The Shadow of COPD
Physicians often overlook depression in patients with COPD.
Physicians often overlook depression in patients with COPD. 8/7/2008
By Clare Hawkins, MD, MSc, FAAFP
Feeling sad is a common human experience. But when the cloak of sadness stretches for a long period, it may signal a bigger problem, especially when patients are dealing with chronic disease.
Unfortunately, the insidious transformation into depression often mirrors the adaptive inactivity that comes with chronic obstructive pulmonary disease (COPD). Sadly, this depression is often overlooked in patients with COPD because physicians only concentrate on managing breathing symptoms.
To ensure optimal outcomes, however, physicians need to understand and identify the high prevalence of depression in patients with COPD-and treat them accordingly.
Entangled in depression
COPD affects an estimated 23 million Americans, according to the National Health and Nutrition Survey, a nationwide research project using spirometry criteria for diagnosis.1 Of those with moderate or severe COPD, the prevalence of depression has been estimated at 20 percent to 60 percent.2-4
COPD’s many comorbidities, such as cardiovascular disease, lung cancer, osteoporosis, hormonal changes and muscle wasting,5 can further exacerbate depressive symptoms.
One study, for example, showed a 30 percent prevalence of depression among COPD patients. The authors speculated that the true rate of depression may be even higher, since patients who were depressed may not have bothered to send back the mail-in survey that was integral to the study findings.6 In another primary care study, the rate of depression among COPD patients was 56 percent.7An additional case-control study found a prevalence of depression in 18 percent of COPD patients compared to 3 percent in those without COPD.8
Untreated depression among patients with COPD can have a meaningful impact on treatment protocols, translating into poorer outcomes. Clinically depressed COPD patients have poorer self-reported quality of life than those without depression. This poorer quality of life is correlated with frequent exacerbations, hospitalizations and mortality.9,10
Most importantly, patients who are depressed are less likely to comply with the most effective intervention for COPD, which is smoking cessation. They’re also less likely to stick with follow-up visits and medication regimens, often abandoning treatment for COPD in the first several months.
Given these consequences, physicians must detect the clues and not dismiss depressive symptoms as simply part of COPD. Sometimes the only signs of depression are somatic symptoms, such as pain, insomnia or fatigue. Other clues include guilty -feelings, regrets or perseverations. Patients who stop eating or have notable weight loss also may be suffering from the problem. Anxiety, too, can sometimes be mixed with depression. Obviously, all of these can easily be attributed to COPD symptoms, which is why diagnosing depression is so challenging.
To get a better idea of depression, physicians can use several screening tools, including the Beck Depression Inventory (BDI-II).11,12 The BDI-II is a self-report analysis of depressive symptoms. It’s not designed to be used for a depression diagnosis.13
But the wording of the BDI-II is clear and concise. The test contains 21 items, most of which assess depressive symptoms on a scale of 0 to 3. Some physicians ask all COPD patients to complete this questionnaire. The physician can then act on the results during the clinical encounter by verifying the -diagnosis and initiating therapy.
Doctors also can determine the severity of a patient’s depression using a multiple choice questionnaire, called the Hamilton Depression Inventory (HDI). Max Hamilton originally published this tool in 1960, and it’s now one of the most commonly used scales for rating depression in medical research.14 owever, a revamped 17-item version of the HDI is more commonly used than the original 21-item version.15 The questionnaire rates the severity of symptoms observed in depression, such as low mood, insomnia, agitation, anxiety and weight loss.
HDI is an interviewer-administered and rated measure. Scoring is included.
Depressed patients without COPD have a 55 percent chance of improved mood, but only 35 percent of these patients achieve remission because they often discontinue therapy and relapse. We presume COPD patients have a lower response due to ongoing physical symptoms, cognitive barriers and high refusal rates for treatment.
Fortunately, none of the standard antidepressants are contraindicated in depression. However, it’s important to understand that beta-blocker medications, which benefit the heart, can exacerbate depression and COPD, especially if they’re not cardioselective.
While tricyclic antidepressants are –nexpensive and have a long track record, the drug’s poor dose-response relationship often requires patients to take high doses, producing anticholinergic or sedative side effects. Patients with COPD and depression who attempt suicide using this drug also may be more successful because the drug affects heart rhythm. Even in standard treatment dosages, cardiac effects can be significant. In terms of various choices among tricyclics, nortriptyline is superior to placebo. Other drugs, such as doxepin and desipramine, have not shown this same superiority.
Because of these drawbacks, systemic serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) have largely replaced tricyclics for treating depressed patients. Psychiatrists have favored newer SNRIs, such as Cymbalta or Effexor, which have quicker efficacy and reduced side effect profiles.16 Paroxetine (Paxil) and Fluoxetine (Prozac) are commonly prescribed SSRIs. They’re economical and superior to placebo. However, Paxil may be sedating, and Prozac may be energizing or cause anxiety.
If one agent is ineffective, it may require switching to a different class of agents. Psychiatrists often need to prescribe multiple agents concurrently for refractory patients. Because of cost considerations, physicians should verify which agents are reimbursed under the patients’ insurance formulary. Physicians also should ask which antidepressants, if any, have been taken in the past and whether they’ve been helpful.
While depression certainly involves an imbalance of neurotransmitters, it’s also usually complicated by psychological factors, such as maladaptive coping mechanisms and negative thought patterns. Integrating problem solving, supportive psychotherapy and cognitive therapy may improve treatment adherence. Supportive counseling helps ease the pan of depression and addresses the feelings of hopelessness that accompany depression.
Physicians should employ a comprehensive approach over simply providing medication to deal with depression. Health care providers must be strong therapeutic liaisons and provide psychosocial intervention and good follow-up to ensure optimal results.
To that end, cognitive behavioral therapy (CBT) helps patients change the pessimistic ideas, unrealistic expectations and overly critical self-evaluations that create depression and sustain it. Cognitive therapy also helps the depressed person recognize which life problems are critical and which ones are minor. Thus, patients learn the skills to develop positive life goals.
Only trained counselors should administer CBT, which is different from supportive psychotherapy. Most people will begin to experience relief with six to 10 sessions, and approximately 70 percent to 80 percent of those treated notice significant improvement within 20 to 30 sessions. The more severe the depression, the more sessions a patient may need.
Some patients may not have access to a CBT-trained therapist. Fortunately, medications can be equally as effective as CBT.17 Many patients may also need psychotherapy.
In addition, don’t forget the role of activity in keeping patients well. Exercise is an important adjunct for depression therapy, since the natural endorphins may enhance depression recovery. Moderate, graduated exercise also may help breathing function in people with COPD.
Too frequently, patients with moderate or severe COPD insidiously reduce their activity and become sedentary, creating a cycle that predisposes them to depression. Encourage them to participate in unsupervised exercise or to enroll in a COPD rehabilitation program. Maximizing the therapy of COPD with bronchodilators will equip the patient to better participate in exercise.18It’s especially important to set treatment goals for patients with depression to help them stay with therapy, especially early on when discontinuation is most likely.19 Too frequently, people may discontinue antidepressant medications as symptoms subside. Patients’ relapse rates are substantial when they receive treatment for less than six months. The chance of avoiding a relapse improves for those taking medications for a full year.
Living with COPD is inherently isolating, so it’s important to find ways to help patients reach out to community through connections with family, service groups or formal COPD rehabilitation programs. Depression and COPD can be a crippling combination that affects quality of life and mortality.
As medical providers, we should routinely explore the subtle clues of depression in patients with COPD to provide them with the help they need.
Clare Hawkins, MD, MSc, FAAFP, is director of San Jacinto Methodist Family Medicine Residency in Baytown, Texas. He graduated from the University of Manitoba in Canada and has a master’s degree in community health. He is board-certified in family medicine.
Disclosure: Dr. Hawkins indicates that he has an ongoing relationship with Boehringer Inglehiem and Pfizer, which comarket Tiotropium SPIRIVA for treating COPD.