Depression and Anxiety in COPD: The Role of the Psychiatrist

Airway diseases increase the risk of inflammatory bowel disease.
Airway diseases increase the risk of inflammatory bowel disease.
Although depression and anxiety are two of the most common comorbidities in patients with COPD, they are infrequently treated in this population.

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States,1 affecting an estimated 10.1 million Americans.2 It is associated with multiple comorbidities, including depression and anxiety.3 The prevalence of depression in COPD ranges from 37% to 71%, and anxiety from 50% to 75%.4

Soo Borson, MD, Professor Emerita, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, told Psychiatry Advisor that depression and anxiety are “two of the most common but least treated comorbidities in COPD.”

Less than one-third of COPD patients receive appropriate treatment for anxiety or depression.5,6 Untreated or inappropriately treated depression and anxiety compromise adherence with medical therapy, increase frequency and length of hospital stays during acute exacerbations, and are responsible for poor quality of life and premature death.3

“It is important for psychiatrists to be aware of the high rates of depression and anxiety in patients with COPD and take note of symptoms of these disorders during clinical appointments,” said Borson, who has served as a member of the American College of Chest Physicians (ACCP)’s Workshop Panel on Anxiety and Depression in COPD.

Why are Depression and Anxiety so Prevalent in COPD?

“There are undoubtedly biological connections that account for the high prevalence of depression and anxiety in COPD,” Borson commented. For example, there is an interrelationship between mood disorders, cigarette smoking, and COPD. “Childhood and adolescent depression and anxiety are risk factors for tobacco addiction. And cigarette smoking is the single highest risk factor for developing COPD.”

Emerging evidence also suggests that chronic inflammation may mediate the connection between depressive symptoms and pulmonary function.7,8 Moreover, the drugs that treat COPD can have psychiatric side effects.  For example, inhaled beta-2 agonists can increase anxiety. (See Table 1 below) “The problem is compounded when patients overuse their inhalers in response to dyspnea, which increases these adverse effects,” said Borson.

Table 1
Psychiatric Side Effects of Common COPD Drugs
Drug Class Potential Psychiatric Side Effect
Anticholinergics Anxiety, confusion, delirium, depersonalization, hallucinations
Leukotriene inhibitors Agitation, aggression, anxiousness, dream abnormalities and hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior
Beta-2 agonists Anxiety, restlessness, tremor, tachycardia
Oral corticosteroids Depression, anxiety, mania, psychosis, agitation
Inhaled corticosteroids Psychomotor hyperactivity, sleep disorders, anxiety, aggression, depression
Theophylline Anxiety (especially in blood levels >20 mg/mL), delirium, insomnia, restlessness, mutism, tremor
PDE4 inhibitors Anxiety, suicidality, depression, insomnia
Phosphodiesterase-4 inhibitors: PDE4 inhibitors