effect There have been few longitudinal studies of the development of depression in patients with COPD. The major study, the Health and Retirement Study Polsky et alfollowed adults aged 51—61 years for 10 years.
Subjects were reevaluated biennially. Part of this study examined the occurrence of depressive symptoms after the diagnosis of one of seven medical conditions.
Chronic lung disease excluding asthma was included in the analysis. Within two years of diagnosis the hazard ratio for the development of depressive symptoms was 2. This compares with 3. Depressive symptoms developed 2—4 years after the diagnosis of inflammatory arthritis. COPD, depression, and smoking A number of studies have demonstrated that patients with COPD who also suffer from depression or anxiety are more likely to be smokers van Manen et al ; Wagena et al The primary association appears to be between depression and smoking Almeida and Pfaff ; Gulec et al Anecdotally, psychiatrists report that cigarette smoking appears to have an antidepressant effect.
Generally, depression severely limits the effectiveness of smoking cessation programs Cinciripini et al ; Freedland et al Depression and compliance On theoretical grounds, it has been assumed that depression is associated with poor compliance.
This has been confirmed in studies that relate to asthma treatment. Although anxiety levels were also high, anxiety was not associated with poor compliance. It is possible to postulate that anxiety actually improves compliance, by focusing the patient on their disease and its treatment.
Other cross-sectional studies have confirmed the findings of poor compliance being associated with higher levels of depression Cluley and Cochrane Screening for depression Most of the studies described previously have used diagnostic instruments to diagnose depression. There have not been any studies of screening instruments. In the general literature on depression there have been some attempts at developing screening tools, but these have not always been successful.
The most commonly examined screening instruments are the one and two question screens Whooley et al ; Arroll et al ; Henkel et al These studies demonstrate that the two questions, which relate to the two essential criteria for the diagnosis of depression, are effective.
However, preliminary work Reddy et al indicates that such screening tests are ineffective in patients with chronic diseases. Tiredness, low energy, weight loss, and loss of interest occur in both depression and COPD.
It would seem that instruments such as the Beck Depression Inventory or the Hamilton Depression scale are required. Improvement of depression was unrelated to the use of antidepressant drugs and was attributed to the behavioral interventions of pulmonary rehabilitation [ 21 ]. However, the long-term benefit of PR in reducing anxiety and depression is unknown. In addition, further work is required on the efficacy of maintenance therapy to alleviate these symptoms and achieve full remission.
There is some evidence to suggest that psychological therapy including cognitive behavioral therapy and counselling may improve depressive and anxiety symptoms in patients with COPD [5,6,]. In addition, there is limited availability of psychological therapy in primary care settings for this patient group. It is worth considering making the resources of psychological therapy available using web-technology as a supplement therapy.
The control group received usual care provided by their general practitioners and a monthly phone call by a research nurse. Anxiety decreased in both groups at 12 months. Health mentoring improved the capacity for self-management but the two groups had similar scores of quality of life at the end of the treatment phase.
Depression in COPD – management and quality of life considerations
Moreover, there was no difference in depression scores between the two groups. Bucknall and colleagues [ 23 ] reported that a minority of COPD patients who could learn to implement self-management effectively were younger, and were more likely to be living with others.
These patients had a significantly reduced risk of COPD readmission. Barriers to treatment of interventions The available evidence suggests that less than one third of COPD patients with comorbid depression or anxiety are receiving appropriate treatment for this.
Factors that contribute to the lack of provision of treatment are multi-factorial.
- Depression in the patient with COPD
- Overcoming Depression with COPD
Maurer and co-workers [ 6 ] in their elegant review have reported the multistage barriers for detection and treatment of anxiety and depression in patients with COPD. These include i patient perceived barriers e. In order to address these barriers an integrated treatment approach is required from the healthcare professionals, patients and caregivers. In addition, the healthcare providers should be ready to provide appropriate resources to improve the quality of service provision and clinical practice.
Current screening tools for anxiety and depression in patients with COPD were primarily validated for patients with other chronic diseases. The Hospital Anxiety Depression and the Beck Depression and Anxiety Inventory scales have been recommended as the preferable choice of screening tools for anxiety and depression in patients with COPD [ 6 ].
However, some of the items in these scales contain somatic symptoms, which make it difficult to decipher because of the overlap symptoms of COPD and depression or anxiety. Thus, designing disease-specific anxiety and depression scales for patients with COPD is a worthy future endeavor.
Challenges for research and clinical practice There is little evidence to suggest whether routine screening which is resource intensive may improve treatment for anxiety and depression in patients with COPD.
Therefore, healthcare professionals should play an active role, at least for those identified with clinical depression and anxiety, to ensure appropriate treatment, and to monitor its efficacy. However the lack of strong evidence for the efficacy of antidepressant drug therapy in patients with COPD with comorbid depression and anxiety, necessities well-controlled clinical trials to explore efficacy of antidepressant drug therapy in inducing sustained remission.
At the moment, PR programmes do not provide special provision for COPD patients with clinically significant anxiety and depression and whether interventions that are specifically targeted designed by the severity of respiratory impairment, gender, culture and duration of illness may have impact in terms of prognosis is worthy of investigation.
Depression in COPD – management and quality of life considerations
Conclusion Untreated comorbid anxiety and depression in patients with COPD have devastating consequences, overwhelm the coping strategies of COPD patients and their caregivers and may increase healthcare utilization. There are some promising findings regarding pulmonary rehabilitation, smoking cessation, psychological and antidepressants drug therapy in reducing anxiety and depressive symptoms in patients with COPD.Depression and COPD
However, these findings require further testing to examine their efficacy in well-controlled, randomized controlled trials, with larger samples and long-term follow-up. Myocardial infarction and other comorbidities with chronic obstructive pulmonary disease: Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: Int J Geriatr Psychiatry. Association of anxiety and depression with pulmonary-specific symptoms in chronic obstructive pulmonary disease.
Int J Psychiatry in Medicine. Anxiety disorders in patients with COPD: Anxiety and depression in COPD: