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Independent Effect of Depression and Anxiety on Chronic Obstructive Pulmonary Disease Exacerbations and Hospitalizations

¹ Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada; ² Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University Health Center, Montreal, Canada; ³ Child and Family Research Institute, Children's and Women's Health Center, Department of Pediatrics and Department of Health Care and Epidemiology, University of British Columbia, Vancouver, Canada; and ⁴ Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China

Correspondence and requests for reprints should be addressed to Chen Wang, Ph.D., Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, No. 8, Bai Jia Zhuang Road, Chaoyang District, Beijing, China, 100020, E-mail: cyh-birm{at}263.net; and to Jean Bourbeau, M.D., Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Room k1.32, 3650 St. Urbain Street, Montreal, PQ, Canada H2X 2P4, E-mail: jean.bourbeau{at}mcgill.ca

Rationale: Depression and anxiety are significant comorbid and potentially modifiable conditions in chronic obstructive pulmonary disease (COPD), but their effects on exacerbations are not clear.

Objectives: To investigate the independent effect of depression and anxiety on the risk of COPD exacerbations and hospitalizations.

Methods: A multicenter prospective cohort study in 491 patients with stable COPD in China. Multivariate Poisson and linear regression analyses were used, respectively, to estimate adjusted incidence rate ratios (IRRs) and adjusted effects on duration of events.

Measurements and Main Results: Depression and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS) at baseline. Other measurements included sociodemographic, clinical, psychosocial, and treatment characteristics. Patients were then monitored monthly for 12 months to document the occurrence and characteristics of COPD exacerbations and hospitalizations. Exacerbation was determined using both symptom-based (worsening of 1 key symptom) and event-based definitions (1 symptom worsening plus 1 change in regular medications). A total of 876 symptom-based and 450 event-based exacerbations were recorded, among which 183 led to hospitalization. Probable depression (HADS depression score 11) was associated with an increased risk of symptom-based exacerbations (adjusted IRR, 1.51; 95% confidence interval [CI], 1.01–2.24), event-based exacerbations (adjusted IRR, 1.56; 95% CI, 1.02–2.40), and hospitalization (adjusted IRR, 1.72; 95% CI, 1.04–2.85) compared with nondepression (score 7). The duration of event-based exacerbations was 1.92 (1.04–3.54) times longer for patients with probable anxiety (HADS anxiety score 11) than those with no anxiety (score 7).

Conclusions: This study suggests a possible causal effect of depression on COPD exacerbations and hospitalizations. Further studies are warranted to confirm this finding and to test the effectiveness of antidepressants and psychotherapies on reducing exacerbations and improving health resource utilizations.

Key Words: chronic obstructive pulmonary disease • exacerbation • depression • anxiety • risk factor

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject Depression and anxiety are significant comorbid and potentially modifiable conditions in chronic obstructive pulmonary disease, but their effects on exacerbations are not clear. What This Study Adds to the Field This study suggests a possible causal association between depression and chronic obstructive pulmonary disease exacerbation and hospitalization. Interventional trials appear to be warranted to evaluate the effectiveness of antidepressants and psychotherapies on reducing exacerbations.