Research into COPD and asthma has broadly shown an association between respiratory diseases and depression. The 2010 ATS International Conference symposium “Depression and Obstructive Lung Disease: State of the Science and Future Directions” updated attendees on studies of depression’s effects on symptoms, exacerbations and mortality among COPD patients.

Data show a high presence of depression and anxiety among COPD patients, with most research citing a 25 to 50 percent prevalence, said the symposium co-chair, Vincent S. Fan, M.D.

“Depression is common in many chronic illnesses, but recent data suggest that it is more common in COPD than in any other chronic illness, except for congestive heart failure,” said Dr. Fan, who is an assistant professor of medicine at the VA Puget Sound Health Care System at the University of Washington in Seattle.

Depression is also widely under-diagnosed and treated, particularly among patients with respiratory diseases, he said, adding that it is important to understand the interaction between depression, self-management strategies and COPD outcomes.

Studies suggest that depressive symptoms are closely associated with increased rates of exacerbations and mortality among patients with pulmonary obstructive diseases, noted Fernando J. Martinez, M.D., M.S.

The majority of the published literature supports the contention that there seems to be a relationship between depression and mortality among COPD patients, said Dr. Martinez, who is professor of internal medicine, director of pulmonary diagnostic services and co-medical director of lung transplantation at the University of Michigan Health System in Ann Arbor.

Bruce G. Bender, Ph.D., discussed the relationship between depression and asthma in a presentation on the success of self-care among depressed asthma patients. He offered data showing the association between asthma and depression, and a correlation between worsening asthma and increased depression. He also presented research that related depression to poor self-management of illness and an increase in unhealthy behaviors, such as smoking and drug and alcohol use.

In data from a study of adolescents with asthma, “a clustering of risky behaviors that shoot up in the presence of depression raises a red flag that we need to be aware of the presence of depression and the behaviors that go with it,” said Dr. Bender, who is a professor and head of the division of pediatric behavioral health at National Jewish Medical and Research Center in Denver.

“Depressed patients are also three times more likely to be non-adherent with medical recommendations than non-depressed patients,” he added.

In comparing healthy individuals who exercise with the sedentary, Roger Goldstein, M.D., noted that exercise lowers anxiety, stress and fatigue, while at the same time increasing self-esteem and a sense of well-being. Dr. Goldstein said clinicians have found many of the same characteristics in COPD patients who exercise.

In several papers, the beneficial relationship between pulmonary rehabilitation and symptoms of anxiety and depression among COPD and asthma patients has been demonstrated, said Dr. Goldstein, who is professor of medicine and director of the Respiratory Divisional Program in Respiratory Rehabilitation at West Park Healthcare Centre at the University of Toronto in Canada.

“Anxiety and depression are both common psychological co-morbidities of COPD and adversely affect quality of life and physical disabilities,” he said. “But the symptoms of depression and anxiety can be positively impacted by pulmonary rehabilitation.”

Nicholas D. Giardino, Ph.D., described the relationship between psychological distress and the perception of dyspnea. He stressed the interrelationships between psychological and physiological processes that affect COPD, using a diagram of circular pathways as a demonstration tool.

Referring to the top of the circle, “It starts with airflow obstruction, then air trapping, which leads to hyperinflation,” said Dr. Giardino, indicating points on the circle. “Hyperinflation leads to dyspnea and anxiety, which triggers increased respiration rates leading to more hyperinflation and so on.”

A second circle diagram indicated a similar cycle of hyperinflation and dyspnea leading to activity limitations and deconditioning, leading to increased hyperinflation at the top of diagram.

“These are two vicious circles that alternately lead to poor health-related quality of life and poor outcomes for patients with COPD,” said Dr. Giardino, who is an assistant professor of psychiatry at the University of Michigan Health System in Ann Arbor.

Dr. Giardino shared data supporting the notion that dyspnea is fundamentally an emotional reaction to the symptoms of COPD and that an excessive emotional response is associated with a number of poor outcomes in respiratory diseases.

“If we don’t account for the fact that emotional response is central to the process of dyspnea, then we risk not fully understanding dyspnea scientifically and not appreciating its impact on our patients,” he said.

In a pair of presentations on treating depression in COPD patients, Huong Q. Nguyen, Ph.D., R.N., described using Internet resources as interventions for patients with depression, while Jeffrey A. Cully, Ph.D., discussed cognitive behavioral therapy (CBT).

Dr. Nguyen, who is an associate professor at the University of Washington School of Nursing in Seattle, outlined data on using information and communications technology involving the Web and mobile phones to provide depression therapies for COPD patients.

Her presentation touched on online peer support groups, automated, Internet-based self-help and therapist-facilitated interventions, including telepsychiatry.

Dr. Cully, who is an assistant professor of psychiatry at the Michael E. DeBakey VA Medical Center at Baylor College of Medicine in Houston, stressed the need for integrating mental health professionals into the pulmonary care setting to avoid working clinically in silos. He also emphasized that psychotherapy should be considered for COPD patients in addition to, or instead of, drug therapy when appropriate.

“I think CBT really complements the self management approach toward which medicine is moving,” he said. “It’s asking patients to take an active role [in their care], and there are direct clinical applications for CBT, the hallmark of which is changing one’s thoughts about their illness.”

Soo Borson, M.D., began her presentation by asking the question, “Should all [COPD] patients with symptoms of depression be treated with antidepressants?” Dr. Borson called the available data on the use of antidepressants in COPD patients “shockingly weak.” Evidence does suggest that the clearest treatment effect occurs in patients with major depression, she said, recommending the use of the PHQ-9 survey as the standard for diagnosing major depression and monitoring treatment.

Dr. Borson, a professor of psychiatry and behavioral sciences at the University of Washington in Seattle, encouraged including treatment of depression in comprehensive chronic disease care, with the realization that evidence indicates depression worsens outcomes in COPD.