Examining the Relationships Between COPD and Anxiety and Depression

Marilyn W. Edmunds, PhD, NP; Laurie Scudder, MS, NP


March 18, 2009

This Viewpoint offers a guide to the latest clinical and research findings of value to advanced practice nurses and other clinicians.

Chronic Obstructive Pulmonary Disease, Anxiety, and Depression: State of the Science

Putman-Casdorph H, McCrone S
Heart Lung. 2009;38:34-47

Article Summary

Chronic obstructive pulmonary disease (COPD) is a leading cause of disability and death, affecting approximately 11.4 million people in the United States and millions more across the world. The death rate associated with COPD has doubled in the past 30 years, documenting the healthcare system's failure to make an impact on this problem. Psychiatric comorbidities, particularly anxiety and depression, have been linked to increased mortality, decreased functional status, and decreased quality of life in these patients. This study reviewed the literature to determine the state of the science of COPD, anxiety, and depression, and to identify nursing implications derived from these findings.

A review of the literature was conducted using PubMed and CINAHL databases and targeting research trials and reviews from 2000 to the present. Seventy-five relevant papers focusing on COPD, anxiety, and depression were identified, and others were found from the reference lists of these articles. A wide range of sample sizes, health status of subjects, and specific study aims was found. Most studies were cross-sectional and sample sizes varied. Patients were recruited from inpatient, outpatient, and emergency department settings. Many studies used predominantly male subjects, aged 40 to 89 years.

COPD severity also varied among subjects. A variety of instruments, including the Beck Anxiety Inventory, Spielberger State Trait Anxiety Inventory, Hamilton Anxiety Rating Scale, and Profile of Mood States, was used to measure anxiety and depression or depressive symptoms in these patients. The Spielberger State Trait Anxiety Inventory, used most often to measure anxiety in adults, helps to distinguish between feelings of anxiety and depression. With so much variability among these studies, it is possible that this review could significantly underestimate the number of patients with COPD who have concurrent anxiety, depression, or both.

A key finding of this literature review is that the prevalence of anxiety and depression in patients with COPD is greater than that in the general population. The literature documents the significant effect that anxiety and depression have on patients with COPD and helps explain why this condition carries such a high mortality rate. Depression has been found to negatively affect exercise capacity, the use of inpatient and outpatient health services, the number of hospital admissions, and the patient's health perception and well-being. Depression may also lead to early addictive smoking, and recurrent depression impedes smoking cessation attempts.

Both depression and anxiety have been found to negatively affect COPD treatment, including pulmonary rehabilitation. Patients with COPD and depression were more often noncompliant with medical treatment, experienced more impaired functional status and increased symptom burden, and reported a decreased quality of life. In some studies, these patients had a higher mortality rate, while in others, mortality was decreased. There were discrepant results regarding the efficacy of pharmacologic interventions to relieve anxiety, depression, and respiratory symptoms; and to achieve physical comfort.

The literature also suggests that patients with anxiety and depression may fear the stigma of mental illness and therefore focus on their somatic symptoms rather than acknowledge their emotional problems. At a system level, there is poor integration of mental healthcare in the primary care system. Patients often fail to accept a diagnosis of depression or anxiety, or a referral for psychiatric services.

The conclusion of the authors was that although the prevalence of anxiety and depression among patients with COPD is significantly higher than that in the general population, there are serious barriers to the recognition and treatment of these comorbid conditions. Thus, routine assessment and screening for anxiety and depression in all patients diagnosed with COPD should be considered.


This survey of the literature confirms some common-sense observations. Many individuals who have physical limitations imposed by COPD are also victims of anxiety and depression. These comorbidities confound the treatment strategies that might otherwise limit the severity of COPD and improve quality of life.

Are clinicians unaware of the complex mental and physical relationships in patients with COPD? It is likely that providers, who are often stressed by lack of time, focus on interventions to treat the physiologic symptoms of COPD rather than evaluate patients' emotional symptoms. Some clinicians may believe that depression and anxiety are simply part of the symptom profile of patients with airway obstructions. Many primary care clinicians report neither being comfortable or interested in treating anxiety and depression -- believing that they do not have the depth of preparation that allows them to diagnose and treat these mental health problems. The US healthcare system is fractured into separate physical and mental health treatment systems, and if a patient is being seen for a physical problem, it is often difficult to access the mental health system in a timely manner.

The results of this literature search should arm nurses and other clinicians with information to help them become more sensitive to the mental health status of their patients with COPD. More emphasis on managing anxiety and depression should alert the whole healthcare team to address these problems in patients whose primary complaints are physical.



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