Impact of anxiety and depression on chronic obstructive pulmonary disease exacerbation risk

BMI moderates the relationship between depression and chronic obstructive pulmonary disease: A cross‑sectional survey

BACKGROUND

Prior research has established a connection between depression and chronic obstructive pulmonary disease (COPD). However, the influence of age and BMI on this association remains unclear.

OBJECTIVES

We used the National Health and Nutrition Examination Survey (NHANES) database to explore the relationship between depression and COPD, and to investigate whether age and Body mass index (BMI) act as moderators in this relationship.

METHODS

We analyzed data from 10,940 participants in the NHANES database. Depression served as the independent variable. COPD status served as the outcome variable. We employed multivariable logistic regression to examine the relationship between depression and COPD.

RESULTS

Of the 10,940 respondents surveyed, about 3.9 % had COPD and 8.5 % had depression. The prevalence of depression in COPD patients was significantly greater than the prevalence of overall respondents (21.1 % VS.8.5 %). We found that the association between depression and COPD was mediated by BMI status. Controlling for other covariates, the association between depression and COPD increased significantly. For the underweight group, the impact of depression on the risk of COPD was lower compared to the normal BMI group.

CONCLUSION

This study confirms a significant association between depression and COPD, with BMI serving as a moderator. These findings enhance our understanding of the complex interplay between depression and COPD and underscore the importance of considering individual physical health characteristics in clinical assessments. The results have significant implications for clinical practice and public health policymaking.

Clinical Characteristics and Frequency of Chronic Obstructive Pulmonary Disease Exacerbations in Korean Patients: Findings From the KOCOSS Cohort 2012-2021

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) exert a substantial burden on patients and healthcare systems; however, data related to the frequency of AECOPD in the Korean population are limited. Therefore, this study aimed to describe the frequency of severe, and moderate or severe AECOPD, as well as clinical and demographic characteristics of patients with chronic obstructive pulmonary disease (COPD) in South Korea.

METHODS

Data from patients aged > 40 years with post-bronchodilator forced expiratory volume in 1 second (FEV1)/forced vital capacity ≤ 70% of the normal predicted value from the Korea COPD Subgroup Study database were analyzed (April 2012 to 2021). The protocol was based on the EXAcerbations of COPD and their OutcomeS International study. Data were collected retrospectively for year 0 (0-12 months before study enrollment) based on patient recall, and prospectively during years 1, 2, and 3 (0-12, 13-24, and 25-36 months after study enrollment, respectively). The data were summarized using descriptive statistics.

RESULTS

Data from 3,477 Korean patients (mean age, 68.5 years) with COPD were analyzed. Overall, most patients were male (92.3%), former or current smokers (90.8%), had a modified Medical Research Council dyspnea scale score ≥ 1 (83.3%), and had moderate airflow limitation (54.4%). The mean body mass index (BMI) of the study population was 23.1 kg/m², and 27.6% were obese or overweight. Hypertension was the most common comorbidity (37.6%). The mean blood eosinophil count was 226.8 cells/μL, with 21.9% of patients having ≥ 300 cells/μL. A clinically insignificant change in FEV1 (+1.4%) was observed a year after enrollment. Overall, patients experienced a mean of 0.2 severe annual AECOPD and approximately 1.1 mean moderate or severe AECOPD. Notably, the rates of severe AECOPD remained generally consistent over time. Compared with patients with no exacerbations, patients who experienced severe exacerbations had a lower mean BMI (21.7 vs. 23.1 kg/m²; P < 0.001) and lower lung function parameters (all P values < 0.001), but reported high rates of depression (25.5% vs. 15.1%; P = 0.044) and anxiety (37.3% vs. 16.7%; P < 0.001) as a comorbidity.

CONCLUSION

Findings from this Korean cohort of patients with COPD indicated a high exacerbation burden, which may be attributable to the unique characteristics of the study population and suboptimal disease management. This highlights the need to align clinical practices with the latest treatment recommendations to alleviate AECOPD burden in Korea.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05750810.

Unraveling the causality between chronic obstructive pulmonary disease and its common comorbidities using bidirectional Mendelian randomization

BACKGROUND

Chronic obstructive pulmonary disease (COPD) frequently coexists with various diseases, yet the causal relationship between COPD and these comorbidities remains ambiguous. As a result, the aim of our study is to elucidate the potential causality between COPD and its common comorbidities.

METHODS

We employed the Mendelian randomization (MR) method to analyze single nucleotide polymorphism (SNP) data of common comorbidities with COPD from FinnGen and Integrative Epidemiology Unit (IEU) databases. Causality was primarily assessed using the inverse variance weighting (IVW) method. Multivariable Mendelian randomization (MVMR) analysis was also conducted to eliminate the interference of smoking-related phenotypes. Sensitivity analysis was conducted to ensure the reliability of our findings.

RESULTS

Preliminary univariable MR revealed an increased risk of lung squamous cell carcinoma (LUSC) (IVW: OR = 1.757, 95% CI = 1.162-2.657, P = 0.008), chronic kidney disease (CKD) (IVW: OR = 1.193, 95% CI = 1.072-1.326, P < 0.001), chronic periodontitis (IVW: OR = 1.213, 95% CI = 1.038-1.417, P = 0.012), and heart failure (HF) (IVW: OR = 1.127, 95% CI = 1.043-1.218, P = 0.002). Additionally, the reverse MR analysis indicated that genetic susceptibility to HF (IVW: OR = 1.272, 95% CI = 1.084-1.493, P = 0.003), obesity (IVW: OR = 1.128, 95% CI = 1.056-1.205, P < 0.001), depression (IVW: OR = 1.491, 95% CI = 1.257-1.770, P < 0.001), and sleep apnea syndrome (IVW: OR = 1.209, 95% CI = 1.087-1.345, P < 0.001) could raise the risk of COPD. The MVMR analysis showed no causal effect of COPD on susceptibility to chronic periodontitis after adjusting for smoking.

CONCLUSIONS

Our study identified that COPD may elevate the risk of LUSC, HF, and CKD. Additionally, our analysis revealed that HF, sleep apnea symptoms, depression, and obesity might also increase the susceptibility to COPD. These findings revealed a potential causal relationship between COPD and several prevalent comorbidities, which may provide new insights for disease early prediction and prevention.

The prevalence of anxiety and depression in bronchiectasis patients and their association with disease severity: a cross-sectional study

Bronchiectasis is a chronic lung disease characterized by recurrent respiratory symptoms. Several studies demonstrated that psychological comorbidities are common in patients with bronchiectasis. The aim of this study is to investigate the prevalence of anxiety and depression in bronchiectasis patients and assess their association with disease severity. In this cross-sectional study, we included patients diagnosed with bronchiectasis. The study was conducted using an interviewer-administered questionnaire via phone calls and data collected from the electronic medical records at JUH. The questionnaire included patients' demographics and disease characteristics. Anxiety and depression were assessed using GAD7 and PHQ9 respectively. Bronchiectasis disease severity was assessed using BSI and FACED score. The total number of included patients was 133. Moreover, 53.4% of the participants were females while the rest were males (46.6%). PHQ9 demonstrated that 65.4% of the patients had depression. Regarding anxiety, GAD7 scale showed that 54.1% of the patients had anxiety. Pearson correlation showed that bronchiectasis severity index was significantly associated only with PHQ9 depression scores (r = 0.212, P value = 0.014). The prevalence of depression and anxiety is high among patients with bronchiectasis. We believe that patients affected with bronchiectasis should be screened for depression to improve their quality of life.

Exploring Patterns of COPD Exacerbations and Comorbid Flare-Ups

Background

Comorbidities are known to complicate disease management in patients with Chronic Obstructive Pulmonary Disease (COPD). This is partly due to lack of insight into the interplay of acute exacerbations of COPD (AECOPD) and comorbid flare-ups. This study aimed to explore patterns of AECOPDs and comorbid flare-ups.

Methods

Data of increased symptoms were extracted from a 12-month daily symptom follow-up database including patients with COPD and comorbidities (chronic heart failure (CHF), anxiety, depression) and transformed to visualizations of AECOPDs and comorbid flare-up patterns over time. Patterns were subsequently categorized using an inductive approach, based on both predominance (ie, which occurs most often) of AECOPDs or comorbid flare-ups, and their simultaneous (ie, simultaneous start in ≥ 50%) occurrence.

Results

We included 48 COPD patients (68 ± 9 years; comorbid CHF: 52%, anxiety: 40%, depression: 38%). In 25 patients with AECOPDs and CHF flare-ups, the following patterns were identified: AECOPDs predominant (n = 14), CHF flare-ups predominant (n = 5), AECOPDs nor CHF flare-ups predominant (n = 6). Of the 24 patients with AECOPDs and anxiety and/or depression flare-ups, anxiety and depression flare-ups occurred simultaneously in 15 patients. In 9 of these 24 patients, anxiety or depression flare-ups were observed independently from each other. In 31 of the included 48 patients, AECOPDs and comorbid flare-ups occurred mostly simultaneously.

Conclusion

Patients with COPD and common comorbidities show a variety of patterns of AECOPDs and comorbid flare-ups. Some patients, however, show repetitive patterns that could potentially be used to improve personalized disease management, if recognized.

Phenotypes, Etiotypes, and Endotypes of Exacerbations of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease is a major health problem with a high prevalence, a rising incidence, and substantial morbidity and mortality. Its course is punctuated by acute episodes of increased respiratory symptoms, termed exacerbations of chronic obstructive pulmonary disease (ECOPD). ECOPD are important events in the natural history of the disease, as they are associated with lung function decline and prolonged negative effects on quality of life. The present-day therapy for ECOPD with short courses of antibiotics and steroids and escalation of bronchodilators has resulted in only modest improvements in outcomes. Recent data indicate that ECOPD are heterogeneous, raising the need to identify distinct etioendophenotypes, incorporating traits of the acute event and of patients who experience recurrent events, to develop novel and targeted therapies. These characterizations can provide a complete clinical picture, the severity of which will dictate acute pharmacological treatment, and may also indicate whether a change in maintenance therapy is needed to reduce the risk of future exacerbations. In this review we discuss the latest knowledge of ECOPD types on the basis of clinical presentation, etiology, natural history, frequency, severity, and biomarkers in an attempt to characterize these events.

Validation of the Generalized Anxiety Disorder-7 in patients with COPD: a cross-sectional study

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) often have comorbid generalized anxiety disorder (GAD), which requires early screening in respiratory clinics. The Generalized Anxiety Disorder-7 (GAD-7) questionnaire is a brief and commonly used screening tool for GAD but has not been validated among patients with COPD in China.

METHODS

Stable patients with COPD from a cross-sectional observational study were assessed using the GAD-7 questionnaire and then assessed by a senior psychiatrist to confirm a diagnosis of GAD according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Demographic characteristics, spirometry, and patient-reported outcomes were collected. Cronbach's α coefficient was calculated, and receiver operating curve (ROC) analysis was performed to validate the GAD-7.

RESULTS

A total of 226 patients with COPD were enrolled, and 50 (22.1%) of these patients were diagnosed with GAD. The Cronbach's α coefficient for the GAD-7 was 0.869, which indicated good internal consistency. ROC curve analysis showed that the GAD-7 had an area under the curve (AUC) value of 0.829 (95% CI: 0.774-0.876) for identifying GAD. The optimal cut-off score was ≥ 4, with a sensitivity of 66.0% and a specificity of 89.2%. Higher GAD-7 scores were significantly associated with health-related quality of life and the symptom burden of COPD. The discriminatory power of GAD-7 did not differ statistically when stratified by COPD severity.

CONCLUSIONS

The GAD-7 was shown to be a reliable and valid screening tool for patients with COPD in China, and its screening performance for GAD was not influenced by disease severity.

Depressive symptoms predict the incidence of common chronic diseases in women and men in a representative community sample

BACKGROUND

Depression, the most frequent and harmful mental disorder, has been associated with specific somatic diseases as the leading cause of death. The purposes of this prospective study were to predict incident chronic diseases based on baseline depressive symptoms and to test sex-dependent effects.

METHODS

In a representative German community sample of over 12 000 participants, baseline depressive symptoms (assessed using the Patient Health Questionnaire-9) were tested as a predictor of new onset of cardiovascular disease (CVD), chronic obstructive lung disease, diabetes, cancer, and migraine at 5-year follow-up. To study disease incidence, we created subsamples for each chronic disease by excluding participants who already had the respective disease at baseline. Potential confounders were included in logistic regression models and sex-specific analyses were performed.

RESULTS

Controlling for demographic characteristics and loneliness, in men and women, baseline depressive symptoms were predictive of CVD, chronic obstructive lung disease, diabetes, and migraine, but not of cancer. When we additionally adjusted for metabolic and lifestyle risk factors, there was an 8% increase of chronic obstructive lung disease and migraine per point of depressive symptoms. There was a trend for CVD (4%; p = 0.053). Sex-sensitive analyses revealed trends for the relevance of depressive symptoms for CVD in men (p = 0.065), and for diabetes in women (p = 0.077).

CONCLUSIONS

These findings underscore the need to implement screening for depression in the treatment of major somatic illnesses. At the same time, depressed patients should be screened for metabolic and lifestyle risk factors and for somatic diseases and offered lifestyle interventions.

Anxiety and Depressive Symptoms in Patients with COPD: Modifiable Explanatory Factors

Anxiety and depressive symptoms affect up to 80% of people with chronic obstructive pulmonary disease (COPD). To reduce this symptom burden, clinicians should target modifiable explanatory factors while accounting for nonmodifiable explanatory factors of these symptoms. The purpose of this secondary data analysis was to examine which modifiable factors explain anxiety and depressive symptoms in COPD. This secondary data analysis of 1,760 COPD patients used multiple regression to explain anxiety and depressive symptoms from sets of modifiable patient characteristics and demographic controls. Clinically significant symptoms of anxiety or depression presented in 29.6% (n = 526) of participants, and 20.6% (n = 363) had both. Significant modifiable explanatory factors of both disorder symptoms were perceived functional status, functional capacity, psychosocial impact, symptom self-management, and significant symptoms for the other. Somatic symptom burden and dyspnea explained anxiety and depressive symptoms, respectively. Addressing these modifiable factors may reduce anxiety and depressive symptoms in patients with COPD.

Nonpharmacological management of psychological distress in people with COPD

Psychological distress is prevalent in people with COPD and relates to a worse course of disease. It often remains unrecognised and untreated, intensifying the burden on patients, carers and healthcare systems. Nonpharmacological management strategies have been suggested as important elements to manage psychological distress in COPD. Therefore, this review presents instruments for detecting psychological distress in COPD and provides an overview of available nonpharmacological management strategies together with available scientific evidence for their presumed benefits in COPD. Several instruments are available for detecting psychological distress in COPD, including simple questions, questionnaires and clinical diagnostic interviews, but their implementation in clinical practice is limited and heterogeneous. Moreover, various nonpharmacological management options are available for COPD, ranging from specific cognitive behavioural therapy (CBT) to multi-component pulmonary rehabilitation (PR) programmes. These interventions vary substantially in their specific content, intensity and duration across studies. Similarly, available evidence regarding their efficacy varies significantly, with the strongest evidence currently for CBT or PR. Further randomised controlled trials are needed with larger, culturally diverse samples and long-term follow-ups. Moreover, effective nonpharmacological interventions should be implemented more in the clinical routine. Respective barriers for patients, caregivers, clinicians, healthcare systems and research need to be overcome.

Insomnia in chronic obstructive pulmonary disease and associations with healthcare utilization and costs

Insomnia has been linked to adverse chronic obstructive pulmonary disease (COPD) outcomes including exacerbations, yet its impact on COPD-related healthcare utilization and costs is unknown. In this study, we investigated the associations between insomnia and healthcare utilization and costs in patients with COPD. A retrospective cohort of veterans with COPD were identified from national Veterans Affairs administration data for fiscal years 2012-2017. Insomnia was operationalized as having an insomnia diagnosis based on International Classification of Disease codes or having a prescription of > 30 doses of a sedative-hypnotic medication in a given fiscal year. The index date for insomnia was the first date when dual criteria for COPD and insomnia was met. The index date for those without insomnia was set as the COPD index date. Our primary outcomes were 1-year healthcare utilization and costs related to outpatient visits and hospitalizations after index date. COPD-related healthcare utilization variables included number of prescription fills of corticosteroids and/or antibiotics and outpatient visits and hospitalizations with a primary diagnosis of COPD. Out of 1,011,646 patients (96% men, mean age 68.4 years) diagnosed with COPD, 407,363 (38.8%) had insomnia. After adjustment for confounders, insomnia was associated with higher rates of outpatient visits, hospitalizations, and fills for corticosteroids and/or antibiotics, longer hospital length of stay, and $10,344 higher hospitalization costs in the 12 months after index date. These findings highlight the importance of insomnia as a potentially modifiable target for reducing the burden of COPD on patients and healthcare systems.

The Impact of Anxiety and Depression in Chronic Obstructive Pulmonary Disease

Patients with COPD (chronic obstructive pulmonary disease) are at a higher risk of comorbid conditions such as anxiety and/or depression, which in turn increase their symptom burden and rehospitalizations compared to the general population. It is important to investigate the pathophysiology and clinical implications of mental health on patients with COPD. This review article finds that COPD patients with anxiety and/or depression have a higher rehospitalization incidence. It reviews the current screening and diagnosis methods available. There are pharmacological and non-pharmacologic interventions available for treatment of COPD patients with depression based on severity. COPD patients with mild depression benefit from pulmonary rehabilitation and cognitive behavioral therapy, whereas patients with severe or persistent depression can be treated with pharmacologic interventions.

Characterising hospitalisation risk for chronic obstructive pulmonary disease exacerbations: Bedside and outpatient clinic assessments of easily measured variables

OBJECTIVE

To identify the characteristics of people with chronic obstructive pulmonary disease (COPD) who require hospitalisation for exacerbations.

METHODS

People with COPD were recruited either during hospitalisation or from out-patient respiratory medicine clinics. Hospital admissions were tracked throughout the 5-months recruitment period. For participants who were admitted, hospital readmissions were tracked for at least 30 days following discharge. Participants were grouped as either needing; (i) no hospital admission during the study period (no admission; ø-A), (ii) one or more hospital admissions during the study period but no readmission within 30 days of discharge (no rapid readmission; ø-RR) or (iii) one or more hospital admissions with a readmission within 30 days of discharge (rapid readmission; RR).

RESULTS

Compared with the ø-A group (n=211), factors that independently increased the risk of ø-RR (n=146) and/or RR (n=57) group membership were being aged >60 years, identifying as an Indigenous person (relative risk ratio, 95% confidence interval 7.8 [1.8 to 34.0]) and the use of a support person or community service for activities of daily living (1.5 [1.0 to 2.4]. A body mass index ≥25 kg/m2 was protective.

CONCLUSIONS

Variables recorded at the bedside or in clinic provided information on hospitalisation risk.

Effects of a nutritional intervention on impaired behavior and cognitive function in an emphysematous murine model of COPD with endotoxin-induced lung inflammation

One cluster of the extrapulmonary manifestations in chronic obstructive pulmonary disease (COPD) is related to the brain, which includes anxiety, depression and cognitive impairment. Brain-related comorbidities are related to worsening of symptoms and increased mortality in COPD patients. In this study, a murine model of COPD was used to examine the effects of emphysema and repetitive pulmonary inflammatory events on systemic inflammatory outcomes and brain function. In addition, the effect of a dietary intervention on brain-related parameters was assessed. Adult male C57Bl/6J mice were exposed to elastase or vehicle intratracheally (i.t.) once a week on three consecutive weeks. Two weeks after the final administration, mice were i.t. exposed to lipopolysaccharide (LPS) or vehicle for three times with a 10 day interval. A dietary intervention enriched with omega-3 PUFAs, prebiotic fibers, tryptophan and vitamin D was administered from the first LPS exposure onward. Behavior and cognitive function, the degree of emphysema and both pulmonary and systemic inflammation as well as blood-brain barrier (BBB) integrity and neuroinflammation in the brain were assessed. A lower score in the cognitive test was observed in elastase-exposed mice. Mice exposed to elastase plus LPS showed less locomotion in the behavior test. The enriched diet seemed to reduce anxiety-like behavior over time and cognitive impairments associated with the presented COPD model, without affecting locomotion. In addition, the enriched diet restored the disbalance in splenic T-helper 1 (Th1) and Th2 cells. There was a trend toward recovering elastase plus LPS-induced decreased expression of occludin in brain microvessels, a measure of BBB integrity, as well as improving expression levels of kynurenine pathway markers in the brain by the enriched diet. The findings of this study demonstrate brain-associated comorbidities - including cognitive and behavioral impairments - in this murine model for COPD. Although no changes in lung parameters were observed, exposure to the specific enriched diet in this model appeared to improve systemic immune disbalance, BBB integrity and derailed kynurenine pathway which may lead to reduction of anxiety-like behavior and improved cognition.

The Additional Medical Expenditure Caused by Depressive Symptoms among Middle-Aged and Elderly Patients with Chronic Lung Diseases in China

Depression is one of the most common comorbidities in patients with chronic lung diseases (CLDs). Depressive symptoms have an obvious influence on the health function, treatment, and management of CLD patients. In order to investigate the additional medical expenditure caused by depressive symptoms among middle-aged and elderly patients with CLDs in China, and to estimate urban–rural differences in additional medical expenditure, our study used data from the 2018 China Health and Retirement Longitudinal Study (CHARLS) investigation. A total of 1834 middle-aged and elderly CLD patients were included in this study. A generalized linear regression model was used to analyze the additional medical expenditure on depressive symptoms in CLD patients. The results show that depressive symptoms were associated with an increase in medical costs in patients with CLDs. Nevertheless, the incremental medical costs differed between urban and rural patients. In urban and rural patients with more severe comorbid CLD and depressive symptoms (co-MCDs), the total additional medical costs reached 4704.00 Chinese Yuan (CNY) (USD 711.60) and CNY 2140.20 (USD 323.80), respectively. Likewise, for patients with lower severity co-MCDs, the total additional medical costs of urban patients were higher than those of rural patients (CNY 4908.10 vs. CNY 1169.90) (USD 742.50 vs. USD 176.90). Depressive symptoms were associated with increased medical utilization and expenditure among CLD patients, which varies between urban and rural areas. This study highlights the importance of mental health care for patients with CLDs.

Relationship between clinical anxiety and patient outcomes in patients with chronic obstructive lung disease exacerbation in the emergency department

Purpose

Anxiety is a comorbidity that is not routinely addressed in patients with chronic obstructive lung disease (COPD) exacerbation in the emergency department (ED). Anxiety in patients with COPD exacerbation can be related with negative outcomes. The Generalized Anxiety Disorder 7 (GAD-7) score is an easy-to-use tool to determine anxiety. This study aimed to investigate the relationship between GAD‑7 score and patient outcomes in patients with COPD exacerbation in the ED.

Methods

A prospective, cross-sectional study was conducted in a tertiary academic ED between July 2019 and January 2021. Patients admitted to the ED with COPD exacerbation were included. A GAD‑7 score of ≥ 10 was defined as clinically significant anxiety. Negative outcomes were defined as a composite outcome that included recurrent ED visits, intensive care unit admission, and mortality. The relationship between clinically significant anxiety and negative outcomes within 30 days was determined.

Results

A total of 92 patients were assessed for eligibility and 80 were included in the study. Thirty-seven patients (46.3%) experienced negative outcomes. Although no significant difference was detected in median GAD‑7 scores between patients with positive and negative outcomes, negative outcomes were significantly higher in patients who had a GAD‑7 score of ≥ 10 (n = 25, p = 0.03). A sensitivity of 43.2%, specificity of 79.1%, positive likelihood ratio of 2.1 and negative likelihood ratio of 0.7 were determined for GAD‑7 score in predicting negative outcome.

Conclusion

In patients with COPD exacerbation in the ED, a GAD‑7 score of ≥ 10 was associated with 30-day negative outcomes.

Impact of anxiety and depression on the prognosis of copd exacerbations

Background

Frequent and highly prevalent as comorbidities in Chronic Obstructive Pulmonary Disease (COPD) patients, both depression and anxiety seem to have an impact on COPD prognosis. However, they are underdiagnosed and rarely treated properly.

Aim

To establish the prevalence of depression and anxiety in patients admitted for Acute Exacerbation of COPD (AECOPD) and determine their influence on COPD prognosis.

Methods

Prospective observational study conducted from October 1, 2016 to October 1, 2018 at the following centers in Galicia, Spain: Salnés County Hospital, Arquitecto Marcide, and Clinic Hospital Complex of Santiago de Compostela. Patients admitted for AECOPD who agreed to participate and completed the anxiety and depression scale (HADS) were included in the study.

Results

288 patients (46.8%) were included, mean age was 73.7 years (SD 10.9), 84.7% were male. 67.7% patients were diagnosed with probable depression, and depression was established in 41.7%; anxiety was probable in 68.2% and established in 35.4%. 60.4% of all patients showed symptoms of both anxiety and depression. Multivariate analysis relates established depression with a higher risk of late readmission (OR 2.06, 95% CI 1.28; 3.31) and a lower risk of mortality at 18 months (OR 0.57, 95% CI 0.37; 0.90).

Conclusion

The prevalence of anxiety and depression in COPD patients is high. Depression seems to be an independent factor for AECOPD, so early detection and a multidisciplinary approach could improve the prognosis of both entities. The study was approved by the Ethical Committee of Galicia (code 2016/460).

Assessing Symptom Burden and Depression in Subjects With Chronic Respiratory Insufficiency

Objectives: Patients with chronic respiratory insufficiency suffer from advanced disease, but their overall symptom burden is poorly described. We evaluated the symptoms and screening of depression in subjects with chronic respiratory insufficiency by using the Edmonton symptom assessment system (ESAS). Methods: In this retrospective study, 226 subjects with chronic respiratory insufficiency answered the ESAS questionnaire measuring symptoms on a scale from 0 (no symptoms) to 10 (worst possible symptom), and the depression scale (DEPS) questionnaire, in which the cut-off point for depressive symptoms is 9. Results: The most severe symptoms measured with ESAS (median [interquartile range]) were shortness of breath 4.0 (1.0-7.0), dry mouth 3.0 (1.0-7.0), tiredness 3.0 (1.0-6.0), and pain on movement 3.0 (0.0-6.0). Subjects with a chronic obstructive pulmonary disease as a cause for chronic respiratory insufficiency had significantly higher scores for shortness of breath, dry mouth, and loss of appetite compared to others. Subjects with DEPS ≥9 reported significantly higher symptom scores in all ESAS categories than subjects with DEPS <9. The area under the receiver operating characteristic curve for ESAS depression score predicting DEPS ≥9 was 0.840 (P < .001). If the ESAS depression score was 0, there was an 89% probability of the DEPS being <9, and if the ESAS depression score was ≥4, there was an 89% probability of the DEPS being ≥9. The relation between ESAS depression score and DEPS was independent of subjects' characteristics and other ESAS items. Conclusions: Subjects with chronic respiratory insufficiency suffer from a high symptom burden due to their advanced disease. The severity of symptoms increases with depression and 4 or more points in the depression question of ESAS should lead to a closer diagnostic evaluation of depression. Symptom-centered palliative care including psychosocial aspects should be early integrated into the treatment of respiratory insufficiency.

The HUNT study: Association of comorbidity clusters with long-term survival and incidence of exacerbation in a population-based Norwegian COPD cohort

BACKGROUND AND OBJECTIVE

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease often viewed as part of a multimorbidity complex. There is a need for better phenotyping of the disease, characterization of its interplay with other comorbidities and its association with long-term outcomes. This study aims to examine how clusters of comorbidities are associated with severe exacerbations and mortality in COPD.

METHODS

Participants with potential COPD were recruited from the second (1995-1997) and third (2006-2008) survey of the HUNT Study and followed up until April 2020. Ten objectively identified comorbidities were clustered using self-organizing maps. Severe COPD exacerbations requiring hospitalization were assessed using hospital data. All-cause mortality was collected from national registries. Multivariable Cox regression was used to calculate hazard ratios (HRs) with 95% CIs for the association between comorbidity clusters and all-cause mortality. Poisson regression was used to calculate incidence rate ratios (IRRs) with 95% CI for the cumulative number of severe exacerbations for each cluster.

RESULTS

Five distinct clusters were identified, including 'less comorbidity', 'psychological', 'cardiovascular', 'metabolic' and 'cachectic' clusters. Using the less comorbidity cluster as reference, the psychological and cachectic clusters were associated with all-cause mortality (HR 1.23 [1.04-1.45] and HR 1.83 [1.52-2.20], adjusted for age and sex). The same clusters also had increased risk of exacerbations (unadjusted IRR of 1.24 [95% CI 1.04-1.48] and 1.50 [95% CI 1.23-1.83], respectively).

CONCLUSION

During 25 years of follow-up, individuals in the psychological and cachectic clusters had increased mortality. Furthermore, these clusters were associated with increased risk of severe COPD exacerbations.

Depressive symptoms and chronic lung disease in middle-aged and older Chinese adults: Prospective bidirectional association and mediation analysis

BACKGROUND

We investigated the prospective bidirectional association between depressive symptoms and chronic lung disease (CLD) and explored biologically and behaviorally relevant mediators in this bidirectional association among Chinese middle-aged and older population in the China Health and Retirement Longitudinal Study.

METHODS

Multivariable-adjusted Cox proportional hazard models were used to examine baseline depressive symptoms in relation to incident CLD risk among 12,546 adults and examine CLD condition in association with incidence of elevated depressive symptoms among 6,929 participants from 2011 to 2018. Elevated depressive symptoms were assessed with the 10-item Center for Epidemiologic Studies Depression scale and CLD was determined by self-reported physician diagnosis. Causal mediation analysis was performed to examine the direct and indirect effects of a priori selected nine blood biomarkers and four lifestyle factors in the bidirectional association.

RESULTS

Elevated depressive symptoms significantly increased CLD risk by 68% (HR=1.68, 95%CI=1.46-1.93) after a mean follow-up of 5.9 years and the strong positive association was consistently shown in almost all the subgroups. Having positive CLD status at baseline was associated with 17% increased risk of developing elevated depressive symptoms (HR=1.17, 95%CI=1.01-1.35) during an average of 4.6 years follow-up period. Significant inflammatory, metabolic or pulmonary function related mediators were not identified.

LIMITATIONS

Inadequate follow-up time and limited mediator variable information may reduce chance of identifying significant mediators.

CONCLUSIONS

Elevated depressive symptoms and CLD were mutual risk factors in middle-aged and older Chinese adults. Early screening and treatment of depression is needed to reduce CLD risk and related comorbidities including new-onset depression so as to relieve substantial disease burdens of CLD and depression in China.

Prevalence and Newly Diagnosed Rates of Multimorbidity in Older Medicare Beneficiaries with COPD

Few studies have quantified the multimorbidity burden in older adults with chronic obstructive pulmonary disease (COPD) using large and generalizable data. Such evidence is essential to inform evidence-based research, clinical care, and resource allocation. This retrospective cohort study used a nationally representative sample of Medicare beneficiaries aged 65 years or older with COPD and 1:1 matched (on age, sex, and race) non-COPD beneficiaries to: (1) quantify the prevalence of multimorbidity at COPD onset and one-year later; (2) quantify the rates [per 100 person-years (PY)] of newly diagnosed multimorbidity during in the year prior to and in the year following COPD onset; and (3) compare multimorbidity prevalence in beneficiaries with and without COPD. Among 739,118 eligible beneficiaries with and without COPD, the average number of multimorbidity was 10.0 (SD = 4.7) and 1.0 (SD = 3.3), respectively. The most prevalent multimorbidity at COPD onset and at one-year after, respectively, were hypertension (70.8% and 80.2%), hyperlipidemia (52.2% and 64.8%), anemia (42.1% and 52.0%), arthritis (39.8% and 47.7%), and congestive heart failure (CHF) (31.3% and 38.8%). Conditions with the highest newly diagnosed rates before and following COPD onset, respectively, included hypertension (39.8 and 32.3 per 100 PY), hyperlipidemia (22.8 and 27.6), anemia (17.8 and 20.3), CHF (16.2 and 13.2), and arthritis (12.9 and 13.2). COPD was significantly associated with increased odds of all measured conditions relative to non-COPD controls. This study updates existing literature with more current, generalizable findings of the substantial multimorbidity burden in medically complex older adults with COPD-necessary to inform patient-centered, multidimensional care.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.1968815 .

MULTI-PHACET: multidimensional clinical phenotyping of hospitalised acute COPD exacerbations

Background

The generic term “exacerbation” does not reflect the heterogeneity of acute exacerbations of COPD (AECOPD). We utilised a novel algorithmic strategy to profile exacerbation phenotypes based on underlying aetiologies.

Methods

Patients hospitalised for AECOPD (n=146) were investigated for aetiological contributors summarised in a mnemonic acronym ABCDEFGX (A: airway virus; B: bacterial; C: co-infection; D: depression/anxiety; E: eosinophils; F: failure (cardiac); G: general environment; X: unknown). Results from clinical investigations were combined to construct AECOPD phenotypes. Relationships to clinical outcomes were examined for both composite phenotypes and their specific aetiological components. Aetiologies identified at exacerbation were reassessed at outpatient follow-up.

Results

Hospitalised AECOPDs were remarkably diverse, with 26 distinct phenotypes identified. Multiple aetiologies were common (70%) and unidentifiable aetiology rare (4.1%). If viruses were detected (29.5%), patients had longer hospitalisation (7.7±5.6 versus 6.0±3.9 days, p=0.03) despite fewer “frequent exacerbators” (9.3% versus 37%, p=0.001) and lower mortality at 1 year (p=0.03). If bacterial infection was found (40.4%), patients were commonly “frequent exacerbators” (44% versus 18.4%, p=0.001). Eosinophilic exacerbations (28%) were associated with lower pH (7.32±0.06 versus 7.36±0.09, p=0.04), higher venous carbon dioxide tension (P_vCO2) (53.7±10.5 versus 48.8±12.8, p=0.04), greater noninvasive ventilation (NIV) usage (34.1% versus 18.1%) but shorter hospitalisation (4 (3–5) versus 6 (4–9) days, p<0.001) and lower infection rates (41.4% versus 80.9%, p<0.0001). Cardiac dysfunction and severe anxiety/depression were common in both infective and non-infective exacerbations. Characteristics identified at exacerbation often persisted after recovery.

Conclusions

Hospitalised AECOPDs have numerous causes, often in combination, that converge in complex, multi-faceted phenotypes. Clinically important differences in outcomes suggest that a phenotyping strategy based on aetiologies can enhance AECOPD management.

Hospitalised #AECOPD present as complex multidimensional clinical phenotypes, often comprising multiple distinct aetiologies. Profiling AECOPDs according to their multifactorial aetiological components has important prognostic and therapeutic implications.https://bit.ly/3nIHEnO

The Relationship Between Anxiety, Depression and Treatment Adherence in Chronic Obstructive Pulmonary Disease: A Systematic Review

Background

Almost half of the people with chronic obstructive pulmonary disease (COPD) do not adhere to the prescribed treatments and report anxiety and depression as comorbidities, resulting in higher rates of exacerbations, hospitalizations, and worse clinical outcomes.

Objective

This systematic review provided a synthesis of studies about the relationships between anxiety, depression, and adherence in people affected by COPD.

Methods

English language publications were searched in the PUBMED, SCOPUS, PsycInfo, Web of Science, PsycArticles, and Cochrane Library databases from December 2020 to March 2021, following PRISMA guidelines. The reference lists of eligible studies and other relevant systematic reviews were also searched. Data extraction and critical appraisal were undertaken by two reviewers working independently. The reference lists of eligible studies and other relevant systematic reviews were also searched. Data extraction and critical appraisal were undertaken by two reviewers working independently.

Results

A total of 34 studies (23 quantitative and 2 qualitative studies, 9 reviews) were included. The relationship between depression and treatment adherence was significant and negative. Adherence to both rehabilitation, psychological, and antidepressant pharmacological treatments in depressed patients was linked to a decreased risk of hospitalization. Moreover, depressed patients compliant with an antidepressant were more likely to adherent to COPD maintenance inhalers. On the other hand, the associations between anxiety and adherence were poorly investigated and high heterogeneity characterized the studies, leading to a weak and variable relationship as well as too few interventions.

Conclusion

The systematic review highlights the variability in estimates of the relationship between depression, anxiety, and treatment adherence in COPD. It could be explained by methodological differences across the included studies. This suggests that standardization is critical to improving the precision of the estimates. Recommendations for future research include attention to causal inferences, an exploration of mechanisms to explain the relationships between both anxiety and depression and adherence in COPD, and a comprehensive, systematic approach.

Chronic Obstructive Pulmonary Disease: Epidemiology, Biomarkers, and Paving the Way to Lung Cancer

Chronic obstructive pulmonary disease (COPD), the frequently fatal pathology of the respiratory tract, accounts for half a billion cases globally. COPD manifests via chronic inflammatory response to irritants, frequently to tobacco smoke. The progression of COPD from early onset to advanced disease leads to the loss of the alveolar wall, pulmonary hypertension, and fibrosis of the respiratory epithelium. Here, we focus on the epidemiology, progression, and biomarkers of COPD with a particular connection to lung cancer. Dissecting the cellular and molecular players in the progression of the disease, we aim to shed light on the role of smoking, which is responsible for the disease, or at least for the more severe symptoms and worse patient outcomes. We summarize the inflammatory conditions, as well as the role of EMT and fibroblasts in establishing a cancer-prone microenvironment, i.e., the soil for ‘COPD-derived’ lung cancer. We highlight that the major health problem of COPD can be alleviated via smoking cessation, early diagnosis, and abandonment of the usage of biomass fuels on a global basis.

Prevalence and Determinants of Mental Health among COPD Patients in a Population-Based Sample in Spain

(1) Background: To assess the prevalence of mental disorders (depression and anxiety), psychological distress, and psychiatric medications consumption among persons suffering from COPD; to compare this prevalence with non-COPD controls and to identify which variables are associated with worse mental health. (2) Methods: This is an epidemiological case-control study. The data were obtained from the Spanish National Health Survey 2017. Subjects were classified as COPD if they reported suffering from COPD and the diagnosis of this condition had been confirmed by a physician. For each case, we selected a non-COPD control matched by sex, age, and province of residence. Conditional logistic regression was used for multivariable analysis. (3) Results: The prevalence of mental disorders (33.9% vs. 17.1%; p < 0.001), psychological distress (35.4% vs. 18.2%; p < 0.001), and psychiatric medications consumption (34.1% vs. 21.9%; p < 0.001) was higher among COPD cases compared with non-COPD controls. After controlling for possible confounding variables, such as comorbid conditions and lifestyles, using multivariable regression, the probability of reporting mental disorders (OR 1.41; 95% CI 1.10–1.82).), psychological distress (OR 1.48; 95% CI 1.12–1.91), and psychiatric medications consumption (OR 1.38 95% CI 1.11–1.71) remained associated with COPD. Among COPD cases, being a woman, poor self-perceived health, more use of health services, and active smoking increased the probability of suffering from mental disorders, psychological distress, and psychiatric medication use. Stroke and chronic pain were the comorbidities more strongly associated with these mental health variables. (4) Conclusions: COPD patients have worse mental health and higher psychological distress and consume more psychiatric medications than non-COPD matched controls. Variables associated with poorer mental health included being a woman, poor self-perceived health, use of health services, and active smoking.

Depression, chronic obstructive pulmonary disease, and healthcare utilization: Results from the Korean Longitudinal Study of Aging (KLoSA)

BACKGROUND

Depression is a common comorbidity among people with chronic obstructive pulmonary disease (COPD), but the health effects of depression in this group of patients remain poorly understood. The purpose of the present study was to investigate the association between COPD and depression, and the effects of comorbid COPD and depression on health care utilization.

METHODS

Our study sample included 10,180 Korean adults (4,437 men and 5,743 women; all aged ≥ 45 years) who participated in the cross-sectional Korean Longitudinal Study of Aging (KLoSA). The participants were required to self-report any previous diagnosis of COPD. Depression was assessed with the 10-item Center for Epidemiologic Studies Depression Scale (CES-D10). Health care utilization was defined as multiple physician visits (≥6) and multiple hospital admissions (≥2) in the previous year.

RESULTS

Participants with COPD had a higher prevalence of depression than those without COPD (16.8% vs. 38.1%, respectively; P < 0.001). After adjustment for covariates, participants with COPD had a significantly higher likelihood of multiple physician visits (odds ratio [OR], 95% confidence interval [CI], 1.80 [1.26-2.58]) and multiple hospital admissions (OR [95% CI], 1.62 [1.04-3.51]), while those with COPD plus depression had a higher likelihood of multiple hospital admissions (OR [95% CI], 2.71 [2.34-5.48]).

CONCLUSIONS

We found a positive association between COPD and depression. Depression in patients with COPD is associated with an increased likelihood of multiple hospital admissions.

Sex differences in risk factors for depressive symptoms in patients with COPD: The 2014 and 2016 Korea National Health and Nutrition Examination Survey

Background

Although depression is a common comorbidity of chronic obstructive pulmonary disease (COPD), the role of sex remains unexplored. We evaluated sex differences of risk factors of depressive symptoms in adults with COPD.

Methods

This was a population-based cross-sectional study using data from the 2014 and 2016 Korea National Health and Nutrition Examination Survey. Spirometry was used to identify patients with COPD, defined as a FEV₁/FVC ratio < 0.7. Presence of depressive symptoms was defined as a total score ≥ 5 on the Patient Health Questionnaire-9.

Results

17.8% of participants expressed depressive symptoms. Relative regression analysis revealed that female sex (RR 2.38; 95% CI 1.55–3.66; p < 0.001), living alone (RR 1.46; 95% CI 1.08–1.97; p = 0.013), current smoker (RR 1.70; 95% CI 1.15–2.52; p = 0.008), underweight (RR 1.58 95% CI 1.00–2.49; p = 0.049), and GOLD Stage III/IV (RR 1.92; 95% CI 1.19–3.09; p = 0.007) were the risk factors for depressive symptoms. Low income, living alone, multiple chronic disorders, and low BMI were risk factors of depressive symptoms in male, whereas low educational attainment, urban living, and current smoking were risk factors in female.

Conclusions

Female sex is a main risk factor of depressive symptoms in adults with COPD. As risk factors of depressive symptoms in COPD patients vary according to their sex, different approaches are needed to manage depression in males and females with COPD.

Developing a complex intervention whilst considering implementation: the TANDEM (Tailored intervention for ANxiety and DEpression Management) intervention for patients with chronic obstructive pulmonary disease (COPD)

BACKGROUND

Guidelines now call for a thorough and comprehensive description of the development of healthcare interventions to aid evaluation and understanding of the processes of change. This was the primary aim of this study but we also recognised that effective interventions are commonly not implemented in clinical practice. It is suggested that insufficient attention is given to the implementation process at the development phase of interventions. This study outlines the 5 step iterative process we adopted for considering both implementation and effectiveness issues from the outset of intervention development. We use the development of a complex intervention Tailored intervention for ANxiety and DEpression Management (TANDEM) in patients with chronic obstructive pulmonary disease to illustrate this process.

METHODS

Intervention development built upon the Medical Research Council framework for developing complex interventions and the person-based approach for development of behavioural interventions. Building an expert team, specifying theory, qualitative data collection and pre-piloting were all critical steps in our intervention development and are described here.

RESULTS

Contact with experts in the field, and explicitly building on previous work, ensured efficiency of design. Qualitative work suggested guiding principles for the intervention such as introducing mood in relation to breathlessness, and providing flexible tailoring to patients' needs, whilst implementation principles focused on training selected respiratory professionals and requiring supervision to ensure standards of care. Subsequent steps of intervention development, pre-piloting and intervention refinement led to an intervention that was deemed acceptable and if successful will be ready for implementation.

CONCLUSIONS

The TANDEM study was developed efficiently by building on previous work and considering implementation issues from the outset, with the aim that if shown to be effective it will have more rapid translation in to the health care system with accelerated patient benefits.

TRIAL REGISTRATION

ISRCTN ISRCTN59537391 . Registered on 20 March 2017. Protocol version 6.0, 22 April 2018.

Evaluation of Hospital Admission Status for Emergency Department Patients Seen for Chronic Obstructive Pulmonary Disease Exacerbation: A Retrospective Observational Study

Background: Chronic obstructive pulmonary disease (COPD) is a common and preventable condition. The disease accounts for a large economic burden in the US health care system. Better control and prevention of COPD exacerbations can help prevent presentations to already-crowded emergency departments (EDs) and hospitals. The objective of our study was to identify variables associated with hospital admission status in ED patients presenting with COPD exacerbation. Methods: We conducted a retrospective observational study of patients seen at 1 of 3 US EDs from 2012 to 2014 with a primary diagnosis related to COPD exacerbation. Hospital admission status was modeled using patient characteristic data via adaptive least absolute shrinkage and selection operator logistic regression. Study results are presented as adjusted odds ratios with 95% CIs. Planned post hoc model dependency and external data sensitivity analyses were conducted. Results: The study sample included 1,165 unique patients with COPD with an ED encounter related to exacerbation at 1 of the 3 reviewed hospitals. Approximately half of these patients had a hospital admission. Variables inversely associated with an admission included oxygen saturation and number of prior ED encounters for COPD exacerbation. Variables positively associated with admission were initial ED heart rate, patient age, and documented comorbidities of anxiety and/or depression. These mental health comorbidities had the strongest association with admission status. Conclusion: Understanding the characteristics of admitted patients may help direct resources and outpatient services to prevent encounters. Of note, the study revealed mental health variables as being strongly associated with admission status.

Anxiety sensitivity and respiratory disease outcomes among individuals with chronic obstructive pulmonary disease

OBJECTIVE

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Depression and anxiety worsen COPD and lead to greater respiratory symptom severity and health care utilization. Fear of physical sensations of anxiety (AS-P) is known to exacerbate respiratory symptoms. The current study investigated the unique contribution of AS-P in respiratory symptom exacerbations, emergency department visits, hospitalizations, and COPD-related functional health status, controlling for medical characteristics, depression, and anxiety.

METHOD

The sample included 535 adults with COPD (M_age = 56.57; 58.1% male). Participants were recruited from a web-based panel of adults with chronic respiratory disease and completed an online battery of self-report measures.

RESULTS

Consistent with hypotheses, AS-P significantly increased the likelihood of acute symptom exacerbations by 12% and respiratory-related emergency department visits and hospitalizations by 7% during the prior 12 month period. Additionally, AS-P demonstrated a unique, large effect (f² = 0.37) on COPD-related functional health status.

CONCLUSION

Fear of physical sensations contributed to worse respiratory outcomes and health care utilization among adults with COPD. Screening for AS-P may effectively identify at-risk COPD patients, while reducing AS-P through targeted interventions may result in decreased symptom severity, functional limitations, and burden on the health care system.

[Risk Assessment of Acute Exacerbation in COPD Patients in the Context of Pulmonary Follow-Up Rehabilitation Based on the Prevalence and Severity of Comorbidities]

INTRODUCTION

 Acute COPD exacerbations (AECOPD) in the context of pulmonary rehabilitation (PR) are frequent and dangerous complications and, in addition to impairing quality of life, lead to an interruption of PR and jeopardize PR success. In this study, a correlation between the health status and an increased risk of AECOPD is described. The question arises whether the Charlson Comorbidity Index (CCI) or the Cumulative Illness Rating Scale (CIRS) are suitable for the preventive detection of COPD patients at risk for exacerbation in PR.

PATIENTS AND METHODS

 In a retrospective study, data of COPD patients who underwent PR in 2018 were analyzed with the CCI as the primary endpoint. All data were taken from the Phoenix Clinical Information System, and COPD exacerbations were recorded. The 44 patients (22 with and 22 without exacerbation during PR) required according to the sample size planning were randomly recruited from this pool of patients (using a random list for each group). CCI and CIRS were determined for all the cases included in the two groups. The primary endpoint (CCI) was evaluated by group comparison of the arithmetic means and Welch test. This was supported by further statistical measures of position and dispersion (median, quartile, standard deviation).In addition, the optimal cut-off point for discrimination in AECOPD and non-AECOPD patients was obtained via Receiver Operating Characteristic (ROC) analysis for both the CCI and the CIRS.

RESULTS

 Out of 244 COPD patients who underwent PR for an average of 21 days, 59 (24 %) suffered AECOPD that required treatment during PR. The 22 patients with AECOPD had a mean CCI of 6.77 (SD: 1.97) and the 22 patients without AECOPD had a mean CCI of 4.32 (SD: 1.17). This difference of -2.45 was statistically significant at a level of significance of 5 % (p < 0.001; 95 % CI: [-3.45; -1.46]). The ROC analysis led to 6 as the optimal cut-off point for the CCI, with 81.8 % sensitivity for determining an AECOPD and 86.4 % specificity with an area under the curve (AUC) value of 0.87. The optimal cut-off point for CIRS was 19 with a sensitivity of 50 %, a specificity of 77.2 % and an AUC of 0.65.

CONCLUSION

 COPD patients with acute exacerbation during PR have a higher CCI. The CCI allows the risk of AECOPD to be assessed with high sensitivity and specificity in participants with COPD in an inpatient PR program.

Impact of insomnia and obstructive sleep apnea on the risk of acute exacerbation of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a major health burden worldwide. Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is characterized by worsening of patients' respiratory symptoms that requires a modification in medication. This event could accelerate disease progression and increase the risk of hospital admissions and mortality. Both insomnia and obstructive sleep apnea (OSA) are prevalent in patients with COPD, and are linked to increased susceptibility to AECOPD. Improper treatment of insomnia may increase the risk of adverse respiratory outcomes for patients with COPD, while effective continuous positive airway pressure (CPAP) treatment may reduce the risk of AECOPD and mortality in patients with overlap syndrome. Sleep disorders should be considered in clinical management for COPD.

BEAM study (Breathing, Education, Awareness, Movement): a randomised controlled feasibility trial of tai chi exercise in patients with COPD

BACKGROUND

Despite therapeutic advances, the management of chronic obstructive pulmonary disease (COPD) remains complex. There is growing interest in multidimensional, mind-body exercises to improve both physical and psychosocial aspects of COPD burden. Few US data are available in this population on tai chi (TC) a mind-body exercise incorporating physical activity, breathing and mindful awareness. We explored feasibility and preliminary efficacy of TC in COPD in an US academic medical setting.

METHODS

Patients with COPD Global Obstructive Lung Disease (GOLD) stages 2-4 were randomised to a 12-week TC programme or education control. At 12 weeks, those in TC were randomised again to continue in maintenance classes or not to further explore optimal duration. All groups were followed to 24 weeks. Feasibility/safety parameters were analysed descriptively. Preliminary between-group differences were estimated in symptoms (dyspnoea, fatigue), health-related quality-of-life (Chronic Respiratory Questionnaire CRQ), cognitive-emotional measures (mood, COPD self-efficacy) and functional status (6 min walk test, lower body strength, flexibility, physical activity).

RESULTS

Ninety-two subjects were randomised (N=61 TC, N=31 education). Mean age was 68±8 years, 66% male, mean forced expiratory volume in 1 s % predicted 57±13, 28% were GOLD stage 3-4. Overall retention was 85%. Nineteen adverse events occurred, most being study-unrelated COPD exacerbations. From baseline to 12 weeks, there were between-group improvements favouring TC, in CRQ-total (Cohen's d effect size (ES)=0.46; adj mean diff (AMD)=0.31), CRQ-emotion (ES=0.54; AMD=0.49), Centre for Epidemiologic Studies Depression (ES=-0.37; AMD=2.39) and Patient-Reported Outcome Measurement Information System (PROMIS)-fatigue (ES=-0.34; AMD=-0.17). From baseline to 24 weeks, there was an improvement favouring TC in CRQ-dyspnoea (ES=0.41; AMD=0.46). Among TC participants, there was a positive effect of maintenance classes on self-efficacy (ES=-0.69; AMD=-0.40), 6 min walk (ES=0.56; AMD=49.26 feet), PROMIS-fatigue (ES=-0.41; AMD=-0.28) and chair stand (0.43; AMD=0.56).

CONCLUSION

TC in patients with COPD is feasible and safe. Preliminary analyses support a potential modest role in improving quality-of-life, cognitive-emotional health and function that should be further studied.

TRIAL REGISTRATION NUMBER

NCT01551953.

IRB REFERENCE

BIDMC 2010P-000412; VA 2540.

Behavioural activation therapy for depression in adults with non-communicable diseases

BACKGROUND

Depression is common in people with non-communicable diseases (NCDs) such as cardiovascular disease, diabetes, cancer, and chronic respiratory conditions. The co-existence of depression and NCDs may affect health behaviours, compliance with treatment, physiological factors, and quality of life. This in turn is associated with worse outcomes for both conditions. Behavioural activation is not currently indicated for the treatment of depression in this population in the UK, but is increasingly being used to treat depression in adults.

OBJECTIVES

To examine the effects of behavioural activation compared with any control group for the treatment of depression in adults with NCDs. To examine the effects of behavioural activation compared with each control group separately (no treatment, waiting list, other psychological therapy, pharmacological treatment, or any other type of treatment as usual) for the treatment of depression in adults with NCDs.

SEARCH METHODS

We searched CCMD-CTR, CENTRAL, Ovid MEDLINE, Embase, four other databases, and two trial registers on 4 October 2019 to identify randomised controlled trials (RCTs) of behavioural activation for depression in participants with NCDs, together with grey literature and reference checking. We applied no restrictions on date, language, or publication status to the searches.

SELECTION CRITERIA

We included RCTs of behavioural activation for the treatment of depression in adults with one of four NCDs: cardiovascular disease, diabetes, cancer, and chronic respiratory conditions. Only participants with a formal diagnosis of both depression and an NCD were eligible. Studies were included if behavioural activation was the main component of the intervention. We included studies with any comparator that was not behavioural activation, and regardless of reported outcomes.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, including independent screening of titles/abstracts and full-text manuscripts, data extraction, and risk of bias assessments in duplicate. Where necessary, we contacted study authors for more information.

MAIN RESULTS

We included two studies, contributing data from 181 participants to the analyses. Both studies recruited participants from US hospital clinics; one included people who were recovering from a stroke and the other women with breast cancer. For both studies, the intervention consisted of eight weeks of face-to-face behavioural therapy, with one study comparing to poststroke treatment as usual and the other comparing to problem-solving therapy. Both studies were at risk of performance bias and potential conflict of interest arising from author involvement in the development of the intervention. For one study, risks of selection bias and reporting bias were unclear and the study was judged at high risk of attrition bias. Treatment efficacy (remission) was greater for behavioural activation than for comparators in the short term (risk ratio (RR) 1.53, 95% confidence interval (CI) 0.98 to 2.38; low-certainty evidence) and medium term (RR 1.76, 95% CI 1.01 to 3.08; moderate-certainty evidence), but these estimates lacked precision and effects were reduced in the long term (RR 1.42, 95% CI 0.91 to 2.23; moderate-certainty evidence). We found no evidence of a difference in treatment acceptability in the short term (RR 1.81, 95% CI 0.68 to 4.82) and medium term (RR 0.88, 95% CI 0.25 to 3.10) (low-certainty evidence). There was no evidence of a difference in depression symptoms between behavioural activation and comparators (short term: MD -1.15, 95% CI -2.71 to 0.41; low-certainty evidence). One study found no difference for quality of life (short term: MD 0.40, 95% CI -0.16 to 0.96; low-certainty evidence), functioning (short term: MD 2.70, 95% CI -6.99 to 12.39; low-certainty evidence), and anxiety symptoms (short term: MD -1.70, 95% CI -4.50 to 1.10; low-certainty evidence). Neither study reported data on adverse effects.

AUTHORS' CONCLUSIONS

Evidence from this review was not sufficient to draw conclusions on the efficacy and acceptability of behavioural activation for the treatment of depression in adults with NCDs. A future review may wish to include, or focus on, studies of people with subthreshold depression or depression symptoms without a formal diagnosis, as this may inform whether behavioural activation could be used to treat mild or undiagnosed (or both) depressive symptoms in people with NCDs. Evidence from low-resource settings including low- and middle-income countries, for which behavioural activation may offer a feasible alternative to other treatments for depression, would be of interest.

Activities of daily living in patients with chronic obstructive pulmonary disease with depressive symptoms

ABSTRACT This cross-sectional study assessed the activities of daily living (ADL) and risk factors for developing depressive symptoms in patients with chronic obstructive pulmonary disease (COPD) and was carried out at the pulmonology outpatient clinic of the Hospital Universitário Oswaldo Cruz. Two hundred two (202) patients with COPD participated in the study. We evaluated the sociodemographic and anthropometric data, the ADL by means of Pulmonary Functional Status and Dyspnea Questionnaire - Modified version (PFSDQ-M), and the presence of depressive symptoms using the Beck Depression Inventory (BDI). All domains (dyspnea, fatigue and activity changes) of PFSDQ are compromised in patients with depressive symptoms. The prevalence of depressive symptoms was 38.6%. The chance of developing these symptoms was higher for those who used more than one bronchodilator (OR: 2.82, CI 95%: 1.47-5.38, p=0.002), presented dyslipidemias (OR: 2.74, CI95%: 1.24-6.07, p=0.012), had a heart disease (OR: 2.82, CI 95%: 1.18-6.74, p=0.020), presented expectoration (OR: 2.44, CI 95%: 1.2-4.95, p=0.014) or did not have a partner (OR: 2.58, CI 95%: 1.36-4.9, p=0.004). COPD patients with depressive symptoms had all domains of ADL compromised compared to patients without these symptoms.

Management of the COPD Patient with Comorbidities: An Experts Recommendation Document

Background

Chronic obstructive pulmonary disease (COPD) is associated with multiple comorbidities, which impact negatively on patients and are often underdiagnosed, thus lacking a proper management due to the absence of clear guidelines.

Purpose

To elaborate expert recommendations aimed to help healthcare professionals to provide the right care for treating COPD patients with comorbidities.

Methods

A modified RAND-UCLA appropriateness method consisting of nominal groups to draw up consensus recommendations (6 Spanish experts) and 2-Delphi rounds to validate them (23 Spanish experts) was performed.

Results

A panel of Spanish internal medicine experts reached consensus on 73 recommendations and 81 conclusions on the clinical consequences of the presence of comorbidities. In general, the experts reached consensus on the issues raised with regard to cardiovascular comorbidity and metabolic disorders. Consensus was reached on the use of selective serotonin reuptake inhibitors in cases of depression and the usefulness of referring patients with anxiety to respiratory rehabilitation programmes. The results also showed consensus on the usefulness of investigating the quality of sleep, the treatment of pain with opioids and the evaluation of osteoporosis by lateral chest radiography.

Conclusion

This study provides conclusions and recommendations that are intended to improve the management of the complexity of patients with COPD and important comorbidities, usually excluded from clinical trials.

The Association of Low Income and High Stress with Acute Care Use in COPD Patients

INTRODUCTION

Low-income chronic obstructive pulmonary disease (COPD) individuals are known to have higher rates of COPD-related hospitalizations and readmissions. Levels of psychological stress are also higher in low-income populations and may be associated with acute care use. We sought to: (1) determine the association between stress and acute care use in COPD, (2) evaluate the social determinants of health (SDH) in low and high stress individuals, and (3) determine the association between low income and high stress with acute care use.

MATERIALS AND METHODS

Using results from a survey-based study of individuals with COPD at the University of Alabama (UAB), we used multivariable regression modeling to evaluate the association of high stress with acute care use (COPD-related emergency department [ED] visits or hospitalizations). We then compared SDH between low and high stress groups and evaluated the association of low income + high stress with acute care use in a secondary model.

RESULTS

We included 126 individuals in our study. The high stress group was more likely to be < 65 years old and female. No differences in race, smoking, years of smoking, body mass index, dyspnea, or lung function (forced expiratory volume in 1 second [FEV1]%) by stress group were observed. The high stress group had a 2.5-fold increased adjusted odds of acute care use (adjusted odds ratio [AOR]95% confidence interval [CI], 2.51, 1.06-5.98) compared to the low stress group, while the low-income + high stress group had a 4-fold increased adjusted odds of acute care use (AOR, 95% CI, 4.38, 1.25-15-45) compared to high-income + low-stress group.

CONCLUSIONS

Acute care use and stress are associated in COPD. These associations are more pronounced in the low-income + high stress population who disproportionately contribute to health care utilization and frequently lack the resources needed to cope with stress.

Emergency room visits for chronic obstructive pulmonary disease in Illinois counties: An epidemiological study based on the Social Ecological Model

Objectives

This study aimed to determine the predictive capability of the Social Ecological Model for emergency room visits for acute exacerbation of chronic obstructive pulmonary disease.

Methods

County-level secondary data ( n = 102) on emergency room visits for chronic obstructive pulmonary disease were retrieved from the Illinois Department of Public Health for 2016. Data for variables operationalized from the intrapersonal, interpersonal, institutional, community, and public policy levels of the Social Ecological Model were retrieved from several sources. Geographic information system software was used to examine the spatial distribution of emergency room visits for chronic obstructive pulmonary disease in Illinois. Robust linear regression analysis was used to examine significant predictors of emergency room visits for chronic obstructive pulmonary disease.

Results

A regression model with all five levels of the Social Ecological Model accounted for 50% of the variability in emergency room visits for chronic obstructive pulmonary disease, F(24,77) = 4.62, p < 0.001. Statistically significant predictors of emergency room visits for chronic obstructive pulmonary disease were observed within the interpersonal, institutional, and community levels of the Social Ecological Model.

Discussion

Community health practitioners working to develop programs aimed at controlling chronic obstructive pulmonary disease exacerbations in Illinois should consider multiple levels of influence.

Tailored, psychological intervention for anxiety or depression in people with chronic obstructive pulmonary disease (COPD), TANDEM (Tailored intervention for ANxiety and DEpression Management in COPD): protocol for a randomised controlled trial

BACKGROUND

People with chronic obstructive pulmonary disease (COPD) are at increased risk of depression and anxiety, which greatly reduces their quality of life and is associated with worse outcomes; but these psychological co-morbidities are under-recognised and undertreated in COPD patients. Pulmonary rehabilitation (PR) improves mood for up to 6 months but health practitioners under-refer, and patients commonly fail to attend/complete PR. Research suggests that complex non-pharmacological interventions, including both psychological and exercise components, may reduce anxiety and depression in COPD. We have developed a tailored, cognitive behavioural approach (CBA) intervention for patients with COPD and co-morbid anxiety and/or depression ('TANDEM'), which precedes and optimises the benefits of currently offered PR. We hypothesise that such a psychological intervention, delivered by supervised, trained respiratory healthcare professionals, will improve mood in patients with mild to moderate anxiety and/or depression and encourage uptake and completion of PR.

METHODS

We will conduct a multi-centre, pragmatic, randomised controlled trial of the TANDEM intervention compared to usual care across the Midlands, London, the South East and Bristol, UK. We will train healthcare professionals familiar with COPD to deliver the manualised, tailored, face-to-face, one-to-one intervention weekly for 6-8 weeks. We will recruit 430 participants from primary, community and secondary care with confirmed COPD and moderate to very severe airflow limitation, who are eligible for assessment for PR, and who screen positive for symptoms of mild/moderate depression and/or anxiety using the Hospital Anxiety and Depression scale (HADS). Participants will be randomised 1.25:1 (intervention: usual care). The co-primary outcomes are the HADS anxiety and depression subscale scores at 6 months; participants will be followed up to 12 months. Secondary outcomes include uptake and completion of PR and healthcare resource use. There will be a parallel process evaluation and a health economic evaluation.

DISCUSSION

The TANDEM intervention has the potential to optimise the unrealised synergy between a psychological intervention and PR. The CBA sessions will precede PR and target individuals' cognitions, behaviours and symptoms associated with anxiety and depression to decrease psychological morbidity and increase effective self-management amongst patients with COPD.

TRIAL REGISTRATION

ISRCTN, ID: ISRCTN59537391. Registered on 20 March 2017. Protocol version 6.0, 22 April 2018.

Improvement In Self-Reported Physical Functioning With Tiotropium/Olodaterol In Central And Eastern European COPD Patients

Background

Reduced physical activity is associated with increased morbidity and mortality in patients with COPD. Studies suggest that treatment with the long-acting muscarinic antagonist tiotropium and the long-acting β₂-agonist olodaterol increases exercise capacity. This study assessed the effects of a fixed-dose combination (FDC) of tiotropium/olodaterol (delivered via Respimat^®) on physical functioning in patients with stable COPD in a “real-world setting”.

Methods

An international, open-label, single-arm, non-interventional study conducted in nine countries measuring changes in self-reported physical functioning in COPD patients treated with tiotropium/olodaterol 5/5 μg FDC for approximately 6 weeks. The primary endpoint was therapeutic success, defined as a minimum 10-point increase in the 10-question Physical Functioning Questionnaire (PF-10) score. Secondary endpoints included absolute change in PF-10 from Visit 1 to Visit 2, patient general condition (measured by Physician’s Global Evaluation score) and patient satisfaction with the treatment and device (assessed by Patient Satisfaction Questionnaire at the end of the study period).

Results

Therapeutic success was observed in 67.8% of 7218 patients (95% CI 66.7, 68.8) in the final analysis set after approximately 6 weeks of treatment with tiotropium/olodaterol. Mean change in PF-10 score between Visit 1 and Visit 2 was 16.6 points (95% CI 16.2, 17.0). Therapeutic success was 64.3% (95% CI 63.0–65.6%) in patients with infrequent (≤1) and 76.1% (95% CI 74.3–77.9%) in patients with frequent (≥2) exacerbations (p<0.0001). Patient general condition improved as indicated by an improvement in Physician’s Global Evaluation scores between visits. Most patients were very satisfied or satisfied with tiotropium/olodaterol treatment in general (81%), reported inhalation satisfaction (85%), and satisfactory handling of the device (84%). 1.3% of patients reported an investigator-defined drug-related adverse event.

Conclusion

Treatment with tiotropium/olodaterol led to an improvement in self-reported physical functioning in patients with COPD.

Cognitive behavioural therapy (CBT) for patients with chronic lung disease and psychological comorbidities undergoing pulmonary rehabilitation

Background

The study aimed to determine the effects of adding cognitive behavioural therapy (CBT) to pulmonary rehabilitation to treat patients with chronic lung disease and comorbid anxiety and/or depression symptoms.

Methods

An open, parallel group, randomised controlled trial (RCT) was conducted, with longitudinal follow-up of 12 months. CBT was delivered in 2 face-to-face sessions and 4 phone sessions to patients with depression or anxiety undergoing pulmonary rehabilitation. The main outcome measures were change in Geriatric Depression Scale (GDS) and Geriatric Anxiety Inventory (GAI); secondary outcomes were St. Georges Respiratory Questionnaire (SGRQ), 6-minute walk test (6MWT) and pulmonary rehabilitation attendance.

Results

A total of 65 patients were randomized to Intervention (n=24) and Control (n=41) groups. Of the 24 patients in the Intervention group, 6 patients (25%) withdrew and 4 patients (12.5%) failed to attend more than 2 CBT sessions, which was significantly more than the Control group. The majority of patients (75.4%) had chronic obstructive pulmonary disease. Fourteen (21.5%) had symptoms of depression only, 12 (18.4%) had symptoms of anxiety only, and 39 (60.0%) had symptoms of both anxiety and depression. In the Intervention group, GDS significantly improved at the end of pulmonary rehabilitation (mean difference -3.1, 95% CI: -4.39 to -1.70; P=0.0001), 3 months follow-up (mean difference -1.5, 95% CI: -4.17 to -0.75; P=0.008), and at 12 months follow-up (mean difference -1.6, 95% CI: -3.29 to -0.03, P=0.04), compared to baseline. The Control group demonstrated improvement in GDS by the end of pulmonary rehabilitation (mean difference -1.3, 95% CI: -2.4 to -0.27; P=0.01) which was not maintained at 3 months (P=0.14) and 12 months (P=0.25). GAI significantly improved by the end of rehabilitation in both the Intervention (mean difference -2.6, 95% -4.69 to -0.57; P=0.01) and Control groups (mean difference -2.6, 95% -4.16 to -1.14; P=0.001) and there was no significant improvement at 3 and 12 months. No statistically significant differences in changes in GDS or GAI were observed between the Intervention and Control groups at any time point. There was no significant improvement in SGRQ or 6MWT. There was a significant increase in attended pulmonary rehabilitation sessions in the Intervention group, compared to the Control group (mean difference 1.59; 95% CI: 0.11 to 3.07; P=0.03).

Conclusions

In this RCT of patients with chronic lung diseases attending pulmonary rehabilitation, there was no evidence found for improved symptoms of anxiety or depression or health-related quality of life with the addition of CBT given in a mixed face-to-face and telephone format, compared to usual care. Slower than anticipated recruitment, leading to a smaller than planned sample size, and a high dropout rate in the group allocated to CBT may have limited the effectiveness of the behavioural intervention approach in this study.

Behavioural interventions targeting physical activity improve psychocognitive outcomes in COPD

This study explored the impact of a self-management behaviour modification (SMBM) programme with/without bronchodilators and with/without exercise training (ExT) to improve daily physical activity on psychological and cognitive outcomes in COPD patients as a secondary analysis of the PHYSACTO trial. A 12-week, four-group, randomised, partially double-blind, placebo-controlled, parallel-group trial of SMBM in addition to tiotropium 5 µg, tiotropium/olodaterol 5/5 µg, tiotropium/olodaterol 5/5 µg plus ExT, or placebo was conducted in 304 patients. Outcomes included anxiety (Hospital Anxiety and Depression Scale (HADS)-A), depression (HADS-D and Patient-Health Questionnaire (PHQ)-9) and cognitive function (Montreal Cognitive Assessment (MoCA)). All outcomes showed statistically and clinically significant improvements after 12 weeks independent of treatment group. However, greater improvements in HADS-A and MoCA were seen in patients who exhibited greater increases in physical activity and exercise capacity, respectively, whereas greater improvements in HADS-D and PHQ-9 were seen in patients who exhibited increases in either physical activity or exercise capacity. The results indicate that SMBM with/without bronchodilators or ExT was associated with improved psychological and cognitive functioning. Anxiety reduced with increased physical activity, cognitive function improved with increased exercise capacity, and depression reduced with increases in either physical activity or exercise capacity. Interventions that increase daily physical activity or exercise capacity may improve psychological and cognitive outcomes in COPD.

Impact of Disease-Specific Fears on Pulmonary Rehabilitation Trajectories in Patients with COPD

Disease-specific fears predict health status in chronic obstructive pulmonary disease (COPD), but their role in pulmonary rehabilitation (PR) remains poorly understood and especially longer-term evaluations are lacking. We therefore investigated changes in disease-specific fears over the course of PR and six months after PR, and investigated associations with PR outcomes (COPD assessment test (CAT) and St. Georges respiratory questionnaire (SGRQ)) in a subset of patients with COPD (n = 146) undergoing a 3-week inpatient PR program as part of the STAR study (Clinicaltrials.gov, ID: NCT02966561). Disease-specific fears as measured with the COPD anxiety questionnaire improved after PR. For fear of dyspnea, fear of physical activity and fear of disease progression, improvements remained significant at six-month follow-up. Patients with higher disease-specific fears at baseline showed elevated symptom burden (CAT and SGRQ Symptom scores), which persisted after PR and at follow-up. Elevated disease-specific fears also resulted in reduced improvements in Quality of Life (SGRQ activity and impact scales) after PR and at follow-up. Finally, improvement in disease-specific fears was associated with improvement in symptom burden and quality of life. Adjustment for potential confounding variables (sex, smoking status, age, lung function, and depressive symptoms) resulted in comparable effects. These findings show the role of disease-specific fears in patients with COPD during PR and highlight the need to target disease-specific fears to further improve the effects of PR.

Contributions of cardiovascular risk and smoking to chronic obstructive pulmonary disease (COPD)-related changes in brain structure and function

Background

Brain damage and cardiovascular disease are extra-pulmonary manifestations of chronic obstructive pulmonary disease (COPD). Cardiovascular risk factors and smoking are contributors to neurodegeneration. This study investigates whether there is a specific, COPD-related deterioration in brain structure and function independent of cardiovascular risk factors and smoking.

Materials and methods

Neuroimaging and clinical markers of brain structure (micro- and macro-) and function (cognitive function and mood) were compared between 27 stable COPD patients (age: 63.0±9.1 years, 59.3% male, forced expiratory volume in 1 second [FEV1]: 58.1±18.0% pred.) and 23 non-COPD controls with >10 pack years smoking (age: 66.6±7.5 years, 52.2% male, FEV1: 100.6±19.1% pred.). Clinical relationships and group interactions with brain structure were also tested. All statistical analyses included correction for cardiovascular risk factors, smoking, and aortic stiffness.

Results

COPD patients had significantly worse cognitive function (p=0.011), lower mood (p=0.046), and greater gray matter atrophy (p=0.020). In COPD patients, lower mood was associated with markers of white matter (WM) microstructural damage (p<0.001), and lower lung function (FEV1/forced vital capacity and FEV1) with markers of both WM macro (p=0.047) and microstructural damage (p=0.028).

Conclusion

COPD is associated with both structural (gray matter atrophy) and functional (worse cognitive function and mood) brain changes that cannot be explained by measures of cardiovascular risk, aortic stiffness, or smoking history alone. These results have important implications to guide the development of new interventions to prevent or delay progression of neuropsychiatric comorbidities in COPD. Relationships found between mood and microstructural abnormalities suggest that in COPD, anxiety, and depression may occur secondary to WM damage. This could be used to better understand disabling symptoms such as breathlessness, improve health status, and reduce hospital admissions.

Depression predicts emergency care use in people with chronic obstructive pulmonary disease: a large cohort study in primary care

Background: Depression is common in people with chronic obstructive pulmonary disease (COPD) and has been associated with a variety of poor outcomes. A large proportion of health care costs in the UK are spent on emergency care. This study examined the prospective relationship between depression and use of emergency care in patients with COPD managed in primary care.

Methods: This was a twelve-month, prospective longitudinal study of 355 patients with COPD in six primary care practices in the UK. Baseline measures included demographic characteristics, depression and anxiety, severity of COPD, presence or absence of other chronic diseases, and prior use of emergency care. Outcome measures were (a) number of emergency department (ED) visits; or (b) an emergency hospital admission in the follow-up year.

Results: Older age, number of comorbid physical health conditions, severity of COPD, prior use of emergency care, and depression were all independently associated with both ED attendance and an emergency hospital admission in the follow-up year. Subthreshold depression (HADS depression score 4–7) was associated with a 2.8 times increased odds of emergency hospital admission, and HADS depression >8 was associated with 4.8 times increased odds.

Conclusion: Depression is a predictor of emergency care in COPD, independent of severity of disease or physical comorbidity. Even mild (subthreshold) symptoms of depression more than double the risk of using emergency care, suggesting there is a strong case to develop and deploy integrated preventive strategies in primary care that can promote mental health in people with COPD.

The efficacy of mindfulness-based interventions for patients with COPD: a systematic review and meta-analysis protocol

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a common chronic respiratory disease. It has adverse effects on patients' physical health, mental well-being and quality of life. The purpose of mindfulness-based interventions (MBIs) is to raise non-judgemental awareness and attention to current internal and external experiences. This means the attention is shifted from perceived and involuntary inner activities to current experience, keeping more curious, open and accepting attitudes towards current experience. Although some studies on the intervention effect of MBIs in patients with COPD have been conducted, the results are controversial, especially on dyspnoea, level of mindfulness and quality of life. Therefore, a systematic review of MBIs in patients with COPD is required to provide available evidence for further study.

METHODS AND ANALYSIS

In this study, different studies from various databases will be involved. Randomised controlled trials(RCTs)/quantitative studies, qualitative studies and case studies on the effect of MBIs in patients with COPD aged over 18 years will be included. We will search the literature in the databases of PubMed, Excepta Medica Base (EMBASE), Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, PsycINFO and China National Knowledge Infrastructure(CNKI). The primary outcomes will include efficacy of MBIs for patients with COPD in terms of dyspnoea, depression and anxiety. The secondary outcomes will include efficacy of MBIs in terms of quality of life, mindful awareness, 6-minute walk test(6MWT) and nutritional risk index. Data extraction will be conducted by two researchers independently, and risk of bias of the meta-analysis will be evaluated based on the Cochrane Handbook for Systematic Reviews of Interventions. All data analysis will be conducted by data statistics software Review Manager V.5.3. and Stata V.12.0.

ETHICS AND DISSEMINATION

Since this study is a systematic review, the findings are based on the published evidence. Therefore, examination and agreement by the ethics committee are not required in this study. We intend to publish the study results in a journal or conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42018102323.

Determinants for concomitant anxiety and depression in people living with chronic obstructive pulmonary disease

OBJECTIVE

Anxiety and depression are common comorbidities in people diagnosed with chronic obstructive pulmonary disease (COPD). Despite concomitant psychological symptomatology being reported in 22-48% of people with COPD, most literature focuses on identifying the risk factors for anxiety or depression separately. Therefore, our objective was to determine whether there is an association between people living with concomitant anxiety and depression and sociodemographic risk factors in people and living with COPD.

METHODS

This was a cross-sectional study of 242 people living with COPD. Symptomatology of anxiety and depression were assessed using the Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI-II). Univariate and multivariable logistic regression models were used to test the association between symptomatology and demographic predictor variables. Odds ratios and 95% confidence intervals were derived.

RESULTS

Of the 242 people included, 48.8% (n = 118) had no symptoms of anxiety or depression and 33.5%% (n = 81) had symptomatology for both. Multivariable modelling suggested younger age, having a carer, having a previous psychological medical history, having a higher number of comorbidities and poorer quality of life were associated with concomitant anxiety and depression compared to those without symptomatology.

CONCLUSION

Further work should be done to build upon our results which adds to the limited literature surrounding risk factors for concomitant psychological symptomatology to facilitate future discussion surrounding reducing these detrimental comorbidities in people with COPD.