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Anxiety and Depression in Chronic Obstructive Pulmonary Disease: Recognition and Management

January 31, 2018|Cleveland Clinic Journal of Medicine
Abebaw Mengistu Yohannes, PhD;Alan Kaplan, MD;Nicola A. Hanania, MD, MS
Author and Disclosure Information

Abebaw Mengistu Yohannes, PhD
Azusa Pacific University, Department of Physical Therapy, Azusa, California

Alan Kaplan, MD
Family Physician Airways Group of Canada, University of Toronto, Toronto, Ontario, Canada

Nicola A. Hanania, MD, MS
Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, Texas

Dr. Yohannes has no conflicts to disclose.

Dr. Kaplan has served as a consultant or speaker for AstraZeneca; Boehringer Ingelheim, GmbH; GlaxoSmithKline; Grifols; Johnson & Johnson; Novartis Pharmaceuticals Corporation; Novo Nordisk Inc.; Paladin Labs Inc.; Pfizer Inc.; Purdue Pharma L.P.; and Trudell Medical International. 

Dr. Hanania received honoraria for serving as a consultant or advisory board member for AstraZeneca; Boehringer Ingelheim, GmbH; F. Hoffmann-La Roche Ltd; GlaxoSmithKline; Mylan Laboratories Inc.; Novartis Pharmaceuticals Corporation; Teva Pharmaceutical Industries Ltd.; and Sanofi-Regeneron. His institution has received research grant support from AstraZeneca; Boehringer Ingelheim, GmbH; Cheisi USA, Inc.; F. Hoffmann-La Roche Ltd; and GlaxoSmithKline.

Funding for this article was provided by AstraZeneca LP (Wilmington, DE, USA). Medical writing support was provided by Hannah Burke, BSc, of Core (London, UK) and editorial support was provided by Maryam Vahdat, PGDip, of Core (London, UK), which were funded by AstraZeneca LP (Wilmington, DE, USA), in accordance with Good Publication Practice guidelines (Battisti WP et al. Ann Intern Med. 2015;163:461–464. doi: 10.7326/M15-0288).

This article is being co-published in The Journal of Family Practice and Cleveland Clinic Journal of Medicine.

Diagnosis of anxiety and depression in patients with COPD

The underdiagnosis and undertreatment of anxiety and depression in this population is common and can adversely affect patient outcomes.6,7,9,10,58 Hence, it is crucial that anxiety and depression are identified and more effectively managed in clinical practice.10

Primary care practitioners are the main point of contact for many patients with COPD,6,59,60 and so can play a key role in screening for and early identification of anxiety and depression. However, detection of mood disorders by primary care practitioners is challenging for several reasons. These include the lack of a standardized approach in diagnosis, and inadequate knowledge or confidence in assessing psychological status (particularly given the number of strategies available for screening patients for mood disorders),6 as well as factors associated with time constraints, such as competing agendas, duration of visits, and high patient load.6,61 Furthermore, system-level barriers, such as lack of electronic medical records and adequate health insurance, as well as any communication gaps between primary care and mental health care, may hinder the detection and management of anxiety and depression.6 In addition, patients themselves may have a limited understanding of these comorbidities, or may be hesitant to discuss symptoms of anxiety or depression with their primary care practitioner owing to stigma around mental illness.6 

Patients with COPD should be screened and assessed for anxiety and depression, and the United States Preventive Services Task Force recommends that clinicians screen for depression in all adults.6,62 There are several validated screening tools suitable for clinical use:

  • Anxiety Inventory for Respiratory (AIR) Disease scale: a brief, easy-to-use tool for screening and measuring anxiety in COPD.63,64 It is a self-administered scale, and takes approximately 2 minutes to complete. The AIR scale is responsive to PR.64
  • COPD Anxiety Questionnaire (CAF): a reliable tool for early identification of COPD-related anxiety.65
  • Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire (PHQ; available at: https://www.phqscreeners.com/select-screener/): the PRIME-MD comprises 26 yes/no questions on the 5 most common psychiatric disorders, including depression and anxiety.66,67 This is not a diagnostic tool, but a high number of positive responses from a patient in any given module indicates that they require further clinical evaluation.
  • PHQ-2 and PHQ-9 (Table 1; PHQ-9 available at https://www.phqscreeners.com/select-screener/): widely-used self-administered 2- and 9-item versions of the PRIME-MD, specific to depression; similarly, the 3-item PHQ-3 is available for anxiety assessment (Table 2).6,67,68 In a study investigating tools used by family physicians in England to assess depression, over 75% used PHQ-9.69
  • PHQ-2 and PHQ-9 screening questionnaires for depression
    PHQ-3 screening questionnaire for anxiety
    Generalized Anxiety Disorder 7-item (GAD-7) scale: an efficient, self-report scale that scores 7 common anxiety symptoms and can be used for screening and severity assessment of GAD in clinical practice.70
  • Hospital Anxiety and Depression Scale (HADS) and General Health Questionnaire-version 20 (GHQ-20): both can be used to screen for psychologic distress in patients with COPD.71
  • The Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI): two 21-item self-report questionnaires that are widely used in the United States to evaluate anxiety and depression.72

In addition to specific anxiety and depression questionnaires (Tables 1 and 2), more general COPD assessments tools, such as the COPD Assessment Test and the COPD Clinical Questionnaire, also incorporate questions that may be indicative of symptoms of these comorbidities in patients with COPD.73

Management of anxiety and depression in COPD

Even though anxiety and depression are among the most common and burdensome comorbid conditions in COPD, less than one-third of patients with these comorbidities receive effective intervention.6,10 Primary care providers have an excellent opportunity to impact this care gap.

Recommendations for the treatment of psychiatric symptoms in patients with COPD
Figure 1. Recommendations for the treatment of psychiatric symptoms in patients with COPD.76
It is important that all health care professionals involved in the care of patients with COPD are vigilant for anxiety and depressive symptoms, as well as the possibility of a major anxiety or depressive disorder. Communication with other multidisciplinary team members is central to ensuring appropriate psychiatric treatment in patients with COPD, particularly sharing key information about medication history, warning signs of depression and anxiety, and any indication of suicide ideation.74 Referral to palliative care teams can also help to manage these psychological comorbidities in patients with severe COPD at advanced stages.75

As in non-COPD patients, comorbid depression and anxiety may be treated with nonpharmacologic and/or pharmacologic interventions (Figure 1).76

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