D5. Assessment and management of anxiety and depression

Symptoms of anxiety and depression and associated disorders are common in people with COPD (Ng 2007, Xu 2008, Weiss 2022) and have a range of negative impacts [evidence level III].

A retrospective cohort study of 80,088 U.S. Medicare recipients found a 34% higher 30-day readmission rate in COPD patients with depression, and 43% higher in those with anxiety (Singh 2016). These and other co-existing psychological disorders were also associated with being less likely to have follow up appointments (23.8% versus 16.25%). Although the study design had the potential for confounding by severity of disease, the relationships of psychological disorders with readmissions were much higher than index admission ICU length of stay or need for mechanical ventilation. The results therefore support the case that depression and anxiety are important independent predictors of readmission.

Anxiety symptoms in COPD are associated with worse quality of life (Blakemore 2014), self-management (Dowson 2004) and exercise performance (Eisner 2010) [evidence level III], and with increased medical symptom reporting (Katon 2007), exacerbations (Laurin 2012), hospitalisations (Gudmundsson 2005), length of hospitalisations (Xu 2008), medical costs (Katon 2007), and mortality (Celli 2008) [evidence level III]. The prevalence of one anxiety disorder in particular, panic disorder, is approximately 10 times greater in COPD than the population prevalence of 1.5 to 3.5%, and panic attacks are commonly experienced (American Psychiatric Association 2004, Smoller 1996).

People with COPD are not only at high risk of symptoms of depression and mood disorders but are at higher risk than people with other chronic conditions (Ng 2007 [evidence level III],  Siraj 2020 [evidence level III-2]). When depressive symptoms are comorbid with COPD they are associated with worse health-related quality of life (HRQoL) (Ng 2007, Hanania 2011) and difficulty with smoking cessation (Ng 2007) [evidence level III], and with increased exacerbations (Laurin 2012), hospitalisations (Bula 2001, Xu 2008, Hanania 2011), length of hospitalisations (Ng 2007) [evidence level III], medical costs (Bula 2001), and mortality (Bula 2001, Ng 2007) [evidence level III]. Depressive symptoms have been more strongly associated over four years with patient reported outcomes, including symptom control and physical activity related dyspnoea, than with change in FEV₁ (O’Toole 2022) [evidence level II]. Depression may also influence decisions about end-of-life issues (Stapleton 2005). In summary, these findings support the benefit of screening for symptoms of depression and anxiety in people with COPD and of providing mental health care as a component of comprehensive multidisciplinary care.

Treatment – Cognitive behaviour therapy

Cognitive behaviour therapy (CBT) has been shown to be an effective treatment for panic disorder in the physically healthy (Mitte 2005) [evidence level I]. There is however inconsistent evidence from randomised controlled trials regarding the effect of CBT on health outcomes in COPD. Some studies report positive effects of CBT on anxiety and/or depressive symptoms in people with COPD (Williams 2020), in preventing the development of panic attacks and panic disorder (Livermore 2010), and reducing ratings of dyspnoea (Livermore 2015, Yohannes 2017). A 2019 Cochrane review concluded that, while CBT may be an effective treatment for depression in COPD, the quality of the evidence is currently limited (Pollok 2019). Similarly, a rapid review of 33 studies (24 of which were controlled clinical trials or randomised controlled trials) demonstrated that symptoms of depression and anxiety can be decreased by CBT (Williams 2020) [evidence level I].

A nurse-delivered minimalist version of CBT (1-2 home visits of 20-60 minutes duration) provided clinically and statistically significant improvements on the Hospital Anxiety Depression Scale (HADS) and also the Chronic Respiratory Disease Questionnaire (CRQ) Mastery scale at 3 month follow up in the intervention arm (n=22) compared to the control arm (n=22) (Bove 2016). In a larger RCT, self-help leaflets for anxiety management were compared to a brief nurse led CBT intervention with self-help leaflets in 279 patients with COPD. At 3 months the CBT groups had greater improvements in the HADS Anxiety subscale [3.4 (95% CI 2.62–4.17, p<0.001)] compared to the active control (leaflets) [1.88 (95% CI 1.19–2.55, p<0.001)]. The effect was maintained at 12 months. The CBT intervention was also cost effective (Heslop-Marshall 2018). In a trial of 28 patients undergoing pulmonary rehabilitation, CBT was associated with an improvement in fatigue, stress, depression and anxiety scores over the 3 month follow up period (Luk 2017).

Mindfulness-based cognitive therapy in conjunction with pulmonary rehabilitation also improved depressive symptoms compared to pulmonary rehabilitation alone (Farver-Vestergaard 2018).

A 2023 multi-centre RCT investigated individualised CBT-based psychological intervention, for anxiety and depression symptoms in 430 people with COPD. Trained and supervised respiratory health professionals delivered the intervention (9 topics) over 6 to 8 weeks in weekly face-to-face or telephone sessions (45 to 60 minutes each session). Compared to usual care, the intervention showed no effect on the co-primary outcome of HADS-A (mean difference, 95% CI, -0.60, -1.40 to 0.21) or HADS-D (mean difference -0.66, 95% CI -1.39 to 0.07) at six months. Nor did the intervention improve any of the secondary outcomes at 6 or 12 months or influence the completion of pulmonary rehabilitation. There were more deaths in the intervention arm 13/242 (5%) compared to the control arm 3/181 (2%), however none were associated with the intervention. A health economic analysis suggested the intervention was highly unlikely to be cost-effective (Taylor 2023) [evidence level II]. Despite the robust body of evidence supporting the role of CBT in managing symptoms of anxiety and depression for people with chronic conditions, this study found that CBT delivered by respiratory health professionals did not improve anxiety and depression symptoms in people with COPD. Studies investigating alternative models of care for anxiety and depression symptoms in COPD are needed, particularly those in which qualified mental health professionals are facilitating the prescribed psychological interventions.

Treatment – Pharmacotherapy

A record linkage study in Canada found that elderly COPD patients prescribed benzodiazepines for anxiety were at increased risk of an outpatient exacerbation (NNH 66, 95% CI 57–79) or an emergency department visit for COPD or pneumonia (NNH 147, 95% CI 123–181).  There was also a slightly elevated albeit not significant risk of hospital admission (Vozoris 2014) [evidence level III-2].  Caution is warranted in using these medications, due to their potential depressive effects on respiratory drive (Shanmugam 2007), and their inherent risks in the elderly of dependence, cognitive impairment, and falls (Uchida 2009).

A 2018 Cochrane systematic review conducted to assess the effectiveness and safety of pharmacological interventions for depression in patients with COPD, concluded that there was not enough evidence relating to efficacy and safety to make recommendations on use of SSRIs (Pollok 2018) [evidence level I]. In a meta-analysis involving two RCTs of 148 participants there was no difference in the primary outcome of change in depressive symptoms post-intervention (SMD 0.75, 95% CI -1.14 to 2.64; I² = 95%).  Due to the risk of bias and high level of heterogeneity in depression levels, as well as in the types of medication and doses used, these results should be interpreted with caution (Pollok 2018). Case management to support adherence to antidepressant medication in conjunction with attending pulmonary rehabilitation has been associated with improvements in both depression and dyspnoea-related disability (Alexopoulos 2016). As for anxiety symptoms, psychiatrists can advise on the most appropriate medications for particular patients (Shanmugam 2007).

Multiple systematic reviews have demonstrated that pulmonary rehabilitation is associated with short-term reductions in anxious and depressive symptoms (Coventry 2013, Yohannes 2017, Gordon 2019). The existing evidence warrants the referral of anxious and depressed people with COPD to clinical psychologists and psychiatrists for assessment and treatment. People with COPD and depression that are referred to mental health specialists have lower odds of two-year mortality than those treated in primary care settings (Jordan 2009). Screening for clinically significant anxiety and depression, given their serious impacts, should therefore be part of routine care (including during admissions for exacerbations) (Lecheler 2017).  The Hospital Anxiety Depression Scale (HADS) is an example of an easily administered, widely used screening questionnaire, developed for use with medical patients (Zigmond 1983), and used in numerous studies of people with COPD (Ng 2007, Xu 2008, Bock 2017) [evidence level III].  Another screening option is the Patient Health Questionnaire (PHQ), which screens for symptoms of the most seen mental disorders in medical patients – depression, generalised anxiety, panic attacks, somatoform and eating disorders. The full scale, or the depression and anxiety subscales, may be administered (Spitzer 1994). The PHQ has the advantages of high statistical reliability and validity, while being an easily administered measure that is available on the internet at no cost (Kroenke 2010).