D4. Treat anxiety and depression

Anxious and depressive symptoms and disorders are common comorbidities in people with COPD(Yellowlees et al., 1987, Kunik et al., 2005, Ng et al., 2007, Xu et al., 2008, Eisner et al., 2010) and have a range of negative impacts [evidence level I] 

Anxiety symptoms in COPD are associated with worse quality of life (Giardino et al., 2010), self-management (Dowson et al., 2004) and exercise performance (Eisner et al., 2010), and with increased medical symptom reporting(Katon et al., 2007), exacerbations(Eisner et al., 2010), hospitalisations (Yellowlees et al., 1987, Gudmundsson et al., 2005, Livermore et al., 2010), length of hospitalisations (Xu et al., 2008), medical costs (Katon et al., 2007, Livermore et al., 2010), and mortality (Celli et al., 2008a). The prevalence of one anxiety disorder in particular, panic disorder, is approximately 10 times greater in COPD than the population prevalence of 1.5 – 3.5%, and panic attacks are commonly experienced (American Psychiatric Association, 2004, Smoller et al., 1996). Cognitive behaviour therapy has been shown to be an effective treatment for panic disorder in the physically healthy (Mitte, 2005) [evidence level I]. There is promising evidence from a number of small randomised controlled trials that cognitive behaviour therapy can treat anxiety symptoms in COPD (de Godoy and de Godoy, 2003, Hynninen et al., 2010, Livermore et al., 2010), and prevent the development of panic attacks and panic disorders (Livermore et al., 2010). Despite the common use of benzodiazepines in clinical practice, there is a lack of published evidence on their safety and effectiveness for treating anxiety in COPD. Caution is warranted in using these medications, due to their potential depressive effects on respiratory drive (Shanmugam et al., 2007), and their inherent risks in the elderly of dependence, cognitive impairment, and falls (Uchida et al., 2009). SSRI's (such as sertraline) have been recommended as better first line pharmacological therapies for anxiety in COPD. Psychiatrists can advise on the most appropriate medications for particular patients (Shanmugam et al., 2007).

People with COPD are not only at high risk of depressive symptoms and mood disorders, but are at higher risk than people with other chronic conditions(Ng et al., 2007, Omachi et al., 2009). When depressive symptoms are comorbid with COPD they are associated with worse health related quality of life (Ng et al., 2007, Omachi et al., 2009) and difficulty with smoking cessation(Ng et al., 2007), and with increased exacerbations (Xu et al., 2008, Jennings et al., 2009) hospitalisations (Bula et al., 2001, Xu et al., 2008), length of hospitalisations (Ng et al., 2007), medical costs (Bula et al., 2001), and mortality (Bula et al., 2001, Ng et al., 2007). Depression may also influence decisions about end of life issues (Stapleton et al., 2005). As is the case for anxiety symptoms in COPD, there is evidence from small, randomised controlled trials that depressive symptoms can be decreased by cognitive behaviour therapy (de Godoy and de Godoy, 2003, Hynninen et al., 2010). Evidence for the effectiveness of particular antidepressant medications for mood disorders in COPD is still limited, with a few small, randomised controlled trials conducted (Argyropoulou et al., 1993, Lacasse et al., 2004, Eiser et al., 2005). Treatment with antidepressants can be complicated by poor tolerance of side effects such as sedation, which may cause respiratory depression (Evans et al., 1997). As with anxiety symptoms, psychiatrists can advise on which pharmacological treatments may be most appropriate for patients.

Larger randomised controlled trials evaluating the effectiveness of both psychological and pharmacological therapies for psychiatric disorders in COPD are clearly required. (Baraniak and Sheffield, 2011)[evidence level I]. However, the existing evidence still warrants the referral of anxious and depressed people with COPD to clinical psychologists and psychiatrists for assessment and treatment. Depressed COPD patients referred to mental health specialists have lower odds of two year mortality than those treated in primary care settings (Jordan et al., 2009). Screening for clinically significant anxiety and depression, given their serious impacts, should therefore be part of routine care. The Hospital Anxiety Depression Scale is an example of an easily administered, widely used screening questionnaire, developed for use with medical patients (Zigmond and Snaith, 1983), and utilised in numerous studies of people with COPD(Gudmundsson et al., 2005, Ng et al., 2007, Xu et al., 2008, Livermore et al., 2010, Eisner et al., 2010).

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