Comorbid anxiety and depressive symptoms increase the risk of elevated morbidity, disability, and premature mortality in patients with COPD,” explains Abebaw M. Yohannes, PhD, MSc, FCCP, ATSF. “They are frequent causes of emergency care utilization and hospital admissions in this patient group. In addition, they exert significant burden, misery, social isolation, and impaired QOL on patients and their caregivers and contribute to poor treatment compliance, and heighten the dropout rate from a pulmonary rehabilitation program. Therefore, it is important to identify these comorbid symptoms and treat them adequately.”

For a study published in Respiratory Medicine, Dr. Yohannes and colleagues identified the pathways between symptoms of COPD, depression, and anxiety. They used a network analysis, a new method for determining the pathophysiology of mental health disorders, in patients with COPD.

Interconnection of COPD & Depressive Symptoms Illustrated

Using data from the COPDGene study, 1,587 patients with COPD from were included. The Bayesian Gaussian Graphical Model was used to emphasize the correlations between symptoms of COPD (measured via the COPD Assessment Test [CAT]) and depression and anxiety (measured via the Hospital Anxiety and Depression Scale [HADS)]). The researchers also assessed the role of socio-demographic characteristics, health status, and lung function.

A rendering was created that depicted five interconnected pathways in the network analysis from patients with COPD and comorbid symptoms of anxiety and depression, notes Dr. Yohannes. Based on their redundancy, 14 HADS items were combined into six variables. “The analysis, illustrated by nodes and communities, show how anxiety relates to tension, worry, fear, and panic,” he says. “Depressive symptoms are tied to sadness and lack of pleasure in life. Physical impairment relates to low energy and breathlessness. Also, the impact of respiratory problems correlated with lack of confidence, sleep problems, and chest tightness (Figure).

These points, he says, are highly relevant for clinicians when interacting with their patients with COPD. “We found that nodes and communities representative of characteristic COPD symptoms were highly interconnected. For example, cough and phlegm are closely related to chest tightness, sleep problems, and breathlessness, which in turn are linked to items related to physical and activity limitations.”

Anxiety & Depression Are Not Frequently Assessed in COPD

The key takeaway from this study, according to Dr. Yohannes and colleagues, is that anxiety and depressive symptoms are not frequently assessed, identified, and treated in patients with COPD. “We suggest identifying these symptoms in routine clinical practice,” Dr. Yohannes says. “Clinicians need to use a validated anxiety and depressive symptoms scale, such as HADS or the Anxiety Inventory for Respiratory Disease (AIR).

Patients with COPD identified with high levels of anxiety and depressive symptoms should be referred to a psychiatrist for further assessment, who may prescribe antidepressant drug therapy for major depression or anxiety. For mild to moderate symptoms, exercise therapy and/or cognitive behavioral therapy are worthy of consideration.”

Following acute exacerbations, patients with COPD should be referred to a pulmonary rehabilitation program, he adds. “Pulmonary rehabilitation has been shown to be effective in ameliorating anxiety and depressive symptoms and improving exercise capacity and quality of life in patients with COPD.”

For future research, the study team concurred that prospective, randomized controlled trials with large sample sizes are needed to show the efficacy of antidepressant drug therapy in patients with COPD with comorbid symptoms of anxiety and depression. “Where appropriate and available, clinicians should consider a collaborative care model approach to treat these symptoms in patients with COPD,” Dr. Yohannes says.