Adequate initial antidepressant treatment among patients with chronic obstructive pulmonary disease in a cohort of depressed veterans

Longer Duration of Palliative Care in Patients With COPD Is Associated With Death Outside the Hospital

BACKGROUND

Patients with advanced chronic obstructive pulmonary disease (COPD) have a significant symptom burden despite maximal medical therapy, yet few are referred for concomitant palliative care.

OBJECTIVE

To evaluate the utilization and impact of palliative care on the location of death and to identify clinical variables associated with palliative care contact.

DESIGN

Retrospective chart review from 2010 to 2016 at the VA Western New York Healthcare System using ICD-9/10 diagnosis of COPD. Palliative care contact was identified by Z51.5 or stop code 353.

RESULTS

Only 0.5% to 2% of living patients received palliative care, increasing abruptly at death (6%). Lower diffusion capacity for carbon monoxide (DLCO) (greater emphysema) was associated with palliative care contact, independent of comorbid disease burden or age. Initial outpatient contact was associated with a longer duration of palliative care (P = .003) and death in a home-like setting. Outpatient palliative care was associated with more severe airflow obstruction (forced expiratory volume in 1 second, percent predicted [FEV1%]), whereas greater disease exacerbation frequency was associated with inpatient contact. COPD patients not referred to palliative care had a greater comorbid disease burden, similar FEV1%, fewer disease exacerbations, and a greater DLCO.

CONCLUSION

Few patients with COPD received palliative care, similar to national trends. Initial outpatient palliative contact had the longest duration of care and death in the preferred home environment. The extent of emphysema (DLCO reduction) and more frequent disease exacerbations identified in patients were more likely to receive palliative care. Our study begins to define the benefits of palliative care in advanced COPD and confirms underutilization in the years before death, where a prolonged impact on the quality of life may be realized.

Chronic physical comorbidity burden and the quality of depression treatment in primary care: a systematic review

OBJECTIVE

We examined whether the treatment and follow-up care for depression in routine primary care differs between adults with higher chronic physical comorbidity burden compared to adults with lower chronic physical comorbidity burden and explored factors leading to divergent results across studies.

METHODS

We conducted a systematic review of English and French articles using Medline, Embase, PsycINFO, CINAHL and Cochrane Controlled Trials Register from inception to July 2013. Reference list and reverse citation searches were also conducted. Search terms included depression, primary care, general practitioner, chronic disease and comorbidity. Study eligibility required inclusion of relevant quality indicators and data contrasting participants with higher and lower chronic physical comorbidity burden. Study selection and quality appraisal were carried out independently by two review authors. A narrative synthesis of results was performed.

RESULTS

Our search yielded 5817 unique citations and 46 studies met inclusion criteria. Studies provided data on quality of pharmacotherapy (n=28), psychotherapy (n=4), combined measures of treatment quality (n=14), and follow-up care (n=9). Across studies, evidence that higher chronic physical comorbidity burden was associated with lower depression treatment or follow-up care quality was reported in 13 studies whereas evidence for the opposite relationship was reported in 15 studies. Four studies reported mixed results and 14 studies observed no relationships between comorbidity burden and depression treatment or follow-up care quality.

CONCLUSION

Review findings suggest that chronic physical comorbidity does not consistently lead to lower quality of depression treatment or follow-up care in primary care.

Pharmacological treatment of depression in older patients with chronic obstructive pulmonary disease: impact on the course of the disease and health outcomes

Over 40 % of older chronic obstructive pulmonary disease (COPD) patients suffer from clinically significant depressive symptoms, which may interfere with their daily activities. Untreated depression may increase physical disability, social isolation, hopelessness and healthcare utilization. This review examined the impact of depression on the course of COPD, and the efficacy of antidepressant drug therapy and its implications for clinical practice. The efficacy of antidepressants in published trials in patients with COPD has been inconclusive. Specifically, there has been no clear evidence that antidepressants can induce remission of depression or ameliorate dyspnoea or physiological indices of COPD. Both selective serotonin reuptake inhibitor (SSRI) and tricyclic antidepressant (TCA) studies conducted in depressed COPD patients have been significantly limited by methodological weaknesses including small sample size, sample heterogeneity and variability in the scales used to diagnose and monitor the treatment of depression. For this reason, it remains unclear which SSRIs or TCAs should be favoured in the treatment of depressed COPD patients and what are appropriate dosages and duration ranges. Simply offering antidepressant drugs to older depressed COPD patients is unlikely to improve their condition. Promising treatment strategies such as a collaborative treatment approach and cognitive behavioural therapy should be considered for depressed COPD patients, with or without antidepressant drug therapy. Further studies are needed, including large, randomized, controlled trials with long-term follow-up, to examine the efficacy of antidepressants in patients with COPD.

Burden of COPD in a government health care system: a retrospective observational study using data from the US Veterans Affairs population

Background

Health care utilization and costs among US veterans with chronic obstructive pulmonary disease (COPD) were compared with those in veterans without COPD.

Methods

A cohort of veterans with COPD was matched for age, sex, race, and index fiscal year to a cohort of veterans without COPD (controls) using data from the Veterans Integrated Service Network (VISN) 16 from 10/1/1997 to 9/30/2004. Annual total and respiratory-related health care service utilization, costs of care, comorbidities, and respiratory medication use at the time of diagnosis were assessed.

Results

A total of 59,906 patients with COPD were identified for a 7-year period prevalence of 8.2%, or 82 per 1000 population. Patients with COPD compared with controls had significantly higher all-cause and respiratory-related inpatient and outpatient health care utilization for every parameter examined including mean numbers of physician encounters, other outpatient encounters, emergency room visits, acute inpatient discharges, total bed days of care, and percentage of patients with any emergency room visits or any acute inpatient discharge. Patients with COPD had statistically significantly higher mean outpatient, inpatient, pharmacy, and total costs than the control group. The mean Charlson comorbidity index in patients with COPD was 1 point higher than in controls (2.85 versus 1.84, P < 0.001). 60% of COPD patients were prescribed medications recommended in treatment guidelines at diagnosis.

Conclusion

Veterans with COPD compared with those without COPD suffer a tremendous disease burden manifested by higher rates of all-cause and respiratory-related health care utilization and costs and a high prevalence of comorbidities. Furthermore, COPD patients do not receive appropriate treatment for their disease on diagnosis.

Prevalence and risk factors for depressive symptoms in persons with chronic obstructive pulmonary disease

BACKGROUND

Although depression is a risk factor for adverse outcomes in chronic illness, little is known about the prevalence or risk factors for depressive symptoms in chronic obstructive pulmonary disease (COPD).

OBJECTIVE

To determine the prevalence of depressive symptoms in COPD as compared to other chronic illnesses and to identify risk factors for depressive symptoms in COPD.

DESIGN AND PATIENTS

Cross-sectional study of 18,588 persons (1,736 subjects with self-reported COPD), representing a sample of the US population aged > or =50 years who participated in the 2004 Health and Retirement Survey.

MEASUREMENTS

Presence of COPD and other chronic conditions was defined by self-report. Presence of depressive symptoms was assessed using the CES-D8 scale. Participants with a score > or =3 on CES-D8 were classified as having clinically significant depressive symptoms.

MAIN RESULTS

Of 1,736 participants with COPD, 40% had > or =3 depressive symptoms. Depressive symptoms were more common in COPD than in coronary heart disease, stroke, diabetes, arthritis, hypertension, and cancer. Risk factors for > or =3 depressive symptoms in COPD: younger age (OR 1.02/per year younger, 95% CI [1.02-1.03]), female gender (1.2 [1.1-1.3]), current smoking (1.5 [1.3-1.7]), marital status [divorced/separated (1.8 [1.6-2.1]), widowed (1.8 [1.6-2]), never married (1.4 [1.1-1.8]), < or =high school degree (1.6 [1.5-1.8]), dyspnea (2.3 [2.1-2.6]), difficulty walking (2.8 [2.5-3.2]), and co-morbid diabetes (1.2 [1.1-1.4]), arthritis (1.3 [1.2-1.5]) or cancer (1.2 [1.1-1.4]).

CONCLUSIONS

Depressive symptoms are common in COPD and are more likely to occur in COPD than in other common chronic illnesses. The risk factors identified may be used for targeted depression screening in COPD patients.

Effect of care setting on evidence-based depression treatment for veterans with COPD and comorbid depression

BACKGROUND

Patients with chronic obstructive pulmonary disorder (COPD) frequently have co-occurring depressive disorders and are often seen in multiple-care settings. Existing research does not assess the impact of care setting on delivery of evidence-based depression care for these patients.

OBJECTIVE

To examine the prevalence of guideline-concordant depression treatment among these co-morbid patients, and to examine whether the likelihood of receiving guideline-concordant treatment differed by care setting.

DESIGN

Retrospective cohort study.

PATIENTS

A total of 5,517 veterans with COPD that experienced a new treatment episode for major depressive disorder.

MEASUREMENTS AND MAIN RESULTS

Concordance with VA treatment guidelines for depression; multivariate analyses of the relationship between guideline-concordant depression treatment and care setting. More than two-thirds of the sample was over age 65 and 97% were male. Only 50.6% of patients had guideline-concordant antidepressant coverage (defined by the VA). Fewer than 17% of patients received guideline recommended follow-up (> or = 3 outpatient visits during the acute phase), and only 9.9% of the cohort received both guideline-concordant antidepressant coverage and follow-up visits. Being seen in a mental health clinic during the acute phase was associated with a 7-fold increase in the odds of receiving guideline-concordant care compared to primary care only. Patients seen in pulmonary care settings were also more likely to receive guideline-concordant care compared to primary care only.

CONCLUSIONS

Most VA patients with COPD and an acute depressive episode receive suboptimal depression management. Improvements in depression treatment may be particularly important for those patients seen exclusively in primary care settings.