Prevalence of Anxiety and Depression in Patients with Severe COPD: Similar High Levels with and without LTOT

Mental health and quality of life among patients with chronic respiratory failure on domiciliary oxygen: a prospective cohort study from a tertiary care centre in India

OBJECTIVES

The study aims to assess the prevalence of anxiety, depression and the quality of life among patients with chronic respiratory failure and the changes in anxiety and depression scores after initiating domiciliary oxygen.

DESIGN AND SETTING

Prospective, single-centre cohort study conducted in a tertiary care hospital in India.

PARTICIPANTS

Patients of Indian origin with chronic respiratory failure who visited the hospital where domiciliary oxygen is indicated were included in the study. Patients with acute respiratory failure on a mechanical ventilator, haemodynamic instability and already-diagnosed psychiatric conditions were excluded from the study.

INTERVENTIONS

Patients who met the inclusion criteria were assessed at baseline, at 3 and 6 months, for anxiety and depression using the 7-item Generalised Anxiety Disorder questionnaire (GAD-7) and 9-item Patient Health Questionnaire (PHQ-9). Quality of life was evaluated using the WHO Quality of Life-BREF questionnaire.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome is the proportion of patients with chronic respiratory failure having depression and anxiety and assessing the changes in anxiety and depression scores after initiating domiciliary oxygen. The secondary outcome is the change in health-related quality of life (HRQOL) of patients on domiciliary oxygen.

RESULTS

121 patients who met the inclusion criteria were included in the study. Of 102 patients who completed the study, 36.2% (n=37) had anxiety and 44.1% (n=45) had depression at baseline. There is a worsening trend in the mean GAD-7 (p=0.003) and PHQ-9 score (p=0.015) in patients over 6 months while on domiciliary oxygen. HRQOL is poor in all the domains at baseline, and there is a progressive worsening during follow-up while on oxygen.

CONCLUSIONS

The worsening trend in anxiety and depression in patients after initiating domiciliary oxygen may be related to social isolation, restricted mobility, economic issues, addictions and frequency of exacerbations. Screening for psychological problems in these patients at baseline and on follow-ups helps early detection, and prompt intervention could improve the quality of life and survival.

Assessing Symptom Burden and Depression in Subjects With Chronic Respiratory Insufficiency

Objectives: Patients with chronic respiratory insufficiency suffer from advanced disease, but their overall symptom burden is poorly described. We evaluated the symptoms and screening of depression in subjects with chronic respiratory insufficiency by using the Edmonton symptom assessment system (ESAS). Methods: In this retrospective study, 226 subjects with chronic respiratory insufficiency answered the ESAS questionnaire measuring symptoms on a scale from 0 (no symptoms) to 10 (worst possible symptom), and the depression scale (DEPS) questionnaire, in which the cut-off point for depressive symptoms is 9. Results: The most severe symptoms measured with ESAS (median [interquartile range]) were shortness of breath 4.0 (1.0-7.0), dry mouth 3.0 (1.0-7.0), tiredness 3.0 (1.0-6.0), and pain on movement 3.0 (0.0-6.0). Subjects with a chronic obstructive pulmonary disease as a cause for chronic respiratory insufficiency had significantly higher scores for shortness of breath, dry mouth, and loss of appetite compared to others. Subjects with DEPS ≥9 reported significantly higher symptom scores in all ESAS categories than subjects with DEPS <9. The area under the receiver operating characteristic curve for ESAS depression score predicting DEPS ≥9 was 0.840 (P < .001). If the ESAS depression score was 0, there was an 89% probability of the DEPS being <9, and if the ESAS depression score was ≥4, there was an 89% probability of the DEPS being ≥9. The relation between ESAS depression score and DEPS was independent of subjects' characteristics and other ESAS items. Conclusions: Subjects with chronic respiratory insufficiency suffer from a high symptom burden due to their advanced disease. The severity of symptoms increases with depression and 4 or more points in the depression question of ESAS should lead to a closer diagnostic evaluation of depression. Symptom-centered palliative care including psychosocial aspects should be early integrated into the treatment of respiratory insufficiency.

Disturbances in branched-chain amino acid profile and poor daily functioning in mildly depressed chronic obstructive pulmonary disease patients

BACKGROUND

Depression is one of the most common and untreated comorbidities in chronic obstructive pulmonary disease (COPD), and is associated with poor health outcomes (e.g. increased hospitalization/exacerbation rates). Although metabolic disturbances have been suggested in depressed non-diseased conditions, comprehensive metabolic phenotyping has never been conducted in those with COPD. We examined whether depressed COPD patients have certain clinical/functional features and exhibit a specific amino acid phenotype which may guide the development of targeted (nutritional) therapies.

METHODS

Seventy-eight outpatients with moderate to severe COPD (GOLD II-IV) were stratified based on presence of depression using a validated questionnaire. Lung function, disease history, habitual physical activity and protein intake, body composition, cognitive and physical performance, and quality of life were measured. Comprehensive metabolic flux analysis was conducted by pulse stable amino acid isotope administration. We obtained blood samples to measure postabsorptive kinetics (production and clearance rates) and plasma concentrations of amino acids by LC-MS/MS. Data are expressed as mean [95% CI]. Stats were done by graphpad Prism 9.1.0. ɑ < 0.05.

RESULTS

The COPD depressed (CD, n = 27) patients on average had mild depression, were obese (BMI: 31.7 [28.4, 34.9] kg/m2), and were characterized by shorter 6-min walk distance (P = 0.055), physical inactivity (P = 0.03), and poor quality of life (P = 0.01) compared to the non-depressed COPD (CN, n = 51) group. Lung function, disease history, body composition, cognitive performance, and daily protein intake were not different between the groups. In the CD group, plasma branched chain amino acid concentration (BCAA) was lower (P = 0.02), whereas leucine (P = 0.01) and phenylalanine (P = 0.003) clearance rates were higher. Reduced values were found for tyrosine plasma concentration (P = 0.005) even after adjustment for the large neutral amino acid concentration (= sum BCAA, tyrosine, phenylalanine and tryptophan) as a marker of dopamine synthesis (P = 0.048).

CONCLUSION

Mild depression in COPD is associated with poor daily performance and quality of life, and a set of metabolic changes in depressed COPD that include perturbation of large neutral amino acids, specifically the BCAAs. Trial registration clinicaltrials.gov: NCT01787682, 11 February 2013-Retrospectively registered; NCT02770092, 12 May 2016-Retrospectively registered; NCT02780219, 23 May 2016-Retrospectively registered; NCT03796455, 8 January 2019-Retrospectively registered.

The 5-year pre- and post-hospitalization treated prevalence of mental disorders and psychotropic medication use in critically ill patients: a Canadian population-based study

PURPOSE

The interplay between critical illness and mental disorders is poorly understood. The purpose of this study is to measure both the treated prevalence of mental disorders and psychotropic medication use before and after hospitalization and the impact of intensive care unit (ICU) admission on these outcomes.

METHODS

Using a population-based administrative database in Manitoba, Canada, 49,439 ICU patients admitted between 2000 and 2012 were compared to two matched comparison groups (hospitalized; n = 146,968 and general population; n = 141,937). Treated prevalence of mental disorders and psychotropic medication prescriptions were measured in the 5-year periods before and after the hospitalization. Multivariable models compared adjusted prevalence ratios (APRs) between populations.

RESULTS

The 5-year treated mental disorder prevalence in the ICU population increased from 41.5% pre-hospitalization to 55.6% post-hospitalization. Compared to non-ICU hospitalized patients, the adjusted treated mental disorder prevalence in ICU patients was lower prior to hospitalization (1-year APR 0.94, 95% CI 0.92-0.97, p < 0.0001; 5-year APR 0.99, 95% CI 0.98-1.00, p = 0.1), but higher following discharge (1-year APR 1.08, 95% CI 1.05-1.11, p < 0.0001, 5-year APR 1.03, 95% CI 1.01-1.05, p < 0.0001). A high proportion of ICU patients received antidepressant, anxiolytic and sedative-hypnotic prescriptions before and after their hospitalization. In multivariable analyses, ICU exposure was associated with an increase in mood, anxiety and psychotic disorders, and sedative-hypnotics use (p < 0.0001 for all Time × Group interactions).

CONCLUSIONS

During the 5 years after admission to ICU, there is a significant increase in treated prevalence of mental disorders and psychotropic medication use compared to the 5 years prior to ICU and compared to general population and hospital cohorts. Prevention and intervention programs that identify and treat mental disorders among survivors of critical illness warrant further study.

Prevalence of anxiety and depression symptoms and their associated factors in mild COPD patients from community settings, Shanghai, China: a cross-sectional study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a serious disease frequently accompanied by anxiety and depression. Few studies have focused on anxiety and depression for mild COPD patients in China. This study aimed to assess the prevalence and associated factors for anxiety and depression among patients with mild COPD in urban communities.

METHODS

A cross-sectional survey of 275 mild COPD patients was conducted in 6 communities randomly sampled from Pudong New Area of Shanghai, China, in 2016. Data on socioeconomic factors and health conditions were acquired through a face-to-face interview as well as a physical examination. The Hospital Anxiety and Depression Scale (HAD) and EQ-5D visual analogue (EQ-5Dvas) were applied to evaluate their mental health and quality of life, respectively. Logistic regression model was used to estimate adjusted odds ratios (aORs) and their 95% confidential intervals (CI) for risk factors associated with anxiety or depression.

RESULTS

Among 275 subjects, 8.1% had anxiety and 13.4% had depression. Logistic regression analysis indicated that female patients were more likely to suffer from anxiety than male patients (aOR = 6.41, 95% CI:1.73-23.80). Poor health status (EQ-5Dvas score < 70) was significantly associated with increased risks of anxiety (aOR = 5.99, 95% CI: 2.13-16.82) and depression (aOR = 2.67, 95% CI: 1.29-5.52).

CONCLUSIONS

There were increased risks of anxiety and depression in mild COPD patients living in urban communities. Female sex and poor health status were significantly correlated to anxiety or depression. More interventions should be developed to reduce the risks of anxiety and depression at the early stage of COPD.

Major Depression in Long-Term Oxygen Therapy Dependent Chronic Obstructive Pulmonary Disease

PURPOSE

We aimed to investigate the frequency of major depression (MD) in long-term oxygen therapy (LTOT) dependent chronic obstructive pulmonary disease (COPD) patients and the effect of depression on patients' compliance with the treatment.

DESIGN AND METHODS

Fifty-four consecutive patients were enrolled in the study and diagnosed as stage 4 COPD according to Global Initiative for Chronic Obstructive Lung Disease guideline. MD was diagnosed with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition/Clinical Version.

FINDINGS

Thirty-four (63.0%) patients had MD. MD frequency was significantly higher in patients who were noncompliant with LTOT compared with compliant patients.

PRACTICE IMPLICATIONS

MD is a common psychiatric disorder in COPD patients receiving LTOT.

Discriminant validity of the Hospital Anxiety and Depression Scale, Beck Depression Inventory (II) and Beck Anxiety Inventory to confirmed clinical diagnosis of depression and anxiety in patients with chronic obstructive pulmonary disease

The objective of this study was to investigate the discriminant validity of commonly used depression and anxiety screening tools in order to determine the most suitable tool for patients with chronic obstructive pulmonary disease (COPD). COPD patients (n = 56) completed the Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory (BDI-II) and Beck Anxiety Inventory (BAI). These scores were compared to confirmed clinical diagnoses of depression and anxiety using the Mini Neuropsychiatric Interview. HADS depression subscale (HADS-D) sensitivity/specificity was 78/81%; BDI-II 89/77%; HADS anxiety subscale (HADS-A) 71/81%; and BAI 89/62%. HADS-D sensitivity/specificity was improved (100/83%) with the removal of Q4 'I feel as if I am slowed down' and adjusted cut-off (≥5). Removal of BDI-II Q21 'Loss of interest in sex' with adjusted cut-off ≥12 resulted in similar improvement (100/79%). No problematic items were identified for HADS-A or BAI. Previously reported low sensitivity/specificity of the HADS for COPD patients was not replicated. Furthermore, simple modifications of the HADS-D markedly improved sensitivity/specificity for depression.BDI-II, HADS-A and BAI produced acceptable sensitivity/specificity unmodified. Pending further research for COPD patients we recommend continued use of the HADS-A with standard cut-off (≥8) and removal of Q4 of the HADS-D with lower cut-off ≥5.

Chronic obstructive pulmonary disease in China: the potential role of indacaterol

Chronic obstructive pulmonary disease (COPD) is becoming a leading cause of morbidity and mortality in China, with tobacco smoking, biomass fuel use and genetic susceptibility being the major risk factors. COPD poses a high economic burden with the total expenditure per patient costing 40% and nearly one-third of an average family income in urban and rural areas of China, respectively. Despite the use of the Global Initiative for Chronic Obstructive Lung Disease strategy document being recommended for the diagnosis and management of COPD, the majority of patients with COPD go undiagnosed or are not managed appropriately by physicians. Long-acting β2-agonists (LABAs) have long been used for symptomatic management of COPD, with salmeterol and formoterol being the commonly used twice-daily treatments. Indacaterol is the first once-daily LABA, approved at a dose of 150 µg once daily in China. Several phase III studies have shown that indacaterol 150 µg improves lung function, breathlessness, health status, exacerbations, rescue medication use and symptoms, as compared with placebo and other bronchodilators, in patients with COPD, with a rapid onset of action following first dose and a good safety and tolerability profile. In this review we elaborate on the efficacy and safety results from several such studies.

Positive association between the plasma levels of 5-hydroxyindoleacetic acid and the severity of depression in patients with chronic obstructive pulmonary disease

BACKGROUND

The role of plasma monoamines in patients with chronic obstructive pulmonary disease (COPD) with depression is unclear. To investigate monoamines in 20 depressed patients with COPD, the plasma concentrations of serotonin, 5-hydroxyindoleacetic acid (5-HIAA), homovanillic acid, and 3-methoxy-4-hydroxyphenylglycol (MHPG) were measured and compared with those in 50 non-depressed COPD patients, and also with 23 age- and gender-matched non-smokers and 13 smokers as non-depressed healthy controls.

METHODS

Diagnosis of depression was assessed using the Centre for Epidemiologic Studies Depression Scale. Plasma concentrations of monoamines were measured by high-performance liquid chromatography.

RESULTS

None of the depressed COPD patients had suicidal ideation. The plasma 5-HIAA level [median, (25% and 75% quartiles)] in depressed COPD patients [6.8 ng/mL, (4.9 and 13.1)] was significantly higher than in non-depressed COPD patients [5.4, (4.2 and 7.5)] (p=0.022) and non-smokers [5.1 (3.8 and 7.2)] (p=0.041), but not smokers [4.7, (4.0 and 6.7)] (p>0.05). The plasma 5-HIAA level (r=0.24, p=0.049) was significantly associated with the severity of depression in patients with COPD. The plasma MHPG level was significantly higher in depressed COPD patients (p=0.043) than in smokers, but was not higher than that in non-depressed COPD patients or non-smokers, although the level of MHPG was not associated with the severity of depression.

CONCLUSION

The plasma 5-HIAA level is increased in depressed COPD patients. Plasma monoamines may be a good biomarker for detection of depression in patients with COPD.

Depression, but not sleep disorder, is an independent factor affecting exacerbations and hospitalization in patients with chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVE

Patients with chronic obstructive pulmonary disease (COPD) may experience depression and sleep disorders, which can adversely affect their health-related quality of life (HRQOL). The aim of this study was to investigate depression and sleep disorders among 85 COPD patients and 46 control subjects, aged 40 years and over.

METHODS

Patients underwent spirometry and arterial blood gas analysis, self-completed St. George's respiratory questionnaire and were assessed on the center for epidemiologic studies depression (CES-D) and the Pittsburgh sleep quality index (PSQI). The frequency of exacerbations among COPD patients was prospectively monitored for 12 months.

RESULTS

The prevalence of depression and sleep disorders was significantly higher among COPD patients than control subjects. The relative risks (95% confidence interval) of depression and sleep disorders were 7.58 (1.03 to 55.8) and 1.82 (1.03 to 3.22), respectively, in COPD patients compared with control subjects. Among COPD patients, there was a correlation between CES-D and PSQI. Lower body mass index, more severe dyspnoea, poorer HRQOL, lower partial pressure of arterial oxygen and higher partial pressure of arterial carbon dioxide were significantly associated with the incidence of depression and sleep disorders. Exacerbations and hospitalizations were more frequent among COPD patients with depression than those with sleep disorders alone or those without depression or sleep disorders.

CONCLUSIONS

Depression and sleep disorders are very common co-morbidities among COPD patients and significantly reduce activities and HRQOL among these patients. Depression, but not sleep disorder, is an independent risk factor for exacerbations and hospitalization among COPD patients.

Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: prevalence, relevance, clinical implications and management principles

OBJECTIVE

To review evidence regarding the prevalence, causation, clinical implications, aspects of healthcare utilisation and management of depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease.

DESIGN

A critical review of the literature (1994-2009).

FINDINGS

The prevalence of depression and anxiety is high in both chronic obstructive pulmonary disease (8-80% depression; 6-74% anxiety) and chronic heart failure (10-60% depression; 11-45% anxiety). However, methodological weaknesses and the use of a wide range of diagnostic tools make it difficult to reach a consensus on rates of prevalence. Co-morbid depression and anxiety are associated with increased mortality and healthcare utilisation and impact upon functional disability and quality of life. Despite these negative consequences, the identification and management of co-morbid depression and anxiety in these two diseases is inadequate. There is some evidence for the positive role of pulmonary/cardiac rehabilitation and psychotherapy in the management of co-morbid depression and anxiety, however, this is insufficient to guide recommendations.

CONCLUSIONS

The high prevalence and associated increase in morbidity and mortality justifies future research regarding the management of anxiety and depression in both chronic heart failure and chronic obstructive pulmonary disease. Current evidence suggests that multi-faceted interventions such as pulmonary and cardiac rehabilitation may offer the best hope for improving outcomes for depression and anxiety.