Symptoms of anxiety and depression in COPD patients entering pulmonary rehabilitation

Risk of pharmacological treatment of anxiety and depression after admission for acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND

Anxiety and depression are very common in patients with COPD and may lead to lower quality of life and higher risk of exacerbations and mortality. This study aimed to examine the incidence of anxiety and depression within one year after admission with acute exacerbation in COPD (AECOPD). The secondary aim was to examine the characteristics of the patients who develop anxiety and depression.

METHODS

This retrospective cohort study used the Danish National Patient Registry. Patients aged 40-90 years admitted for COPD between 01.01.99 and 31.12.18 were included. Patients with mental disorders within 10 years before admission were excluded. Age, sex, educational level, inhaled medication, and comorbidities were evaluated. Anxiety or depression were defined by redemption of anxiolytics or antidepressants within one year after admission.

RESULTS

We included 97,929 patients. Anxiolytics and antidepressants were redeemed by 4 and 5 % of patients respectively. Higher age, male sex, treatment with short acting β2-agonists and short acting muscarinic antagonists, cancer and heart failure were positively associated to risk of anxiety or depression, while diabetes and treatment with triple inhalation therapy showed an inverse association.

CONCLUSION

Respectively four and five per cent of patients redeemed anxiolytics and antidepressants within the first year after their first severe AECOPD. Several patient characteristics were significantly associated to risk of anxiety or depression. The results from this study support that there is a risk of anxiety and depression after AECOPD in addition to the known risk of preexisting anxiety and depression.

The effect of physical fitness on psychological health: evidence from Chinese university students

BACKGROUND

Despite frequent discussions on the link between physical and mental health, the specific impact of physical fitness on mental well-being is yet to be fully established.

METHOD

This study, carried out between January 2022 and August 2023, involved 4,484 Chinese University students from eight universities located in various regions of China. It aimed to examine the association between physical fitness on psychological well-being. Descriptive statistics, t-tests, and logistic regression were used to analyze the association between physical fitness indicators (e.g., Body Mass Index (BMI), vital capacity, and endurance running) and mental health, assessed using Symptom Checklist-90 (SCL-90). All procedures were ethically approved, and participants consented to take part in.

RESULTS

Our analysis revealed that BMI, vital capacity, and endurance running scores significantly influence mental health indicators. Specifically, a 1-point increase in BMI increases the likelihood of an abnormal psychological state by 10.9%, while a similar increase in vital capacity and endurance running decreases the risk by 2.1% and 4.1%, respectively. In contrast, reaction time, lower limb explosiveness, flexibility, and muscle strength showed no significant effects on psychological states (p > 0.05).

CONCLUSION

Improvements in BMI, vital capacity, and endurance running capabilities are associated with better mental health outcomes, highlighting their potential importance in enhancing overall well-being.

Factors associated with anxiety and depression among patients with chronic obstructive pulmonary disease

OBJECTIVES

This study investigated factors associated with anxiety and depression in COPD outpatients.

METHODS

A cross-sectional study of 702 COPD outpatients from two major Jordanian hospitals using the Hospital Anxiety and Depression Scale (HADS) was conducted.

RESULTS

Significant associations were found with gender (Anxiety OR: 5.29, 95%CI: 2.38-11.74; Depression OR: 0.20, 95%CI: 0.08-0.51), disease severity (Anxiety OR: 2.97, 95%CI: 1.80-4.91; Depression OR: 15.95, 95%CI: 5.32-52.63), LABA use (Anxiety OR: 16.12, 95%CI: 8.26-32.26; Depression OR: 16.95, 95%CI: 8.33-34.48), medication count (Anxiety OR: 0.73, 95%CI: 0.59-0.90; Depression OR: 0.51, 95%CI: 0.40-0.64), mMRC score (Anxiety OR: 2.41, 95%CI: 1.81-3.22; Depression OR: 2.31, 95%CI: 1.76-3.03), and inhalation technique (Anxiety OR: 0.95, 95%CI: 0.93-0.97; Depression OR: 0.92, 95%CI: 0.90-0.95). Other factors associated with anxiety included high income, urban living, diabetes, hypertension, LAMA use, and fewer COPD medications. Depression was also linked with heart disease, increased age, and longer disease duration.

CONCLUSION

The prevalence of anxiety and depression among COPD patients necessitates targeted interventions. Future research that recruits a more diverse sample in multiple sites and establishes the cause-effect relationship between the study predictors and outcome could provide a more robust conclusion on factors associated with anxiety and depression among COPD patients.

Global prevalence and risk factors of depression in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis from 2000 to 2022

OBJECTIVE

This study aims to assess the global and regional prevalence and the potential risk factors for depression among COPD patients.

METHODS

Web of Science, EMBASE, PubMed, and PsycINFO databases were searched for the literature related to the prevalence and risk factors of depression in COPD. Random-effect models were performed to pool the global prevalence. Sub-group analysis and meta-regression were conducted to investigate the potential heterogeneity. Meta-analysis was performed only on the risk factors that have been reported in a minimum of three studies.

RESULTS

A total of 79 studies from 25 countries were included. The pooled global prevalence of variably defined depression among COPD patients was 34.5% (95% CI: 30.9-38.1). The odds of depression in COPD patients were 3.53 times higher than in non-COPD participants (95% CI: 2.35-5.29). Meta-regression results showed that region, income level, and research setting are the main sources of heterogeneity. Female sex (OR=1.92), living alone (OR=2.29), BODE index (OR=1.48), dyspnea (OR=3.02), impaired quality of life (OR=1.26), and GOLD stage III∼IV (OR=1.96) were found to be significant risk factors for depression in meta-analyses.

CONCLUSIONS

More than one-third of COPD patients experience depression, with marked variations in prevalence across countries and regions. This study further highlights the need for the consolidation of mental health considerations into COPD treatments. High-quality, longitudinal studies and further research are needed to gain a better understanding of risk and protective factors.

Validation of the Generalized Anxiety Disorder-7 in patients with COPD: a cross-sectional study

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) often have comorbid generalized anxiety disorder (GAD), which requires early screening in respiratory clinics. The Generalized Anxiety Disorder-7 (GAD-7) questionnaire is a brief and commonly used screening tool for GAD but has not been validated among patients with COPD in China.

METHODS

Stable patients with COPD from a cross-sectional observational study were assessed using the GAD-7 questionnaire and then assessed by a senior psychiatrist to confirm a diagnosis of GAD according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Demographic characteristics, spirometry, and patient-reported outcomes were collected. Cronbach's α coefficient was calculated, and receiver operating curve (ROC) analysis was performed to validate the GAD-7.

RESULTS

A total of 226 patients with COPD were enrolled, and 50 (22.1%) of these patients were diagnosed with GAD. The Cronbach's α coefficient for the GAD-7 was 0.869, which indicated good internal consistency. ROC curve analysis showed that the GAD-7 had an area under the curve (AUC) value of 0.829 (95% CI: 0.774-0.876) for identifying GAD. The optimal cut-off score was ≥ 4, with a sensitivity of 66.0% and a specificity of 89.2%. Higher GAD-7 scores were significantly associated with health-related quality of life and the symptom burden of COPD. The discriminatory power of GAD-7 did not differ statistically when stratified by COPD severity.

CONCLUSIONS

The GAD-7 was shown to be a reliable and valid screening tool for patients with COPD in China, and its screening performance for GAD was not influenced by disease severity.

Risk Factors for Depression in Patients with Chronic Obstructive Pulmonary Disease

Depression, anxiety, and panic disorders are common in chronic obstructive pulmonary disease (COPD) and important for the further course of the disease, as they are associated with increased hospital admissions, longer hospital stays, more frequent doctor visits, and a worsened quality of life. There are also indications of premature death in affected patients. Therefore, knowledge of the risk factors for depression in COPD patients is all the more important for early detection and treatment. Hence, Embase, the Cochrane Library, and the MEDLINE/PubMed databases were analyzed for studies on these risk factors. The main factors are as follows: female gender; older/younger age; living alone; higher education; unemployment; retirement; a low quality of life; social isolation; high/low income; high cigarette and alcohol consumption; poor physical fitness; severe respiratory symptoms; high/low body mass index, airway obstruction, dyspnea, exercise capacity index scores; and comorbidities (mainly heart disease, cancer, diabetes, and stroke). This article presents the analyzed medical literature.

Abdominal obesity in COPD is associated with specific metabolic and functional phenotypes

BACKGROUND

Abdominal obesity (AO) is linked to reduced health status and mortality. While it is known that AO is prevalent in chronic obstructive pulmonary disease (AO-COPD), the specific metabolic and functional consequences associated with AO-COPD remain understudied.

METHODS

We studied 199 older adults with COPD and 168 control subjects with and without AO and assessed visceral adipose tissue (VAT) by dual-energy X-ray absorptiometry. VAT > 70th percentile of the control group qualified a subject as AO in a sex specific manner. We measured plasma concentrations and whole body production (WBP) rates of multiple amino acids to assess the metabolic profile. We assessed medical history, body composition by Dual-Energy X-ray Absorptiometry, muscle strength, and cognitive function. We performed statistics by analysis of covariance (p) and FDR (q) for multiple comparisons.

RESULTS

AO-COPD subjects had 27% more VAT (q < 0.01) than AO-Control subjects despite correction for BMI. Branched-chain amino acid concentrations and WBP rates were generally elevated in AO-COPD but whole body clearance rate was only elevated in COPD. Metabolic syndrome comorbidities (p < 0.01) and systemic inflammation (P < 0.05) were most prevalent in the AO-COPD group. Muscle strength was reduced in COPD subjects (p < 0.001), but partially preserved when combined with AO. Cognitive dysfunction and mood disturbances were present in COPD subjects (p < 0.001) with worst performers in AO-COPD (q < 0.05).

CONCLUSION

The presence of AO is associated with specific metabolic and functional phenotypes in COPD. Clinical trial registry Trial registration ClinicalTrials.gov. In the present paper, we report an analysis of the baseline measurements of COPD subjects and healthy controls from the study numbers: NCT01787682, NCT01787682, NCT02157844, NCT02082418, NCT02065141, NCT02770092, NCT02908425, NCT03159390, NCT02780219, NCT03327181, NCT03796455, NCT04928872, NCT04461236, NCT01173354, NCT01154400.

Health Status Stability of Patients in a Medical Rehabilitation Program: What Are the Roles of Time, Physical Fitness Level, and Self-efficacy?

BACKGROUND

Individuals' physical and mental health, as well as their chances of returning to work after their ability to work is damaged, can be addressed by medical rehabilitation.

AIM

This study investigated the developmental trends of mental and physical health among patients in medical rehabilitation and the roles of self-efficacy and physical fitness in the development of mental and physical health.

DESIGN

A longitudinal design that included four time-point measurements across 15 months.

SETTING

A medical rehabilitation center in Germany.

POPULATION

Participants included 201 patients who were recruited from a medical rehabilitation center.

METHODS

To objectively measure physical fitness (lung functioning), oxygen reabsorption at anaerobic threshold (VO2AT) was used, along with several self-report scales.

RESULTS

We found a nonlinear change in mental health among medical rehabilitation patients. The results underscored the importance of medical rehabilitation for patients' mental health over time. In addition, patients' physical health was stable over time. The initial level of physical fitness (VO2AT) positively predicted their mental health and kept the trend more stable. Self-efficacy appeared to have a positive relationship with mental health after rehabilitation treatment.

CONCLUSIONS

This study revealed a nonlinear change in mental health among medical rehabilitation patients. Self-efficacy was positively related to mental health, and the initial level of physical fitness positively predicted the level of mental health after rehabilitation treatment.

CLINICAL REHABILITATION

More attention could be given to physical capacity and self-efficacy for improving and maintaining rehabilitants' mental health.

Effectiveness of a Home-Based Pulmonary Rehabilitation Program in Veterans

Purpose: This study examined the effectiveness and safety of a home-based pulmonary rehabilitation (HBPR) program in Veterans. Methods: Patients were evaluated from five Veteran Affairs facilities that enrolled in the 12-week program. Pre- to postchanges were completed on clinical outcomes using paired t-tests and the Wilcoxon signed rank sum test. Descriptive statistics were used for patient demographics, emergency room visits, and hospitalizations. Results: Two hundred eighty-five patients with a mean age of 69.6 ± 8.3 years enrolled in the HBPR program from October 2018 to March 2020. There was a 62% (n = 176) completion rate of both pre- and post assessments. Significant improvements were detected after completion of the HBPR program in dyspnea (modified Medical Research Council: 3.1 ± 1.1 vs. 1.9 ± 1.1; p < 0.0001); exercise capacity (six-minute walk distance: 263.1 m ± 96.6 m vs. 311.0 m ± 103.6 m; p < 0.0001; Duke Activity Status Index: 13.8 ± 9.6 vs. 20.0 ± 12.7; p < 0.0001; self-reported steps per day: 1514.5 ± 1360.4 vs. 3033.8 ± 2716.2; p < 0.0001); depression (patient health questionnaire-9: 8.3 ± 5.7 vs. 6.4 ± 5.1); nutrition habits (rate your plate, heart: 45.3 ± 9.0 vs. 48.9 ± 9.2; p < 0.0001); multicomponent assessment tools (BODE Index: 5.1 ± 2.5 vs. 3.4 ± 2.4; p < 0.0001), GOLD ABCD Assessment: p < 0.0009); and quality of life (chronic obstructive pulmonary disease assessment test: 25.4 ± 7.7 vs. 18.7 ± 8.5; p < 0.0001). No adverse events were reported due to participation in HBPR. Conclusions: The HBPR program is a safe and effective model and provides an additional option to address the gap in pulmonary rehabilitation access and utilization in the Veterans Affairs.

Associations of Vitamin D, chronic obstructive pulmonary disease and acute exacerbations of COPD with anxiety and depression: a nested case control study

Background: Lower vitamin D levels have not only been associated with chronic obstructive pulmonary disease (COPD), exacerbations and lower lung functions, but also with anxiety and depression. We examined the associations of severity of anxiety and depression using HAM-A (Hamilton Anxiety Rating Scale) and HAM-D (Hamilton Depression Rating Scale) scores with COPD and vitamin D levels. Methods: Observational nested case control study was conducted in MUDHRA cohort. One hundred COPD subjects and 100 age- gender- matched non-COPD subjects (controls) underwent evaluation of socioeconomic status, respiratory symptoms, spirometry, severity of anxiety and depression, six minute walk test and estimation of serum vitamin D levels. Independent association of low vitamin D levels with severity of anxiety and depression was assessed by logistic regression. Results: COPD group had higher mean±SD anxiety and depression scores (HAM-A 8.0±3.5, HAM-D 8.72±4) compared to control group (HAM-A 4.51±2.2, HAM-D 4.3±2). The COPD group had 53 subjects with mild/moderate anxiety/depression whereas control group had 16 subjects with mild/moderate anxiety/depression. In COPD group, subjects with mild/moderate anxiety/depression had lower vitamin D levels compared to subjects with no/minimal anxiety/depression, while the difference in control group was not significant. In logistic regression, anxiety and depression levels had independent association with vitamin D levels, lung function variables, six-minute walk distance and presence of COPD. In COPD subgroup, anxiety and depression levels had independent association with breathlessness, GOLD FEV1 staging, CAT score, SGRQ-C Symptom score and exacerbation of COPD. Conclusions: Greater proportion of COPD subjects suffer from anxiety and depression as compared to subjects without COPD. Severity of anxiety and depression was greater in COPD subjects. Poorer lung functions, higher respiratory symptoms and lower vitamin D levels are associated with higher levels of anxiety and depression in COPD subjects.  There is an urgent need to recognise anxiety and depression in COPD patients.

Update on the Etiology, Assessment, and Management of COPD Cachexia: Considerations for the Clinician

Cachexia is a commonly observed but frequently neglected extra-pulmonary manifestation in patients with chronic obstructive pulmonary disease (COPD). Cachexia is a multifactorial syndrome characterized by severe loss of body weight, muscle, and fat, as well as increased protein catabolism. COPD cachexia places a high burden on patients (eg, increased mortality risk and disease burden, reduced exercise capacity and quality of life) and the healthcare system (eg, increased number, length, and cost of hospitalizations). The etiology of COPD cachexia involves a complex interplay of non-modifiable and modifiable factors (eg, smoking, hypoxemia, hypercapnia, physical inactivity, energy imbalance, and exacerbations). Addressing these modifiable factors is needed to prevent and treat COPD cachexia. Oral nutritional supplementation combined with exercise training should be the primary multimodal treatment approach. Adding a pharmacological agent might be considered in some, but not all, patients with COPD cachexia. Clinicians and researchers should use longitudinal measures (eg, weight loss, muscle mass loss) instead of cross-sectional measures (eg, low body mass index or fat-free mass index) where possible to evaluate patients with COPD cachexia. Lastly, in future research, more detailed phenotyping of cachectic patients to enable a better comparison of included patients between studies, prospective longitudinal studies, and more focus on the impact of exacerbations and the role of biomarkers in COPD cachexia, are highly recommended.

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.

Anxiety and depression in Dutch patients with primary ciliary dyskinesia and their caregivers: associations with health-related quality of life

Background

Primary ciliary dyskinesia (PCD) might be a risk factor for the development of anxiety and depression. This study investigated the associations between anxiety, depression and health-related quality of life (HRQoL) in individuals with PCD and their caregivers.

Methods

Children, adolescents and adults with PCD and their caregivers were invited to participate in a mental health screening programme. During regular yearly outpatient visits, measures of anxiety (GAD-7), depression (PHQ-9), HRQoL (QOL-PCD), lung function (forced expiratory volume in 1 s (FEV₁)) and body mass index (BMI)) were collected and associations of anxiety, depression and HRQoL were estimated.

Results

A total of 103 individuals participated in the mental health screening programme. Elevated levels of anxiety (scores ≥10 on GAD-7) were found in 6% of adults (n=33), 14% of children (n=7), 6% of adolescents (n=17) and 20% of caregivers (n=46, 52% of mothers). Elevated depression levels (scores ≥10 on PHQ-9) were found in 18% of adults, 14% of children, 6% of adolescents and 11% of caregivers. Anxiety and depression were associated with scales on the QOL-PCD. Mothers reported higher anxiety scores than fathers (30% versus 9%, p=0.03). A strong negative relationship was found between depression in caregivers and physical functioning (QOL-PCD) of the child. Anxiety and depression were not significantly associated with anxiety/depression in their child.

Conclusion

This is the first study investigating anxiety and depression in individuals with PCD and their caregivers. Our results revealed elevated levels of anxiety and depression, which were associated with worse HRQoL. These results suggest the need for psychological support in PCD.

Individuals with PCD and their caregivers are at risk of developing symptoms of anxiety and depression, which are associated with worse HRQoL. There is an urgent need for psychological care in PCD, especially in adults with PCD and caregivers.https://bit.ly/3rmbgc9

Management of patients with fibrosing interstitial lung diseases

Purpose

This article summarizes the appropriate use and pharmacology of treatments for fibrosing interstitial lung diseases, with a specific focus on the antifibrotic agents nintedanib and pirfenidone.

Summary

The interstitial lung diseases are a heterogenous group of parenchymal lung disorders with a common feature—infiltration of the interstitial space with derangement of the normal capillary-alveolar anatomy. Diseases characterized by fibrosis of the interstitial space are referred to as the fibrosing interstitial lung diseases and often show progression over time: idiopathic pulmonary fibrosis is the most common fibrotic interstitial lung disease. Historically, therapies for fibrosing lung diseases have been limited in number, questionable in efficacy, and associated with potential harms. Food and Drug Administration (FDA) approval of the antifibrotic agents nintedanib and pirfenidone for idiopathic pulmonary fibrosis in 2014 heralded an era of reorganization of therapy for the fibrotic interstitial lung diseases. Subsequent investigations have led to FDA approval of nintedanib for systemic sclerosis–associated interstitial lung disease and interstitial lung diseases with a progressive phenotype. Although supportive care and pulmonary rehabilitation should be provided to all patients, the role(s) of immunomodulators and/or immune suppressing agents vary by the underlying disease state. Several agents previously used to treat fibrotic lung diseases (N-acetylcysteine, anticoagulation, and pulmonary vasodilators) lack efficacy or cause harm.

Conclusion

With the introduction of effective pharmacotherapy for fibrosing interstitial lung disease, pharmacists have an increasingly important role in the interdisciplinary team managing these patients.

The Effectiveness of Cardiopulmonary Rehabilitation Programs on Psychosocial Factors in Patients With Pulmonary and Cardiac Disease

PURPOSE

Those with chronic cardiac and pulmonary diseases are predisposed to several psychosocial disorders. Tailored rehabilitation programs have been shown to improve physiological and psychosocial well-being. The purpose of this study was, first, to assess the psychosocial improvements among patients with cardiac and pulmonary diseases who have finished cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) programs; second, to assess the differences in psychosocial factors among those patients based on smoking status at the beginning and end of these programs.

METHODS

The CR and PR programs in hospital settings were retrospectively analyzed from 2013-2018. Before and after, all patients completed the sociodemographic characteristics along with the Psychosocial Risk Factor Survey that measures total distress, depression, anxiety, hostility, and social isolation.

RESULTS

There were 355 patients with cardiac and 244 patients with pulmonary disease who completed 6- to 12-wk CR or PR programs. There were significant improvements in all psychosocial symptoms among cardiac patients. Patients with pulmonary disease exhibited significant improvements in all psychosocial factors except for social isolation. Moreover, current smokers in the CR group reported elevated symptoms of several psychosocial scores.

CONCLUSION

These findings provide critical information about the effects of tailored rehabilitation programs among patients with chronic cardiac and pulmonary diseases on psychosocial levels. By using the Psychosocial Risk Factor Survey, we have found that total distress, depression, anxiety, and hostility were reduced among patients who completed the CR or PR programs. Current smokers exhibited the elevated mean scores on psychosocial symptoms in the cardiac group that may be a target for smoking cessation program. The advantages of tailored rehabilitation programs are significant, which may be of benefit for physical, social, behavioral, and psychological well-being.

Erectile Dysfunction in Men with Chronic Obstructive Pulmonary Disease

Erectile dysfunction (ED) seems to be a widespread sexual issue in men affected by chronic obstructive pulmonary disease (COPD). Multiple causes appear to be involved such as hormonal imbalance, smoking habit, chronic inflammation, endothelial dysfunction, chronic hypoxia, psychiatric disorders (depression and anxiety), and medications. ED can have a significant impact on COPD men and consequently on their quality of life, which is usually already compromised. Given this situation, however, pneumologists usually do not properly care for the sexuality of COPD patients especially because men can be reluctant to talk about their intimate issues. The aim of this narrative review is to briefly summarize the evidence emerging from literature and to provide a wide point of view about sexual dysfunction in COPD men.

Physical Frailty in COPD Patients with Chronic Respiratory Failure

Background

The prevalence of physical frailty and its clinical characteristics in advanced chronic obstructive pulmonary disease (COPD) is unknown, as well as the usefulness of functional capacity tests to screen for physical frailty. The aim of the study was to evaluate the proportion and clinical portrait of COPD patients with chronic respiratory failure exhibiting physical frailty at the time of referral to home-based pulmonary rehabilitation. We also evaluate the usefulness of the short physical performance battery (SPPB) and timed-up and go (TUG) as potential screening tools for physical frailty. Finally, we evaluated the specific contribution of gait speed to the frailty Fried total score.

Methods

This was a prospective observational study in which physical frailty was defined using Fried criteria (body mass loss, exhaustion, low physical activity, slower walking and weakness). Clinical portrait was documented from daily physical activity, exercise tolerance, functional capacity, anxiety and depressive symptoms, health-related quality of life, and fatigue scores. The ability of the SPPB and TUG to predict physical frailty was investigated using receiver operating characteristic curves. Contribution of each Fried criteria was evaluated with a principal component analysis (PCA).

Results

Amongst the 44 included participants (FEV₁, 33 ± 13% of predicted), 19 were physically frail. Frail individuals had lower daily steps number, exercise tolerance and functional capacity, and higher fatigue, anxiety, and depressive symptom scores (p<0.05) compared to non-frail individuals. SPPB and TUG did not have an acceptable detection accuracy for screening physical frailty. PCA indicated that gait speed was the main contributor to the Fried total score of physical frailty.

Conclusion

Physical frailty affects a large proportion of COPD patients with chronic respiratory failure starting a home-based intervention and was associated with worse clinical status. Although the present results need to be confirmed by adequately powered studies, gait speed seems to have the potential to become a simple screening tool for physical frailty in this population.

Higher prescription of antidepressants and/or anxiolytics among chronic obstructive pulmonary disease patients

Background:

Chronic obstructive pulmonary disease (COPD) is often accompanied by psychiatric problems, such as depression and anxiety, affecting both treatment outcomes and mortality. Evidence for the number of COPD patients using medication for these disorders is sparse. In this study, chronic antidepressant (ATD) and anxiolytic (ANX) drug use – to identify depression and anxiety – among COPD patients was compared with subjects with or without other chronic diseases.

Methods:

The NControl database containing prescription data of 800 pharmacies including 7 million individuals in The Netherlands was used. Patients of age 55+ years who received frequent prescriptions – at least two/year in 5 out of 6 years – for COPD medication, dermatological drugs, disease-modifying antirheumatic drugs (DMARDs), statins and oral glucose-lowering medication were analyzed for concomitant chronic use of ATDs and ANXs between 1 January 2013 and 1 January 2019. All other subjects aged 55+ years were included as a control group (control group 1). This group was further stratified into a group of subjects that received frequent prescriptions of any kind (control group 2).

Results:

15.2% of the patients that receive COPD treatment (n = 96,319), 15.3% of subjects that are treated for dermatological problems (n = 62,865), 13.2% of subjects that receive DMARDs (n = 7900), 11.6% of statins users (n = 422,376) and 11.4% of oral glucose-lowering medication users (n = 165,975) are also chronically treated for depression or anxiety, compared with 2.6% (control group 1; n = 3,290,608) and 11.4% (control group 2; n = 757,947). In general, female and 75+ years aged subjects showed a higher risk for using ATDs and ANXs chronically. In the COPD and the dermatological patient group the risk was the highest compared with the other patient groups.

Conclusions:

The rates of chronic ATD and ANX use and the risk of having depression and/or anxiety are especially high in COPD patients, indicating that psychiatric problems are more common in COPD than in most other chronic diseases. In general, age and gender strongly influence the risk of chronically using ATDs and ANXs.

The reviews of this paper are available via the supplemental material section.

Profiling of Patients with COPD for Adequate Referral to Exercise-Based Care: The Dutch Model

A loss of physical functioning (i.e., a low physical capacity and/or a low physical activity) is a common feature in patients with chronic obstructive pulmonary disease (COPD). To date, the primary care physiotherapy and specialized pulmonary rehabilitation are clearly underused, and limited to patients with a moderate to very severe degree of airflow limitation (GOLD stage 2 or higher). However, improved referral rates are a necessity to lower the burden for patients with COPD and for society. Therefore, a multidisciplinary group of healthcare professionals and scientists proposes a new model for referral of patients with COPD to the right type of exercise-based care, irrespective of the degree of airflow limitation. Indeed, disease instability (recent hospitalization, yes/no), the burden of disease (no/low, mild/moderate or high), physical capacity (low or preserved) and physical activity (low or preserved) need to be used to allocate patients to one of the six distinct patient profiles. Patients with profile 1 or 2 will not be referred for physiotherapy; patients with profiles 3-5 will be referred for primary care physiotherapy; and patients with profile 6 will be referred for screening for specialized pulmonary rehabilitation. The proposed Dutch model has the intention to get the right patient with COPD allocated to the right type of exercise-based care and at the right moment.

Symptom-based clusters in patients with advanced chronic organ failure identify different trajectories of symptom variations

BACKGROUND

Healthcare needs are complex and heterogeneous in advanced chronic organ failure. However, based on symptom clusters, groups of patients with similar quality of life, care dependency and life-sustaining treatment preferences can be identified.

AIMS

To evaluate the stability of symptom-based clusters over time, and whether and to what extent the clusters are able to predict patients' 2-year survival and hospitalization rates.

METHODS

This is a secondary analysis of a longitudinal observational study including 95 outpatients with chronic obstructive pulmonary disease (COPD) GOLD stage III-IV, 80 outpatients with chronic heart failure (CHF) NYHA stage III-IV and 80 outpatients with chronic renal failure (CRF) requiring dialysis. Patients were clustered into three groups applying K-means algorithm on baseline symptoms' severity and were then longitudinally evaluated. 2-year survival and hospital admissions during 1 year were estimated using Kaplan-Meier curves and Cox models. 1-year tendencies in symptom variation, using mixed linear models, and clusters comparison over time were performed.

RESULTS

The three clusters were unable to predict patients' survival and hospital admissions. Noteworthy, they show different trajectories of symptom variation, with Cluster 1 patients experiencing a worsening of symptoms, associated with an increased care dependency, and Cluster 2 and Cluster 3 patients being stable or having a relief in some symptoms. Although Cluster 1 is becoming more similar to Cluster 2, the three clusters preserve the overall characteristics and differences.

DISCUSSION

Symptom-based clusters might help to identify patients with different trajectories of symptom variations.

CONCLUSION

Symptom clusters do not predict survival and hospital admissions and are stable over time.

Palliative Care Needs and Integration of Palliative Care Support in COPD: A Qualitative Study

BACKGROUND

The provision of palliative care for severe COPD remains low, resulting in unmet needs in patients and carers.

RESEARCH QUESTIONS

What are the palliative care needs of patients living with severe COPD and their caregivers? What views of accessing and providing palliative care and factors influence these experiences. To what extent have palliative care and COPD services been integrated?

STUDY DESIGN AND METHODS

A multicentre qualitative study was undertaken in COPD services and specialist palliative care in the United Kingdom involving patients with severe COPD, their carers, and health professionals. Data were collected using semistructured interviews and were analyzed using framework analysis. Themes were integrated using the constant comparison process, enabling systematic data synthesis.

RESULTS

Four themes were generated from interviews with 20 patients, six carers, and 25 health professionals: management of exacerbations, palliative care needs, access to palliative care and pathways, and integration of palliative care support. Uncertainty and fear were common in patients and carers, with identified needs for reassurance, rapid medical access, home care, and finance advice. Timely palliative care was perceived as important by health professionals. Palliative care was integrated into COPD services, although models of working varied across regions. Reliable screening tools and needs assessment, embedded psychological care, and enhanced training in palliative care and communication skills were perceived to be important by health professionals for timely palliative care referrals and optimized management.

INTERPRETATION

Palliative care increasingly is being implemented for nonmalignant diseases including COPD throughout the United Kingdom, although models of working vary. A theoretical model was developed to illustrate the concept and pathway of the integration of palliative care support. A standardized screening and needs assessment tool is required to improve timely palliative care and to address the significant needs of this population.

Effects of the Health Belief Model-Based Intervention on Anxiety, Depression, and Quality of Life in Chronic Obstructive Pulmonary Disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition. COPD causes a heavy burden on the patients through negative impacts on the quality of life and psychological health. The health belief model (HBM) is proposed and modified by several social psychologists and is confirmed to have benefits in the recovery of various diseases. This research aimed to explore the effects of the HBM-based intervention on anxiety, depression, and quality of life in COPD patients entering pulmonary rehabilitation (PR).

METHODS

This research was conducted at the Tianjin Rehabilitation Recuperate Center of Chinese PLA in 2019. A total of 136 COPD patients were randomized into the intervention group and the control group. In the control group, patients received the PR program. In the intervention group, patients received both PR program and the HBM-based intervention. Quality of life was measured by the COPD assessment test. The outcomes of anxiety and depression were measured by the Hospital Anxiety and Depression Scale.

RESULTS

The HBM-based intervention decreased both anxiety and depression scores among COPD patients. The COPD assessment test score was declined by the HBM-based intervention, which also decreased the serum levels of interleukin-6 and C-reactive protein in COPD patients entering PR.

CONCLUSION

The HBM-based intervention alleviates anxiety and depression, enhances quality of life, and inhibits inflammation in COPD patients entering PR.

Self-efficacy Predicts Success in an Exercise Training-Only Model of Pulmonary Rehabilitation for People With COPD

PURPOSE

To determine whether people with chronic obstructive pulmonary disease (COPD) have characteristics that predict a clinically meaningful response to pulmonary rehabilitation (PR) that includes an education component compared with exercise training alone.

METHODS

Participants were classified as responders or nonresponders to 2 models of PR; exercise training and education (ET + ED, n = 113) or exercise training alone (ET, n = 85). Responders were defined as those who achieved a clinically meaningful change in 6-min walk distance (6MWD) or any of the 4 domains of the Chronic Respiratory Questionnaire (CRQ). Baseline characteristics were compared between responders and nonresponders. The associations between baseline data and change in 6MWD and CRQ following PR were examined, and a binary logistic regression analysis was conducted for each model and primary outcome.

RESULTS

There were no significant differences between the PR models in proportion of responders (ET + ED 92% vs ET 93%). Lower baseline CRQ scores predicted response in respective CRQ domains for fatigue, emotion, and mastery in the ET + ED group, and for dyspnea, fatigue, and mastery in the ET group. Higher baseline self-efficacy predicted 6MWD response and higher socioeconomic status predicted response in CRQ fatigue in the ET model only. There was no predictor of 6MWD response in the ET + ED group.

CONCLUSIONS

Baseline characteristics did not reliably predict a clinically meaningful response to PR that included education. For exercise training alone, higher self-efficacy was a significant predictor for greater improvements in 6MWD, suggesting that those with higher confidence should be considered for this model.

Psychoactive medications in chronic obstructive pulmonary disease patients: From prevalence to effects on motor command and strength

INTRODUCTION

In chronic-obstructive pulmonary disease (COPD) patients, the peripheral muscle weakness is partly due to reduced motor command. The psychoactive medications, which are often prescribed in COPD, are mainly inhibitory and thus may contribute to motor command reduction. The aims were to characterize and quantify the use of these drugs and determine their effects on cortical excitability and inhibition and thus on motor command and muscle weakness in these patients.

METHODS

First, a prevalence study was conducted on 421 COPD patients. Second, cortical excitability, inhibition and voluntary activation were assessed in 40 patients (15 under psychoactive medications vs. 25 controls) by transcranial magnetic stimulation of the rectus femoris. Quadriceps maximal isometric strength was also assessed.

RESULTS

About 48% of the patients were taking psychoactive medication. Benzodiazepines (21%) and antidepressants (13.5%) were the most prescribed. Patients with medications tended to be younger and isolated (p < 0.05). They also showed impaired cortical inhibition and decreased cortical excitability (+36%, p = 0.02). Voluntary activation was reduced (-3.6%, p = 0.04) but quadriceps strength was comparable between groups.

CONCLUSIONS

Psychoactive medications are prevalent in COPD patients. Patients under these medications exhibited brain impairment and reduced motor command. Paradoxically, voluntary strength was unaltered.

Pulmonary Rehabilitation and Exercise Training in Chronic Obstructive Pulmonary Disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a common condition that is becoming increasingly prevalent. It affects 13.2% of the population over age 40 in Germany. In 2020, it will be the third most common cause of morbidity and mortality around the world. It markedly impairs the quality of life of those who suffer from it and presents a major economic challenge to the health-care system.

METHODS

This review is based on pertinent publications retrieved by a selective literature search and on the authors' clinical experience.

RESULTS

Pulmonary rehabilitation (PR) for patients with COPD is supported by evidence on the highest level. It is associated with statistically significant (p <0.001) and clinically relevant improvement in physical performance (6-minute walk distance: + 44 m; 95% confidence interval [33; 55]), shortness of breath (Chronic Respiratory Disease Questionnaire: +0.79 points [0.56; 1.03]), and the quality of life (Saint George´s Respiratory Questionnaire: -6.9 points [-9.3; -4.5]). The benefits of PR are especially evident after an acute exacerbation of COPD: it significantly lowers the rate of readmission to the hospital (odds ratio 0.22 [0.08; 0.58], p = 0.002) and improves physical performance ability (6-minute walk distance: + 62 m [38; 86] and the quality of life (Saint George´s Respiratory Questionnaire: -7.8 points [-12.1; -3.5]; p <0.001 for both).

CONCLUSION

PR is an effective and cost-effective therapeutic intervention that improves physical performance ability, shortness of breath, and the quality of life in patients with COPD, but it has not yet been fully implemented as recommended in the relevant guidelines. There is a need for targeted, problem-oriented referral to a range of PR programs with problem-specific content. The necessary outpatient PR structures still need to be established in Germany.

Glucocorticoid receptor dysfunction orchestrates inflammasome effects on chronic obstructive pulmonary disease-induced depression: A potential mechanism underlying the cross talk between lung and brain

Depression is highly prevalent among patients with chronic obstructive pulmonary disease (COPD). However, depression with COPD comorbidity is often underdiagnosed and undertreated, and pathogenic research is also insufficient. In the present study, we characterised pulmonary and hippocampal dysfunction by researching the interaction between inflammasome-regulated cytokines and glucocorticoid receptor (GR) signalling by investigating the role of fluoxetine (FLU), one of the most widely used antidepressants in clinical practice. Mice were exposed to cigarette smoke (CS) to induce the model of COPD with comorbid depression, and pathological alterations in serum, hippocampus, lung, and bronchoalveolar lavage fluid were determined. Our results showed that the CS procedure induced the accumulation of inflammatory cells (macrophages, neutrophils, and lymphocytes), the production of cytokines, the activation of inflammasome components (NLRP3, ASC, caspase-1), depression-related behaviours, and the stimulation of GR signalling. Intriguingly, glucocorticoid resistance occurred in CS-exposed mice, with elevated serum corticosterone and suppressed hippocampal GR levels, which suggested a novel potential regulatory mechanism underlying COPD-induced depression comorbidity. Furthermore, chronic CS exposure decreased the pGR-S211/pGR-S226 ratio, increased the active nuclear GR, and impaired cytosolic GR binding capacity and GR transcriptional activity, which might be responsible for the activation of the inflammasome-induced inflammatory cascade. These alterations were reversed by chronic FLU treatment, indicating that FLU-mediated GR signalling was involved in the COPD induced inflammasome activation. Our research explored the underlying molecular mechanism of comorbid COPD/depression and provided in vivo evidence that glucocorticoid resistance occurred during CS-induced central nervous system inflammation, a potential mechanism underlying the cross talk between the lung and brain.

Association between chronic obstructive pulmonary disease and risk of erectile dysfunction: a systematic review and meta-analysis

Chronic obstructive pulmonary disease (COPD) is a common chronic disease. Mounting evidence shows that male patients with COPD have an increased risk of developing erectile dysfunction (ED). The aim of this meta-analysis was to assess the relationship between COPD and the risk of ED. To identify relevant studies, the PubMed, Cochrane Library and Embase databases, Chinese Biomedical Literature (CBM), China National Knowledge Infrastructure (CNKI) were systematically searched up to September 2018. Relative risks (RR) and corresponding 95% confidence intervals (CI) were used to estimate the strength of association between COPD and the risk of ED by using random-effects models. Finally, four studies (three cross-sectional, one cohort study) involving 58,307 participants were included. Synthesis results demonstrated that patients with COPD was not significantly associated with an increased overall prevalence of ED (RR = 1.31, 95% CI: 0.95-1.81, P = 0.099) compared to the healthy controls. However, the subgroup analyses showed that the prevalence of moderate ED (RR = 2.44, 95% CI: 1.29-4.59, P = 0.006) and severe ED (RR = 2.77, 95% CI: 1.57-4.94, P = 0.001) were significantly higher in patients with COPD. Evidence from this meta-analysis revealed that patients with COPD had a significantly increased susceptibility to moderate and severe ED, which should remind both clinicians and patients to be aware of the potential hazardous effect of COPD for developing ED.

Implementation of a depression screening protocol among respiratory insufficiency patients

INTRODUCTION

Unnoticed and untreated depression is prevalent among patients with chronic respiratory insufficiency. Comorbid depression causes suffering and worsens patients' outcomes.

OBJECTIVES

The objective of this evaluation was to assess preliminary outcomes of a depression screening protocol among chronic respiratory insufficiency patients at a tertiary care pulmonary outpatient clinic.

METHODS

In the depression screening protocol, the patients filled the Depression Scale (DEPS) questionnaire. Patients whose scores suggested depression were offered the opportunity of a further evaluation of mood at a psychiatric outpatient clinic. The outcomes of the protocol were evaluated retrospectively from the patient records.

RESULTS

During the period of evaluation, 238 patients visited the outpatient clinic. DEPS was administered to 176 patients (74%), of whom 60 (34%) scored ≥9 (out of 30), thus exceeding the cut-off for referral. However, only 13 patients were referred, as the remainder declined the referral. Finally, seven patients were evaluated at the psychiatric clinic, and they all were deemed depressive. Symptoms of depression were most prevalent among patients with a long smoking history, refractory dyspnoea and a history of depression.

CONCLUSION

Depression screening was positive in a third of the patients. The depression screening protocol improved the detection of depression symptoms, but the effects on the patients' treatment and clinical course were small. Rather than referring patients to a psychiatric unit, the evaluation and management of depression should be undertaken at the pulmonary unit.

Ontology-Based Model to Support Ubiquitous Healthcare Systems for COPD Patients

Over the past 30 years, information technology has gradually transformed the way health care is provisioned for patients. Chronic Obstructive Pulmonary Disease (COPD) is an incurable malady that threatens the lives of millions around the world. The huge amount of medical information in terms of complex interdependence between progression of health problems and various other factors makes the representation of data more challenging. This study investigated how formal semantic standards could be used for building an ontology knowledge repository to provide ubiquitous healthcare and medical recommendations for COPD patient to reduce preventable harm. The novel contribution of the suggested framework resides in the patient-centered monitoring approach, as we work to create dynamic adaptive protection services according to the current context of patient. This work executes a sequential modular approach consisting of patient, disease, location, devices, activities, environment and services to deliver personalized real-time medical care for COPD patients. The main benefits of this project are: (1) adhering to dynamic safe boundaries for the vital signs, which may vary depending on multiple factors; (2) assessing environmental risk factors; and (3) evaluating the patient’s daily activities through scheduled events to avoid potentially dangerous situations. This solution implements an interrelated set of ontologies with a logical base of Semantic Web Rule Language (SWRL) rules derived from the medical guidelines and expert pneumologists to handle all contextual situations.

Pulmonary Rehabilitation Reduces Emergency Admission and Hospitalization Rates of Patients with Chronic Respiratory Diseases

OBJECTIVES

Chronic respiratory diseases exert a global health burden with high health care costs, morbidity, and mortality. The aim of the present study was to investigate the effect of pulmonary rehabilitation (PR) on emergency admission and hospitalization rates of patients with chronic respiratory disease.

MATERIALS AND METHODS

In this retrospective cohort study, hospitalization rates and emergency admissions of patients before (December 2014-December 2015) and after PR (January 2015-December 2016) were investigated. Patients with chronic respiratory diseases were included. Chronic obstructive pulmonary disease (COPD) patients were classified based on the Global Initiative Chronic Obstructive Pulmonary Disease assessment scheme. PR was applied by three physiotherapists over 8 weeks (2 days/week). Data on patient demographics, clinical and anthropometric data, spirometry, exercise capacity, and quality of life before and after PR were acquired.

RESULTS

This study evaluated 51 patients, of whom 76% were men. A total of 37 (73%) COPD patients and 14 (27%) non-COPD patients (7 bronchiectasis, 4 interstitial lung disease, and 3 kyphoscoliosis) were included. The patients exhibited significantly improved incremental shuttle walk test (ISWT) and endurance test scores (p<0.05) after PR. Similar to exercise capacity, the patients exhibited significantly improved Modified Medical Research Council (mMRC) score, St. George's Respiratory Questionnaire (SGRQ), anxiety and depression scores (p<0.05) after PR. In COPD patients, differences in pre- and post-PR ISWT, COPD assessment test, mMRC, and SGRQ scores were statistically significant (p=0.001). The number of emergency admissions and hospitalizations significantly decreased after PR (p=0.001; p=0.001). The post-PR FEV₁% of COPD significantly increased (p=0.029).

CONCLUSION

Pulmonary rehabilitation leads to an increase in exercise capacity as well as improved quality of life, resulting in a decrease in emergency admissions and hospitalization rates. Considering the cost of hospitalization, it is important to add PR to the management of patients with chronic respiratory diseases, in addition to medical therapy.

The respiratory physiome: Clustering based on a comprehensive lung function assessment in patients with COPD

Background

While spirometry and particularly airflow limitation is still considered as an important tool in therapeutic decision making, it poorly reflects the heterogeneity of respiratory impairment in chronic obstructive pulmonary disease (COPD). The aims of this study were to identify pathophysiological clusters in COPD based on an integrated set of standard lung function attributes and to investigate whether these clusters can predict patient-related outcomes and differ in clinical characteristics.

Methods

Clinically stable COPD patients referred for pulmonary rehabilitation underwent an integrated assessment including clinical characteristics, dyspnea score, exercise performance, mood and health status, and lung function measurements (post-bronchodilator spirometry, body plethysmography, diffusing capacity, mouth pressures and arterial blood gases). Self-organizing maps were used to generate lung function based clusters.

Results

Clustering of lung function attributes of 518 patients with mild to very severe COPD identified seven different lung function clusters. Cluster 1 includes patients with better lung function attributes compared to the other clusters. Airflow limitation is attenuated in clusters 1 to 4 but more pronounced in clusters 5 to 7. Static hyperinflation is more dominant in clusters 5 to 7. A different pattern occurs for carbon monoxide diffusing capacity, mouth pressures and for arterial blood gases. Related to the different lung function profiles, clusters 1 and 4 demonstrate the best functional performance and health status while this is worst for clusters 6 and 7. All clusters show differences in dyspnea score, proportion of men/women, age, number of exacerbations and hospitalizations, proportion of patients using long-term oxygen and number of comorbidities.

Conclusion

Based on an integrated assessment of lung function variables, seven pathophysiological clusters can be identified in COPD patients. These clusters poorly predict functional performance and health status.

Test Performance Characteristics of the AIR, GAD-7, and HADS-Anxiety Screening Questionnaires for Anxiety in Chronic Obstructive Pulmonary Disease

Rationale: Anxiety is a common comorbidity of chronic obstructive pulmonary disease (COPD) that is associated with higher morbidity and mortality. We evaluated three anxiety screening questionnaires: the Generalized Anxiety Disorder 7-Item Scale (GAD-7), the Hospital Anxiety and Depression Scale Anxiety subscale (HADS-A), and the Anxiety Inventory for Respiratory Disease (AIR).Objectives: To evaluate and compare the test performance characteristics of three anxiety screening questionnaires, using the Mini-International Neuropsychiatric Interview (MINI), version 7.0, as the "gold standard."Methods: Individuals with COPD were recruited at 16 centers. The MINI and questionnaires were administered by trained research coordinators at an in-person visit and readministered by telephone 2-4 weeks later. A composite score for the presence of any Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) anxiety disorder was computed, based on the MINI as the gold standard, compared with a participant screening positive on self-report measures for these analyses.Results: Two hundred and twenty eligible individuals with COPD were enrolled; 219 completed the study. Eleven percent were identified as having a DSM-V anxiety disorder, based on the MINI. Elevated anxiety symptoms based on questionnaires were 38% for the AIR, 30% for the GAD-7, and 20% for the HADS-A. Area under the receiver operating characteristic curve (AUC) was highest for the GAD-7 (0.78; 95% confidence interval [CI], 0.69-0.87), followed by the HADS-A (0.74; 95% CI, 0.64-0.84) and the AIR (0.66; 95% CI, 0.56-0.76). The AUC for the GAD-7 was significantly greater than for the AIR (P = 0.014). Sensitivity was not statistically different among the questionnaires: 77% for the GAD-7, 63% for the HADS-A, and 66% for the AIR. The HADS-A had the highest specificity, 85%, which was significantly higher than that of the GAD-7 (77%; P < 0.001) and the AIR (65%; P < 0.001); GAD-7 specificity was higher than AIR specificity (P < 0.001).Conclusions: Symptoms of anxiety among patients with COPD as identified by screening questionnaires were common and significantly higher than the prevalence of anxiety disorder meeting DSM-V criteria. The GAD-7, the HADS-A and the AIR questionnaires had fair to moderate psychometric properties as screening tools for anxiety in individuals with COPD, indicating the need for improved measures for this patient population.

Assessment of depression before and after inpatient rehabilitation in COPD patients: Psychometric properties of the German version of the Patient Health Questionnaire (PHQ-9/PHQ-2)

BACKGROUND

Depression is a frequent comorbidity of COPD and leads to worse clinical COPD-outcomes. PHQ-9 and PHQ-2 are two widely used brief instruments to assess depression. However, psychometric properties in COPD patients are unknown. This study examines factorial validity, measurement invariance and composite reliability (CR) of PHQ-9/PHQ-2, respectively, and concordance between both tools.

METHODS

This is a secondary analysis of N = 561 COPD patients who filled out the PHQ-9 at the begin (T0), the end (T1) and 3/6/9/12 (T2/T3/T4/T5) months after pulmonary inpatient rehabilitation. Structural equation modeling was used to examine factorial validity and measurement invariance between gender, GOLD disease severity groups and over time. Concordance was assessed using Cohen's Kappa, Yules Y, positive and negative agreement.

RESULTS

A one-factor model (with one freed residual covariance) showed best model fit. At least partial scalar invariance could be established. Concordance between both instruments was substantial. 31.7% (26.2%) COPD patients showed clinically relevant depression according to PHQ-9 (PHQ-2) at T0. At T0-T2, PHQ-9 classified more patients as depressed than did PHQ-2. According to both measures, depression rates declined after rehabilitation. Reliability was high for both PHQ-9 (CR = 0.94) and PHQ-2 (CR = 0.89).

LIMITATIONS

No gold-standard (clinical interview) to assess depression was used. Therefore, diagnostic accuracy for PHQ-9/PHQ-2 remains unclear.

CONCLUSIONS

PHQ-9 and PHQ-2 fulfill important psychometric criteria (factorial validity, invariance, reliability) for measuring depression in COPD. The results support their use in clinical practice to assess severity of depression. Diagnostic accuracy to identify major/minor depression of both instruments should be examined in future studies.

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.

Need of support in people with chronic obstructive pulmonary disease

AIM AND OBJECTIVE

The aim of this study was to describe peoples' experiences and expectations of support when living with chronic obstructive pulmonary disease.

METHOD

We conducted and analysed face-to-face or telephone interviews with 17 individuals (aged 44-77 years) diagnosed with chronic obstructive pulmonary disease. The interviewer asked open-ended questions aimed at encouraging further narration, and we analysed the participants' narratives using a phenomenological hermeneutical approach. This report adheres to the COREQ guidelines.

RESULTS

The overall theme suggests that people with chronic obstructive pulmonary disease describe support as shared knowledge and experiences, based on the following subthemes; similar experiences, the need of genuine professional knowledge, self-reliance versus self-blame, and the Internet - feeling safe but uncertain.

CONCLUSIONS

People with chronic obstructive pulmonary disease find their strength through shared knowledge and dialogical support with others who have similar experiences and with professionals. A person-centred eHealth approach may be suitable for this group as it offers both collaboration and support.

RELEVANCE TO CLINICAL PRACTICE

There is a demand for access to genuine professional knowledge as additional support to patients' own capabilities and needs. Patient associations were assessed as reliable sources of information and to some extent also support, but the importance of access to professional sources was also stressed.

Chronic respiratory disease and high altitude are associated with depressive symptoms in four diverse settings

SETTING

Depression is a prevalent comorbidity of chronic respiratory disease (CRD), and may indicate worse clinical outcomes. The relationship between depression and living with chronic hypoxia due to CRD or residence at altitude has received little attention in resource-poor settings.

OBJECTIVE

To investigate the association between CRD conditions and depressive symptoms in four settings in Peru.

DESIGN

We collected data on CRD and depressive symptoms in adults aged ⩾35 years. Depressive symptoms were measured according to the Center for Epidemiologic Studies Depression scale. Multivariable ordinal logistic regression was used to assess the adjusted odds of being in a higher category of depressive symptoms as a function of CRD.

RESULTS

We analyzed data from 2953 participants (mean age 55.3 years, 49% male). The prevalence of major depressive symptoms was 19%, with significant variation according to setting. Participants with at least one CRD (OR 1.34, 95%CI 1.06-1.69) and those living at altitude (OR 1.64, 95%CI 1.10-2.43) had an increased adjusted odds of being in a higher category of depressive symptoms.

CONCLUSION

We found a high prevalence of depressive symptoms, and a positive association between depressive symptoms with CRD and with living at altitude, both of which cause chronic hypoxia.

Mindfulness-based cognitive therapy in COPD: a cluster randomised controlled trial

A considerable proportion of patients with chronic obstructive pulmonary disease (COPD) entering pulmonary rehabilitation (PR) report psychological distress, which is often accompanied by poor physical health status. Mindfulness-based cognitive therapy (MBCT) has been shown to improve psychological and physical outcomes in other chronic diseases. We therefore evaluated the efficacy of MBCT as an add-on to a standard PR programme in COPD.

COPD patients eligible for PR were cluster randomised to receive either an 8-week, group-based MBCT programme as an add-on to an 8-week PR programme (n=39), or PR alone (n=45). The primary outcomes of psychological distress and physical health status impairment were measured with the Hospital Anxiety and Depression Scale (HADS) and the COPD Assessment Test (CAT) before randomisation (T1), mid- (T2) and post-intervention (T3), and at 3 (T4) and 6 (T5) months’ follow-up .

A statistically significant time×arm effect was found for the HADS (Cohen'sd=0.62, 95% CIs (d)=0.18–1.06, p=0.010). The treatment effect on the CAT failed to reach statistical significance (d=0.42, 95% CIs (d)=−0.06–0.90, p=0.061).

MBCT showed a statistically significant and durable effect on psychological distress, indicating that MBCT may be an efficacious add-on to standard PR programmes in COPD.

Decision Making Concepts for the Remote, Personalized Evaluation of COPD Patients’ Health Status

Introduction: This article is part of the Focus Theme of Methods of Information in Medicine on “Biosignal Interpretation: Advanced Methods for Neural Signals and Images”.

Objectives: This paper presents the main concepts of a decision making approach for the remote management of COPD patients based on the early detection of disease exacerbation episodes.

Methods: An e-diary card is defined to evaluate a number of physiological variables and clinical parameters acquired remotely by means of wearable and environmental sensors deployed in patients’ long-stay settings. The automatic evaluation of the card results in a so-called Chronic Status Index (CSI) whose computation is tailored to patients’ specific manifestation of the disease (i.e., patient’s phenotype). The decision support method relies on a parameterized analysis of CSI variations so as to early detect worsening changes, identify exacerbation severity and track the patterns of recovery.

Results: A preliminary study, carried out in real settings with 30 COPD patients monitored at home, has shown the validity and sensitivity of the method proposed, which was effectively able to timely and correctly identify patients’ critical situation.

Conclusion: The preliminary results showed that the proposed e-diary card, which presents several novel features with respect to other solutions presented in the literature, can be practically used to remotely monitor COPD patients.

Association of comorbid anxiety and depression with chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a disease with known systemic manifestations including psychiatric comorbidities most commonly being depression and/or anxiety. Studies regarding the association of these psychiatric comorbidities in terms of symptom scores, spirometric variables, and hospitalizations among patients of COPD are lacking, especially in India.

MATERIALS AND METHODS

One hundred and twenty-eight patients of COPD attending the Outpatient Department of AIIMS Rishikesh, and fulfilling inclusion criteria were screened by Hospital Anxiety and Depression Scale, and those who scored above the cutoff underwent psychiatric evaluation using the International Classification of Diseases, Tenth Edition Diagnostic Criteria for Research for confirmation of their diagnosis. All patients were then evaluated by physician-administered questionnaire for symptom scores by Modified Medical Research Council Scale (mMRC) for dyspnea, Hindi-validated Clinical COPD Questionnaire (CCQ), and for functional capacity by 6-min walk distance (6MWD) according to the American Thoracic Society Guidelines. All patients also underwent spirometric evaluation, and postbronchodilator forced expiratory volume in 1 s (FEV1), BODE index (body mass index [BMI], postbronchodilator FEV1, mMRC for dyspnea, 6MWD) and a history of hospitalization/exacerbations over the past 1 year was also obtained. Comparison of symptom scores, functional capacity in terms of 6MWD, history of exacerbations or hospitalizations over preceding 1 year and BODE index between patients of COPD with or without anxiety and/or depression was done.

RESULTS

COPD patients with comorbid anxiety and/or depression had higher dyspnea scores and CCQ scores though the proportion of current smokers, BMI, history of hospitalization over the past 1 year, FEV1, and BODE index was not statistically significant between the two groups.

CONCLUSIONS

Depression is a common comorbidity and leads to higher symptom scores as well as poorer quality of life among COPD patients.

Affective symptoms in patients with oropharyngeal dysphagia: A systematic review

OBJECTIVE

Affective disorders are prevalent in different somatic conditions and influence somatic symptom bother and quality of life. Mood and anxiety disorders impact patients' compliance and adherence to treatment. This systematic review summarizes published studies on affective complaints in patients with oropharyngeal dysphagia (OD) in order to determine the quality of studies concerning any association of OD with symptoms of depression and/or anxiety.

METHODS

A literature search was carried out using electronic databases Embase, Medline, Web-of-science, PsycINFO, Cochrane Library, and Google scholar. Two reviewers made the preselecting cut by screening all articles on title and abstract and independently screened the full texts of this initial set of articles. Methodological quality of the studies that met the inclusion criteria was assessed independently.

RESULTS

Twenty-six articles were included in the analysis after full-text screening and by applying the inclusion and exclusion criteria. All studies concluded that symptoms of depression were associated with impaired swallowing function, and 9 out of 12 studies concluded that symptoms of anxiety were associated with functional impairment of swallowing. The reviewers found heterogeneous outcomes and methodological limitations, which prevented data from pooling.

CONCLUSION

Although no meta-analytic conclusions can be drawn, it appears that symptoms of anxiety and depression are common in OD. Caregivers have to be aware of this in order to detect affective comorbidity. Given that affective conditions influence patients' treatment adherence and compliance, integrated care approaches should be advocated in case of comorbidity. Studies on treatment effect are lacking and well-designed prospective research is needed.

Screening tools for evaluation of depression in Chronic Obstructive Pulmonary Disease (COPD). A systematic review

Background: Anxiety and depression are common comorbid disorders in patients with chronic obstructive pulmonary disease (COPD), though estimates of their prevalence vary considerably. Depressive symptoms/depression are important comorbidities in COPD and an increasing interest is shown to these disorders. Depression may lead to reduced quality of life and increased morbidity and mortality. These statements underline the importance of implementing the use of screening instruments for depressive symptoms in a clinical setting. This systematic review evaluates four commonly used screening tools for depression in COPD. Furthermore we assess the prevalence of depression in COPD in the evaluated studies. Design: A literature search identified studies dealing with screening for depression in patients with COPD. We focused on the instruments: Beck Depression Inventory, Geriatric depression scale, Centre for Epidemiological Studies scale on Depression and Hospital and Anxiety Depression Scale. Results: Overall prevalence of depression was 30%. Demographic variations and severity of COPD influenced prevalence. The inter-prevalence of the four screening tools was consistent. We found a low variation between studies using the same tool. Few studies used control groups or compared the screening tool to a psychiatrist evaluation. Conclusions: This article calls for further investigation of the association between COPD and depressive symptoms. The subject is highly relevant for everyday life of patients with COPD and attention needs to be drawn to this issue in both an out- and in-patients.

Prevalence of depression and anxiety in patients with chronic digestive system diseases: A multicenter epidemiological study

AIM

To investigate the prevalence of depression and anxiety in patients with chronic digestive system diseases.

METHODS

A total of 1736 patients with chronic digestive system diseases were included in this cross-sectional study, including 871 outpatients and 865 in-patients. A self-designed General Information for Patients of the Department of Gastroenterology of General Hospitals questionnaire was used to collect each patient’s general information, which included demographic data (including age, sex, marital status, and education) and disease characteristics (including major diseases, disease duration, principal symptoms, chronic pain, sleep disorder, and limited daily activities).

RESULTS

The overall detection rate was 31.11% (540/1736) for depression symptoms alone, 27.02% (469/1736) for anxiety symptoms alone, 20.68% (359/1736) for both depression and anxiety symptoms, and 37.44% (650/1736) for either depression or anxiety symptoms. Subjects aged 70 years or above had the highest detection rate of depression (44.06%) and anxiety symptoms (33.33%). χ² trend test showed: the higher the body mass index (BMI), the lower the detection rate of depression and anxiety symptoms (χ²_trend = 13.697, P < 0.001; χ²_trend = 9.082, P = 0.003); the more severe the limited daily activities, the higher the detection rate of depression and anxiety symptoms (χ²_trend = 130.455, P < 0.001, χ²_trend = 108.528, P < 0.001); and the poorer the sleep quality, the higher the detection rate of depression and anxiety symptoms (χ²_trend = 85.759, P < 0.001; χ²_trend = 51.969, P < 0.001). Patients with digestive system tumors had the highest detection rate of depression (57.55%) and anxiety (55.19%), followed by patients with liver cirrhosis (41.35% and 48.08%). Depression and anxiety symptoms were also high in subjects with comorbid hypertension and coronary heart disease.

CONCLUSION

Depression and anxiety occur in patients with tumors, liver cirrhosis, functional dyspepsia, and chronic viral hepatitis. Elderly, divorced/widowed, poor sleep quality, and lower BMI are associated with higher risk of depression and anxiety.

Assessment of illness acceptance by patients with COPD and the prevalence of depression and anxiety in COPD

Background

COPD is a civilization disease. It affects up to 8%–10% of population >30 years of age. Coexistence of depression occurs in 20%–40% of patients with COPD. Depression and anxiety reduce compliance and worsen prognosis.

Objective

The aims of this study were to determine the degree of illness acceptance among patients with COPD, to examine the relation between disease acceptance and perceived anxiety and depression, and to verify which of the sociodemographic and clinical factors are associated with illness acceptance, anxiety, and depression.

Materials and methods

The study included 102 patients with COPD (mean age 65.8 years), hospitalized due to exacerbations. Acceptance of Illness Scale and Hospital Anxiety and Depression Scale were used. For statistical analysis, Student’s t-test and Pearson’s r correlation coefficient were carried out.

Results

The overall illness acceptance level was moderate with a tendency toward lack of acceptance (mean 20.6, standard deviation [SD] 7.62). The overall scores were 10.2 (SD 3.32) for anxiety and 10.8 (SD 4.14) for depression, which indicate borderline or high intensity of these symptoms. Acceptance of illness was negatively correlated with the intensity of depression symptoms (r=−0.46, P<0.05). Intensity of depression was significantly associated with intensity of smoking, duration of the disease, severity of dyspnea, and living in a rural area.

Conclusion

Early identification and assessment of depression and anxiety symptoms allow health care providers to offer patients at risk of depression a special medical supervision. Rapid start of antidepressant therapy may increase illness acceptance and improve prognosis among patients with COPD.

Pulmonary Rehabilitation for Patients with Chronic Airways Obstruction

Pulmonary rehabilitation is a patient-centered and interdisciplinary intervention with major components of exercise training and self-management education. Although having no direct effect on lung function, this intervention often results in substantial improvements in respiratory symptoms, functional status, and health status. It probably also reduces subsequent health care utilization, especially when provided after a hospitalization for an exacerbation of airways disease. The beneficial effects of pulmonary rehabilitation reflect its ability to reduce the impact of systemic consequences of chronic respiratory disease and to improve patients' self-efficacy through promoting collaborative self-management. Pulmonary rehabilitation is indicated for patients with respiratory diseases (regardless of specific diagnosis) who have persistent symptoms or functional or health status limitation despite otherwise optimal medical therapy. Those patients with severe asthma (particularly those with airways remodeling) or asthma-chronic obstructive pulmonary disease overlap who have daily symptoms and substantial functional/health status limitation despite controller and bronchodilator therapy would be appropriate candidates for pulmonary rehabilitation.

Balance Training in Pulmonary Rehabilitation: EFFECTS ON PSYCHOSOCIAL OUTCOMES

PURPOSE

Balance impairment in chronic obstructive pulmonary disease (COPD) is associated with a worsening of quality of life (QOL) as related with fatigue perception, depression, and anxiety. The aim of this study was to examine the effect of balance training included in pulmonary rehabilitation (PR) on QOL, fatigue perception, depression, and anxiety in patients with COPD.

METHODS

Patients were assigned randomly to an intervention or PR-only group. The intervention group underwent balance training 3 times a week for 6 months concurrently with PR. The PR-only group received 6 months of the standard PR program. Quality of life was assessed at the beginning and at the end of the program using the St. George's Respiratory Questionnaire, fatigue using the Multidimensional Fatigue Inventory, and anxiety and depression using the Hospital Anxiety and Depression Scale. Exercise tolerance was determined from the 6-minute walk test.

RESULTS

After the 6 months of the intervention or PR-only, both the intervention (n = 32) and PR-only (n = 30) groups improved their QOL (activity, impact, and total) with a significant intergroup difference (P < .05) after PR. General fatigue, physical fatigue, and reduced activity decreased in both groups with an intergroup difference (P < .05). Anxiety decreased significantly in both groups with a greater change in the intervention group (P < .01). Only the intervention group had an improved depression score at the end of 6 months.

CONCLUSIONS

Balance training added to PR improved health-related QOL, fatigue, and mental health in patients with COPD.

Depression, body mass index, and chronic obstructive pulmonary disease - a holistic approach

Background

Several clinical studies suggest common underlying pathogenetic mechanisms of COPD and depressive/anxiety disorders. We aim to evaluate psychopathological and physical effects of aerobic exercise, proposed in the context of pulmonary rehabilitation, in a sample of COPD patients, through the correlation of some psychopathological variables and physical/pneumological parameters.

Methods

Fifty-two consecutive subjects were enrolled. At baseline, the sample was divided into two subgroups consisting of 38 depression-positive and 14 depression-negative subjects according to the Hamilton Depression Rating Scale (HAM-D). After the rehabilitation treatment, we compared psychometric and physical examinations between the two groups.

Results

The differences after the rehabilitation program in all assessed parameters demonstrated a significant improvement in psychiatric and pneumological conditions. The reduction of BMI was significantly correlated with fat mass but only in the depression-positive patients.

Conclusion

Our results suggest that pulmonary rehabilitation improves depressive and anxiety symptoms in COPD. This improvement is significantly related to the reduction of fat mass and BMI only in depressed COPD patients, in whom these parameters were related at baseline. These findings suggest that depressed COPD patients could benefit from a rehabilitation program in the context of a multidisciplinary approach.

Illness perceptions, negative emotions, and pain in patients with noncardiac chest pain

Illness-specific cognitions are associated with outcomes in numerous health conditions, however, little is known about their role in noncardiac chest pain (NCCP). NCCP is prevalent, impairing, and associated with elevated health care utilization. Our objective was to investigate the relations between illness perceptions, emotion, and pain in a sample of 196 adult patients diagnosed with NCCP. We found that negative illness perceptions were associated with greater anxiety, depression, chest pain, and pain-related life interference while controlling for the effects of demographic and pain-related variables. These results expand current NCCP theory and may inform future treatment development.