Psychiatric Morbidity in COPD
Dr C Ravindran
Introduction
It is alarming to note that the number of patients with chronic medical
illnesses continues to increase with each passing day. The modern day physician
often is bewildered by the wide array of symptoms that these patients manifest.
The emphasis is slowly being laid on treating the patient as a whole rather than
as a condition. These chronic illnesses are characterized by frequent
alteration of intensity of symptoms, which are often influenced by social and
psychological factors.
Estimates of the prevalence of psychiatric disorders in persons with
chronic medical illnesses are of considerable importance for several reasons. Psychiatric
disorders complicate the clinical assessment of patients with chronic medical
diseases (and vice versa). Primary care physicians may not always detect
psychiatric disorder in patients with medical diseases1,2. The
treatment for the two types of disorder may be complicated by drug interactions3
and finally, coexisting psychiatric disorders could increase both the
utilization of services and the disability of persons with chronic medical conditions. Studies have
determined that 5 to 9% of ambulatory primary care patients suffer from major
depressive illness4, 5. Affective disorder has been found to occur
in 22% to 33% of patients with medical illness in inpatient medical units6.
In a large community study patients with and
without one of eight chronic medical disorders were compared on the basis of
prevalence of psychiatric illnesses7. Results showed that patients
with one or more chronic medical illnesses had a 41% increase in the relative
risk of having any psychiatric disorders. Affective, anxiety and substance use
disorders were each more prevalent in persons with chronic medical conditions.
The prevalence of psychiatric morbidity varies
across different illness. The prevalence of major depression in cardiovascular
diseases is reported to be about 18%8, 9. Major depression is a
significant predictor of mortality in the first 6 months after an acute
Myocardial Infarction10.
In terms of gastrointestinal illnesses,
functional esophageal motility groups of patients have a psychiatric morbidity
of 84%. Studies of psychiatric co-morbidity in irritable bowel syndrome
estimate co-morbidity rates of 42-64 percent of all irritable bowel syndrome patients
11. In patients with renal failure major depression was reported in
30% of studied subjects 12.
Among cancer 20 to 45% of patients at various
stages of illness and treatment suffer from major depression and/or anxiety
disorders. Point prevalence of depression in cancer reported as 6%13 and
24%14. In the case of neurological illnesses we see that patients
with a cerebrovascular accident appear particularly vulnerable to major and minor
depression, with respective prevalence being 26% and 24% respectively15.
In asthma significantly higher prevalence of sporadic panic attacks, social
phobia and panic disorder has been reported than in general population16.
Psychiatric
morbidity in COPD
COPD is a progressive and irreversible disease
to a large extent with oscillating features. Psychiatric issues affect many
facets of the course of COPD from etiology to ongoing symptoms and the
appearance of related respiratory syndromes as well as psychiatric co morbidity
and its effects on rehabilitation17. Agle and Baum18 looked
at the psychosocial needs of patients with COPD and reported that among 23
patients selected for a pulmonary rehabilitation program, 22 displayed symptoms
of anxiety sufficient to interfere with their performance in the program.
They reported
that 74% of their 23
patients had excessive
body preoccupation. When psychological concomitants were evaluated, a
significant difference in psychological disturbances was noticed in patients
with chronic bronchitis matched with a non-bronchitis control from the general
population. McSweeny et al19 reported that 42% of their COPD patients
were primarily depressed and an additional 7% had symptoms of depression. Of
their patients, 8.7% had somatic preoccupation. These findings were validated
by other studies as well.
When 50 consecutive patients who were admitted
to respiratory unit were evaluated, a psychiatric morbidity rate of 58% was
seen with a lower rate of depression (16%) but higher rate (34%) of anxiety 20.
Wells et al looked at the prevalence of anxiety,
affective disorders and substance use in various medical disorders including
chronic lung conditions. They reported increased prevalence of each of three
groups of lifetime psychiatric disorders in all medical conditions and in
particular, persons with chronic lung diseases had an increased adjusted
prevalence of recent affective and substance use but not anxiety disorder. Clues
to the diagnosis of major depressive disorder in patients with COPD include the
perception of activity as effortful, pervasive, pessimism, and diurnal mood
variation with morning worsening and early morning awakening21. When
COPD patients were studied using the Structured Clinical Interview for DSM III-R
(SCID) 22 16% showed anxiety disorder particularly panic disorder. The
subjects who had panic attacks reported significantly more agoraphobic
cognitions and greater concern with bodily sensations than did patients who did
not experience panic23.
A systematic
review24 done on the prevalence of depression in patients with
chronic obstructive pulmonary disease revealed an association between COPD and
depression in four controlled studies. Ten studies were included out of which
only four had a case control design. Two of these studies did not detect
statistically significant association but used a questionable depression
measure. Some researchers have found the prevalence of panic and generalized
anxiety disorders in COPD patients to be greater than 20% and 30% respectively,
much higher than the expected 3% and 15% lifetime prevalence in the general
population25.
In a cross sectional study done on 43 elderly
veteran outpatients, 26% had moderate to severe anxiety, 12% had moderate to
severe depression and 28% had scores reflecting either moderate to severe
anxiety or depressive symptoms26. Among a group of COPD patients who
were referred for pulmonary function testing the overall prevalence rate of
panic disorder was 11%27.
A study was done by Bums and Howell 28
on subjects with disproportionately severe breathlessness in chronic
bronchitis. Thirty-one patients attending a respiratory disease clinic were
noted to be more breathless than could be accounted for the severity of their
pulmonary disease. An investigation mainly psychiatric evaluation was done and
compared with the similar investigation in a control group. Assessment was done
by psychiatric history and examination of mental state. Symptoms of depressive
illness, anxiety or hysterical reaction were more frequent in the
disproportionately breathless group and successful treatment of the psychiatric
disorders was associated with a complete or partial resolution of symptoms of
breathlessness.
There is relative importance of pulmonary
impairment versus other occult physical or psychological factors in the genesis
of sexual dysfunction among COPD. Sexual dysfunction worsens as lung disease
worsens and sometimes COPD may be associated with male impotence in the absence
of any other causes29.
Anxiety
and Depression in COPD
While the exact causes for anxiety and depression have not
been well defined, several variables have been implicated and they include
physical disability, long term oxygen therapy, low body mass index, percentage
predicted FEV1 <50%, poor quality of life, presence of co morbidity, living
alone , female gender, current smoking and low social class status 30,31. Yellowlees et al20 reported clinically significant symptoms of depression and
Panic disorder during COPD exacerbations.
Patients with COPD may have a spectrum of symptom severity
ranging from short term depressive symptoms to dysthymia to clinical
depression. Yohannes et al 32 reported that approximately two
thirds of COPD patient with depression suffer from moderate to severe depression.
This study was done using 137 COPD outpatients, using the MADRS and Geriatric
Mental Health Scale. However, the prevalence of minor or subclinical depression
may be even higher in this population, assuming that it is similar to other
chronic illnesses. Author arrived at the conclusion that approximately one
fourth of COPD patients had unrecognised subclinical depression. Such patients
have a high burden of physical disability and are at a greater risk for major
depression.
The ramifications of receiving inadequate treatment of
psychiatric co morbidity are also a matter of grave concern. Depression and
anxiety are often untreated or undertreated in patients with COPD. It is
estimated that only less than one third of patients were receiving appropriate
treatment30. Untreated or incompletely treated depression and
anxiety have major implications for compliance with medical treatment,
increased frequency of hospital admissions, prolonged length of stay and
increased consultations with primary care physicians. Collaborative care models
developed for the treatment of depression in patients with other chronic
diseases have not been adequately tested in COPD.
The impact of anxiety and depression on COPD patients, their
families and society is significant. Ciechanowski et al33 found that
depressed patients with a chronic medical illness are sicker than their
counterparts and that they may have a lower treatment adherence. Depression has
been found to predict fatigue, shortness of breath and disability in patients with
heart disease or COPD, even after adjusting for severity of illness34. Certain studies have also examined the role of depression in
rehospitalisation and exacerbations. Studies by Fan V S et al 31, and Gudmundsson et al35 found that mood disorder, by compromising
health status may lead to increased risk of hospitalisation and
rehospitalisation. Depression may also be a significant predictor of mortality
following hospitalisation for acute exacerbations36. Depression also
has a profound impact on end of life decisions because depressed patients opt
for “do not resuscitate” decisions37.
Rates of anxiety disorders in patients with COPD,
particularly generalised anxiety disorder and panic disorder are much higher in
the general public, according to a study by Brenes et al in 200338. The study was conducted using a PubMed search of the literature
from 1966 through 2002 using the keywords anxiety, chronic
obstructive pulmonary disease, respiratory diseases, obstructive
lung diseases, and pulmonary rehabilitation. Any articles that
discussed the prevalence of anxiety symptoms or anxiety disorders
among patients with COPD, the impact of anxiety on patients with
COPD, or the treatment of anxiety in COPD patients were included in
the review. The prevalence of GAD among patients with COPD ranges from 10 % to
15.8%,, when using standard diagnostic procedures compared with lifetime rates
of 3.6 to 5.1 % in the general public39. Thus, GAD is at least 3 times more prevalent in COPD patients than in the
general population.
Anxiety has a negative impact on the quality of life of
adults with COPD. It is associated with greater disability and impaired
functional status, specifically in the areas of general health, physical roles,
emotional roles, social functioning, bodily pain, mental health function and
vitality40. The study by Kim et al examined the relationship between
functional status and comorbid anxiety and depression and the
relationship between utilization of health care resources and
psychopathology in elderly patients with chronic obstructive
pulmonary disease (COPD). Elderly male veterans with COPD completed
anxiety, depression, and functional status measures. Anxiety and
depression contributed significantly to the overall variance in
functional status of COPD patients, over and above medical burden
and COPD severity, as measured by the 8 scales of the Medical
Outcomes Study (MOS) 36-item Short Form Health Survey. These studies also
showed that anxiety remains significantly associated with decreased functional status
even after statistically controlling for the effects of overall health status,
including additional medical diseases, COPD severity and dyspnoea. Not only is
anxiety highly common among COPD patients, but the reverse is also true. The
lifetime prevalence of respiratory disease is higher in people with panic
disorder (47%) than with other psychiatric diagnoses. Current and past
frequencies of respiratory diseases were assessed in 30 patients
with panic disorder, 30 patients with obsessive-compulsive disorder,
and 30 patients with eating disorders. Lifetime prevalence of respiratory
disorders was significantly higher in patients with panic disorder
(47%) than in patients with either obsessive-compulsive disorder (13%)
or eating disorder (13%).
Coping,
Social Support and Chronic Illness
Holahan et al, 41 conducted a study on coping and
social support in a sample of late middle aged patients reporting cardiac
illness. The study tested a one year predictive model of depressive symptoms.
Integrative time lag and prospective equation models indicated that for
individuals with cardiac illness, social support and adaptive coping strategies
predicted fewer depressive symptoms.
Weickgenant et al, 42 studied coping activities in low
back pain and relationship with depression. Results indicated that depressed
COPD patients reported more passive avoidant coping strategies than non
depressed low back pain patients and healthy controls.
Henoch et al43 studied impact of coping and social
support on quality of life in patients with lung cancer. There was a
significant correlation between anxiety, depression, and coping capacity with
global quality of life and multivariate analysis showed depression as a
significant predictor. DiMatteo et al44 examined the relationship of social
support to treatment adherence. In a review of the literature from 1948 to 2001, 122 studies were
found that correlated structural or functional social support with patient
adherence to medical regimens. Meta-analyses establish significant average r-effect
sizes between adherence and practical, emotional, and unidimensional social
support; family cohesiveness and conflict; marital status; and living arrangement
of adults.
Qing
Yea et al 45 studied effect of social support on
anxiety and depressive symptoms in patients receiving peritoneal dialysis.
Linear regression analysis indicated that, after adjusting for certain factors,
social support alleviated depressive and anxiety symptoms
Coping and social support in COPD
It was seen that problem solving coping strategies were
inversely related to psychological distress in COPD46. Herbert et al47 examined quality of life and coping strategies of
clients with COPD. A descriptive correlational design was used in 39 clients
with severe COPD. Quality of life was measured by using the Sickness Impact
Profile (SIP) and Cantril's Ladder; coping strategies were measured with
Jalowiec's Coping Scale Revised (JCS). Total coping scores were found to be low
in the population. Women with COPD struggled not only with dyspnea and fatigue,
but with depression, stigma, loss of social support and intimacy48. Breathing techniques, medication, rest, and avoidance measures were
the most frequently used coping strategies. Yuet et al 49 in 2002 studied coping and adjustment in Chinese patients with COPD. A
convenience sample of 54 hospitalized COPD adult patients participated in the
study. All participants had moderate to severe scores in respect of pulmonary
functional status and symptoms. The findings indicated that the participants
adopted limited coping strategies and had poor psychosocial adjustment to their
illness. It is also reported that there is decline in activities of daily life
and social isolation for patient with COPD50.
There is association between psychosocial coping resources
and coping style with Health related Quality of Life, for asthma and COPD51. Fourteen general practitioners in The Netherlands recruited 273 adult
patients with asthma or COPD. Data were collected by a pulmonary function
assessment, a face-to-face interview and validated questionnaires about
psychosocial coping resources (self-efficacy, mastery, self-esteem, and social
support), coping style (avoidant, rational and emotional), and health related
quality of life (HRQoL). Symptoms, lung function, mood and social support has
definite influence on level of functioning of patients with COPD and formed a
positive correlation with social support52.
COPD also places a great burden on spouses of patients.
Keele-card et al 53 assessed thirty
clients with chronic obstructive pulmonary disease (COPD) and their spouses.
They were interviewed to examine differences in their relationships among
loneliness, depression, and social support. Spouses tended to be a little
lonelier than clients, and clients tended to be a little more depressed than
spouses. Spouses were less satisfied with their networks than clients. Social
support satisfaction was linked to loneliness and depression for clients but
not for spouses.
Conclusion
Anxiety and depression are prevalent in COPD, with coping
and social support playing a big role in the functioning of these patients. No
Indian literature could be found that explained the interplay between these
variables in COPD patients. The presence of these factors would also have a
major say in a developing country in India
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