Depression and Anxiety in COPD: The Role of the Psychiatrist

 

The experience of dyspnea can bring on anxiety and panic. In turn, anxiety and panic can increase dyspnea, creating a vicious cycle. In the words of one patient, “It’s scary when you can’t breathe.”⁹ It is important to distinguish between these episodes and panic disorders.³

“Pulmonary rehabilitation helps patients realize that when they feel dyspnea, they are not dying. They learn to regulate their breathing and tolerate increased activity levels,” said Borson.

Psychological Contributors to Anxiety and Depression

Multiple psychological factors contribute to anxiety and depression in COPD. Reduced exercise capacity leads to increased physical disability, reduced social interaction, dependence on caregivers, loss of social role, and loss of self-esteem.¹⁰

In addition, “patients with COPD experience high rates of pessimism about life,” Borson observed. Suicidal thoughts are common and are associated with severe depression and anxiety, more frequent COPD hospitalizations, more severe dyspnea, and disability.¹¹

“Many patients feel unable to tell their physician about their pessimism, sense of futility, and depression,” Borson said. She advised psychiatrists to prioritize follow-up of recently hospitalized COPD patients who are at highest risk of “developing the emotional states linked to suicide.”

She also noted that often, patients who are current or former smokers feel stigma or self-blame, which inhibit conversation with their physicians.

Beyond Anxiety and Depression: Cognitive Impairment in COPD

Many COPD patients experience cognitive impairments, most commonly in attentional and executive functions, followed by impairments in verbal memory and learning.¹²

“Psychiatrists should investigate potential cognitive impairments, which often are not overt,” Borson advised.

She noted that global tools such as the Mini-Mental State Examination (MMSE) may not be sensitive enough to pick up on these subtle impairments and recommended the Trail Making Test (TMT) as a “sensitive measure of mental speed, as well as a fairly good indicator of complex problem solving.” Other standard tests might also be useful.

Pharmacologic Treatment Options

Clinical trials of the efficacy of antidepressants in COPD have been inconclusive.¹³ Nevertheless, antidepressants are typically included in overall management strategies.¹⁴ Some patients decline antidepressants, out of fear of addiction and potential side effects, so it is important for psychiatrists to explain the value of these interventions.¹⁰

Borson reported that participants in her group’s study of depression and suicidal thinking in COPD¹¹ “found antidepressants very effective in improving mood. In fact, they were shocked at how much better they felt.”

There are no major antidepressant contraindications in COPD patients. However caution must be exercised when prescribing bupropion because it is often prescribed for smoking cessation, leading to potential overdose if the patient is already taking it for that indication.¹⁵