Evidence-Based Reviews

COPD: How to manage comorbid depression and anxiety

Current Psychiatry. 2003 November;2(11):45-54

References

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Discussion. Although the estimated prevalence of anxiety among patients with COPD varies widely,¹⁰ anxiety is more prevalent in patients with severe lung disease.¹¹

Panic attacks and anxiety in COPD have been linked to hypoxia, hypercapnia, and hypocapnia. Hyperventilation leads to a decrease in pCO2 , causing a respiratory alkalosis that leads to cerebral vasoconstriction. This ultimately results in anxiety symptoms.

Box 2

Psychiatric comorbidities and COPD: Keys to coordinating care

Communication with other care team members is crucial to psychiatric treatment of patients with COPD. To ensure proper coordination of care:

Medication history. Report changes in psychiatric medication to all doctors. Obtain from the primary care physician a complete list of the patient’s medications and medical problems to prevent drug-drug interactions.
Onset of depression, anxiety. Report warning signs of depression and anxiety to other care team members, and urge doctors to refer patients who exhibit these signs. Primary care physicians often miss these potential warning signs:
Suicidality. Alert other doctors to the warning signs of suicidality. Patients older than 65 and those with depression or chronic health problems are at increased risk of suicide. Many patients with COPD exhibit the following risk factors:

In patients with severe COPD, chronic hypoventilation increases pCO 2 levels. This has been shown in animals to activate a medullary chemoreceptor, which elicits a panic response by activating neurons in the locus ceruleus.

Lactic acid, formed because of hypoxia, is also linked to panic attacks. Investigators have postulated that persons with both panic disorder and COPD are hypersensitive to lactic acid and hyperventilation.¹²

In some patients, shortness of breath causes anticipatory anxiety that can further decrease activity and worsen deconditioning.

The crippling fear that comes with an anxiety or panic disorder can also complicate COPD therapy. Panic and anxiety often interfere with weaning from mechanical ventilation, despite treatment with high-dose benzodiazepines in some cases.¹³ The more frequent or protracted the use of ventilation, the greater the risk of ventilator-associated pneumonia.

COPD drugs that cause anxiety. A comprehensive review of the patient’s medications and lab readings is crucial to planning treatment. Ms. P was concomitantly taking several drugs for COPD that can cause anxiety or panic symptoms (Table 2):

Bronchodilators such as albuterol are agonists that can increase heart rate and cause anxiety associated with rapid heartbeat.
Theophylline, which may act as a bronchodilator and respiratory stimulant, can cause anxiety, especially at blood levels >20 mg/mL. In Ms. P’s case, the combination of ciprofloxacin and theophylline caused a CYP-450 interaction that increased her theophylline level. This is because ciprofloxacin and most other quinolone antibiotics are CYP 1A2 inducers, whereas theophylline is a CYP 1A2 substrate.⁹
High-dose corticosteroids (eg, methylprednisolone) also may contribute to anxiety.

Treatment. SSRIs are an accepted first-line therapy for COPD-related anxiety. Buspirone may also work in some COPD patients. Anticonvulsants such as gabapentin and divalproex are possible adjuncts to antidepressants.

Routine use of benzodiazepines is not recommended to treat anxiety in COPD for several reasons:

These agents can cause respiratory depression in higher doses and thus may be dangerous to patients with end-stage COPD. Reports indicate that benzodiazepines may worsen pulmonary status.¹⁴
Rebound anxiety may occur when the drug is cleared from the system. This may accelerate benzodiazepine use, which can lead to excessively high doses and/or addiction.

Antihistamines such as hydroxyzine are a nonaddictive alternative to benzodiazepines for anxiety control. They may be used as an adjunct to antidepressants if alcohol or drug addiction are present. These agents, however, may have sedating and anticholinergic side effects.

Beta blockers, commonly used to treat performance anxiety, may worsen pulmonary status and are contraindicated in COPD patients.

COPD and comorbidities. Many patients with COPD are taking several medications for comorbid hypertension, diabetes, coronary artery disease, or congestive heart failure. These other conditions or medications may contribute to psychiatric symptoms, diminish the effectiveness of psychiatric treatment, or cause an adverse interaction with a psychotropic.

A thorough review of the patient’s medical records is strongly recommended. Communication with other care team members is critical (Box 2).

PSYCHOSOCIAL TREATMENT

Cognitive-behavioral therapy (CBT) may be effective in treating COPD-related anxiety and depression. CBT involves the correction of unrealistic and harmful thought patterns (such as cat-astrophizing shortness of breath) through techniques such as guided imagery and relaxation. Breathing exercises are also used.⁶

Medically stable patients can be taught “interoceptive exposure” techniques by learning to induce panic symptoms in a controlled setting (such as by hyperventilating in the doctor’s office), then desensitizing themselves to the anxiety. Exposure can also be used in social settings to accustom the patient to feared stimuli.