› Initiate both pharmacologic and psychological therapies for anxiety or depression coexisting with COPD to improve patient outcomes. B
› Consider buspirone as an alternative to benzodiazepines for anxiety coexistent with COPD. B
› Consider motivational interviewing as a behavioral approach to help patients who are ambivalent about or resistant to change. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE › A 66-year-old man you have seen many times for issues related to his chronic obstructive pulmonary disease (COPD) comes in to your clinic for a routine visit. He has been taking budesonide/formoterol twice a day for the last 3 years; however, he has not always been compliant with his medications and has been hospitalized within the last 6 months for disease exacerbations. Today, he says he has difficulty falling asleep and often becomes short of breath, even when physically inactive. His wife, who is accompanying him today, tells you he has become increasingly distant over the past few months and is not as engaged at family outings, which he attributes to labored breathing. They’re both concerned about this change and ask for advice.
Despite the increased awareness that generalized anxiety disorder (GAD) and major depressive disorder (MDD) are common comorbidities of COPD, they remain underdiagnosed and undertreated in patients with COPD. The results are increased rates of symptom exacerbation and rehospitalization.1 Family physicians, who are the primary caregivers for most patients with the disease,2 can maximize patients’ quality of life by recognizing comorbid mental illness, motivating and engaging patients in their disease management, and initiating appropriate treatment.
Anxiety and depression in COPD: A 2-way street
Several studies have assessed the prevalence of psychological disorders in patients with COPD. Affective disorders, mainly GAD and MDD, are the ones most commonly associated with poor COPD prognoses.3,4 GAD is at least 3 times more prevalent in patients with COPD than in the general US population,5 reaching upwards of 55%.1,6 Prevalence of MDD is also high, affecting approximately 40% of patients with the disease.1
GAD and MDD are more prevalent as comorbidities of COPD than they are with other chronic diseases such as orthopedic conditions, pulmonary tuberculosis, hypertension and heart disease, stroke, diabetes, and cancer.5,7-9 Patients with COPD, more so than patients with other serious chronic diseases, report heightened edginess, anxiousness, tiredness, distractibility, and irritability,5 perhaps owing in part to breathlessness and “air hunger.”10
The connection between COPD and GAD or MDD is not unidirectional, with progression of lung disease exacerbating its psychological comorbidities. The interaction is reciprocal, as clarified by Atlantis, et al, in a 2013 systematic review and meta-analysis that assessed key variables in the development of COPD and GAD or MDD.11
COPD increases the risk of MDD, which is associated with increased tobacco consumption, poor adherence with COPD medications, and decreased physical activity.11 Compounding the problem of inactivity is the fact that COPD—particularly longstanding disease—can lead to volume reductions in the anterior cingulate cortex of patients, which correlates with a persistent fear of performing physical activity.12 MDD in the setting of COPD also complicates the already complex interplay between nicotine dependence and attempts at smoking cessation.11
GAD/MDD worsens COPD outcomes
Comorbid GAD and MDD increase demands on our health care system and decrease the quality of life for patients with COPD. Anxious or depressed patients have higher 30-day readmission rates and less frequent outpatient follow-up than COPD patients without these mental comorbidities.6 Patients with comorbidities tend to have a higher prevalence of systemic symptoms independent of COPD severity,7 exhibit poorer physical and social functioning,13 and experience greater impairment of quality of life than patients with lung dysfunction alone.1,14 Patients with GAD or MDD have a 43% increased risk of any adverse COPD outcome, which can include exacerbations, COPD-related diagnoses (eg, emphysema), new anxiety or depression events, and death.11 Specifically, the risk of a COPD exacerbation rises by 31% in patients with comorbid GAD or MDD, and risk of death in those with comorbid MDD increases by 83%.11
GAD or MDD with COPD increases health care utilization and costs per patient when compared with patients who have COPD alone.9 Annual physician visits, emergency-room visits, and hospitalizations for any cause are higher in anxious or depressed COPD patients, and they have a 77% increased chance annually of a COPD-related hospitalization.9 Annual COPD-related health care costs for patients with GAD or MDD are significantly higher than the average COPD-related costs for patients without depression or anxiety, leading to significantly increased all-cause health care costs: $28,961 vs $22,512.9 Addressing and managing comorbid GAD or MDD in COPD patients could substantially reduce health care costs.