Don't Overlook the Impact of These Comorbidities Copd and M Don't Overlook the Impact of These Comorbidities Copd and Mood Disorders, Part 1: Anxiety and Depression

Depression and anxiety are common comorbidities in patients with chronic obstructive pulmonary disease (COPD), and like COPD, they are often underrecognized. Both of these comorbidities can adversely affect the course of COPD. Anxiety, for example, is associated with more severe dyspnea, greater disability, and impaired functional status; it also is a significant predictor of hospitalizations for acute exacerbations of COPD. When evaluating depressive symptoms, it is important to rule out cognitive impairment, particularly in patients with severe COPD and hypoxemia. Treatment options include antidepressants and cognitive behavioral therapy. Participation in a pulmonary rehabilitation program also can help reduce anxiety and depressive symptoms in patients with COPD. (J Respir Dis. 2007;28(3):94-103) Chronic obstructive pulmonary disease (COPD) is a health problem worldwide, and the impact is expected to increase in the next several decades.1 In the United States, COPD has been diagnosed in more than 10 million persons, and an additional 14 million show signs of the disease, although they have not yet received the diagnosis.2 The COPD death rate for women has more than doubled in the past 20 years--from 20.1 to 56.7 per 100,000--and the financial burden of COPD is significant: an estimated $14.7 billion annually for direct medical costs and an estimated $15.7 billion annually for indirect costs (such as loss of productivity and premature mortality).3 Despite the fact that COPD is the fourth leading cause of death in the United States, behind heart disease, cancer, and stroke, it is underrecognized and undertreated.4-6 Primary care physicians have a central role in managing the care of persons with COPD at all stages.7 First is their effort to support and facilitate the patient's and family's smoking cessation, which many of them do in the office setting.5 However, the lack of office spirometry equipment,8 concerns about appropriate timing of home oxygen therapy, and the high frequency of other major morbidities in patients with COPD may encourage the family physician or general internist to send such patients to pulmonary or cardiology specialists.9,10 While specialists are helpful in recommending certain types of therapy,generalists may be better able to provide help for mood disorders11,12--a group of chronic conditions that often negatively affect the course of COPD.13,14 Research shows that deterioration in patient-reported outcomes only weakly correlated with declines in physiological indices, such as forced expiratory volume in 1 second, but more strongly correlated with the presence and severity of mood disorders and the ability to sleep.13 Fatigue is one of the most common complaints of persons with COPD.15 Fatigue makes the activities of daily living difficult if not impossible and greatly decreases pleasure in any activity.15,16 Health care professionals often become so focused on the dyspnea and decline in lung function associated with COPD that they neglect the functional symptoms that are most important to the patient and his or her family.13 Kapella and colleagues17have developed a model that focuses on fatigue in persons with COPD and places dyspnea in the context of the many other concomitant causes of fatigue. In this 2-part article, we review the 3 major nonpulmonary components of fatigue and COPD: depression, anxiety, and sleep disorders. The objective is to provide primary care physicians with effective tools to address the poor quality of life experienced by many of their patients with COPD.18DEPRESSION AND COPD Few physicians are surprised by or unaware of the connection between COPD and depression.16,19,20 In fact, we may believe that depression is a normal part of the grief reaction to the diagnosis of COPD and fail to formally diagnose and treat this serious comorbidity.14 Depression is diagnosable and treatable even in patients with chronic life-threatening conditions.Etiology