Asthma and COPD Complicated by Anxiety and Depression: Implications for Care

Be alert for signs of anxiety and depression in patients with asthma and chronic obstructive pulmonary disease (COPD). A number of studies have found an increased prevalence of these psychological disorders in patients with chronic respiratory diseases. Although the relationship is not completely understood, it is clear that anxiety and depression can adversely affect the course of asthma and COPD. Highlighted here are some of the findings recently reported in the literature.

ASTHMA AND PANIC DISORDER

There is growing recognition of the relationship between anxiety, stress, and asthma.¹ A number of studies have documented an association between asthma and panic disorder.^2-5 For example, a longitudinal community-based study, conducted by Goodwin and Eaton,⁵ found that asthma increased the risk of panic in adults. The results of a recent prospective study by Hasler and associates⁶ are consistent with this but also demonstrate the bidirectional relationship between asthma and panic disorder.

Their study included 591 persons who were observed from age 19 to 40 years.⁶ The study sample was tailored to include persons at risk for psychiatric disorders.

After adjusting for potential confounders, the analysis indicated that active asthma predicted subsequent panic disorder (odds ratio, 4.5) and panic disorder predicted subsequent active asthma (odds ratio, 6.3). The associations were stronger in smokers than in nonsmokers and were stronger in women than in men. Confounders of the relationship between asthma and panic included smoking, anxiety in early childhood, and a family history of allergy.

A number of mechanisms might account for the link between asthma and panic disorder (Table). Having a potentially life-threatening disease such as asthma probably increases anxiety in many patients and may trigger panic attacks in some. In addition, asthma and panic may share certain risk factors. Smoking, for instance, increases the risk of asthma and impairs the response to asthma therapy^7,8; it also increases the risk of panic.⁹ Stress during childhood has also been identified as a risk factor for both asthma and panic.^10-12

IMPACT ON ASTHMA CONTROL

It is becoming increasingly clear that psychological variables can influence the onset and course of asthma. Chronic stress, for example, can trigger asthma exacerbations in children.¹⁰ Anxiety and depression have been associated with a less favorable asthma-related health status in adults.¹³

Lavoie and coworkers¹⁴ found evidence that the presence of a psychiatric disorder is associated with poorer asthma control and asthma-related quality of life. In their study, 406 adults with asthma underwent a structured psychiatric interview, completed the Asthma Control Questionnaire and Asthma Quality of Life Questionnaire, and underwent pulmonary function testing. The results indicated that 34% had a psychiatric diagnosis, such as major depression (15%), panic disorder (12%), or generalized anxiety disorder (5%).

The presence of a psychiatric diagnosis was not associated with a difference in pulmonary function. However, asthma control and quality of life were worse in patients who had a psychiatric diagnosis.¹⁴

COPD, DEPRESSION, AND ANXIETY

Several studies have found that the prevalence of depression is increased in patients with COPD. Van Ede and associates¹⁵ reported that depression was present in 7% to 42% of patients. Another study found that 34% of patients with COPD had an anxiety disorder and 16% had depression.¹⁶

Kunik and colleagues¹⁷ conducted a study that included 1334 persons who had chronic breathing disorders and were receiving care at a VA medical center. Primary Care Evaluation of Mental Disorders (PRIME-MD) screening questions were used to assess the prevalence of anxiety and depression. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th edition,¹⁸ was used to determine the prevalence of anxiety and depression diagnoses in patients with COPD.

The PRIME-MD indicated that 80% of the patients had anxiety or depression. Anxiety or depression was severe in 52% of the patients who had either diagnosis. In the subset of patients with COPD, 65% received a diagnosis of an anxiety and/or depressive disorder. Only 31% of those with such diagnoses were being treated for depression or anxiety; 20% were receiving an antidepressant or anxiolytic agent.

The authors noted that the PRIME-MD had a positive predictive value of 80%.¹⁷ They suggested that the use of such screening instruments could improve the under-recognition and undertreatment of depression and anxiety in this patient population.

The need for better recognition of depression and anxiety in patients with COPD is underscored by evidence of the adverse effects on outcomes.¹⁹ Gudmundsson and associates²⁰ reported a high incidence of anxiety and depression in 416 patients hospitalized for COPD, and they found that anxiety or depression was associated with poorer health status. These authors also found evidence that anxiety is a risk factor for rehospitalization in patients with COPD.²¹

A number of factors may contribute to anxiety and depression in patients with COPD. The functional limitations associated with COPD cause or exacerbate depression in some patients. Pulmonary rehabilitation can address some of these concerns. One study found that participation in an outpatient pulmonary rehabilitation program resulted in decreased anxiety and symptoms of depression in patients with COPD.²²

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