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*Corresponding Author: Iqbal Akhtar Khan, MBBS DTM FACTM PhD, Independent Scholar, Lahore-54792, Pakistan.
Citation: Iqbal Akhtar Khan and Hamza Iltaf Malik (2021) COPD, Depression and COVID-19 Pandemic: A Harrowing, Demoralizing and Deleterious Triad. Clinical Medical Reviews and Reports. 3(8); DOI: 10.31579/2690-8794/095
Copyright: © 2021, Iqbal Akhtar Khan, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 01 July 2021 | Accepted: 10 September 2021 | Published: 23 September 2021
Keywords: COPD, depression, COVID19 pandemic, social distancing, shielding, duicidal ideation
COPD is a highly incapacitating global public health problem, with pulmonary and extra-pulmonary manifestations and usually associated with significant concomitant chronic diseases. With enhanced understanding, it has extensively been reported as a complex, heterogeneous and dynamic disease affecting patients’ health beyond pulmones.
Depression, with prevalence of 322 million people, is a major contributor to the overall global burden of disease. In various epidemiological and clinical studies, its prevalence among patients with COPD varies from 18% to 80%. This deadly duo leads to excessive health care utilization rates and costs including increased rates of exacerbation, sub-optimal adherence to prescribed medications, increased hospital admissions, longer hospital stays and increased hospital readmissions. Moreover, there is increased risk of suicidal ideation, suicidal attempts, and suicidal drug overdose. It is a pity that, in significant cases, the co-morbidity remains under-recognized and under-treated.
The impact of prevailing COVID 19 pandemic, on the dual burden of COPD and depression, and possible remedial measures including “The 6 ways to boost one’s well-being-by Mental Heath UK, “The Living with the Times” toolkit--by WHO” and innovative add-ons like Dance Movement Therapy and Musical Engagement Therapy have been discussed.
Dr. William Briscoe, the then Head of the Pulmonary Division New York Hospital-Cornell Medical Center, was the first person to use the term “Chronic obstructive pulmonary disease (COPD), as an umbrella term for chronic bronchitis, emphysema, and chronic asthmatic bronchitis, at the 9th Aspen Emphysema Conference, in 1965. With enhanced understanding, COPD has extensively been reported as a complex [1], heterogeneous [2] and dynamic [3] disease affecting patients’ health beyond pulmones.
Houben-Wilke et al argue that COPD stands for “Complex obstructive pulmonary disease” [4]. Where as a variety of intra- and extra-pulmonary components and considerable variability between individuals have been reported, the present study deals with depression co-existing with COPD. The consequences of social isolation and shielding on such patients, in the prevailing COVID-19 pandemic, are also being discussed.
“In our society that sets high standards of perfection to be ok and wins, the depressed is commonly considered as an outsider, a marginalized person unable to be in line with standards and rhythms fast and competitive of the time we live”.
Romina Tavormina & Maurilio Tavormina [5].
Depression is a leading cause of ill health and disability worldwide and is a major contributor to the overall global burden of disease. According to the latest estimates from WHO, 322 million people are now living with depression [6]. Despite its enormous clinical and public health impact, depressive illness is often under-diagnosed and under-scored, particularly when it co-exists with physical ailment. This often causes great distress for patients who have mistakenly assumed that symptoms, such as weakness or fatigue, are due to an underlying medical condition [7].
Depression and COPD: Dual Burden
“Depression is the largest cause of mental ill health worldwide, described as a “global burden” or a “global crisis” -----World Federation for Mental Health (WFMH, 2012)
Whereas depression is a common emotional disturbance, its association with chronic diseases has been well documented in literature. The mechanisms responsible for depression in patients with COPD are likely to be multifactorial [8]. “Reactive’’ depression associated with declining health status is more common [9]. In various epidemiological and clinical studies, its prevalence among patients with COPD varies from 18% to 80% (10]. In United States alone, the population with COPD has the highest prevalence of depression amongst the three chronic conditions that affect 60 million people (diabetes, heart disease, and COPD) [11].
In a randomized case control Dutch study, it was found that the prevalence of depression in COPD patients, with severe airways obstruction (FEV1 <50>
In a Polish study, it was found that the incidence of depression was high in patients who had recently experienced an exacerbation (AECOPD) [16].In a US retrospective cohort on COPD patients of 40 years and above , it was found that COPD patients with comorbid depression were 77% more likely to have a COPD-related hospitalization, 48% more likely to have an ER visit, and 60% more likely to have a hospitalization/ ER visit compared to the COPD-Only cohort [17].
Of note, depression is a strong predictor for mortality in patients with COPD, among hospitalized [18] and community patients [19]. In a Dutch study, on hospitalized stable patients with COPD, the depressive symptoms were associated with mortality independent of other factors including male sex, older age and lower peak workload (Wpeak) [20]. Atlantis et al showed that the dual burden increased the risk of mortality by 83% compared to the COPD patients without comorbid depression [21].
Studies, at various settings, suggest that depression in COPD leads to excessive health care utilization rates and costs including increased risk of AECOPD [ 22], non-compliance with medical treatment [[23], increased hospital admission, [24], longer hospital stay, [18] and increased hospital readmission. [25]. In a Romanian exploratory analysis, derived from an ongoing cross-sectional study, carried out to evaluate levels of fatigue and impact on health-related quality of life/health status in patients with COPD, fatigue was the most common detected ‘general’ symptom and also one of the most under-recognised and under-treated manifestation of this malady [26].
Suicidal Ideation, Suicidal Attempts and Suicidal Drug Overdose
“A human being can survive almost anything, as long as she sees the end in sight. But depression is so insidious, and it compounds daily, that it’s impossible to ever see the end”.
Elizabeth Lee Wurtzel (1967-2020)--‘Prozac Nation’ Author
Depression is a well-established risk factor for suicide. In a large case–control study in Family Practices in England, the relative risk of suicide was significantly elevated among patients with COPD compared with those without major chronic illnesses (3.1% versus 1.9%, respectively) [27]. In The DEPREPOC (Depression in COPD), an observational, cross-sectional, multi-center Spanish study designed to analyze the prevalence of depression in COPD patients and to identify factors associated with depression, moderate to severe depression was associated with suicidal ideation [28].
While analyzing suicidal risk, in an epidemiological study in adults ages 18 and older in the United States, it was found that 27.2% of COPD patients had suicidal ideation as compared to 19.6% of subjects without COPD. The history of suicide attempt was significant (15.0% for COPD patients, 6.6% for subjects without COPD [29]. A mixed-methods US study, to examine the prevalence and correlates of suicidal ideation in patients with stable moderate to very severe COPD, revealed that this was common in COPD, may occur disproportionately in women, can persist despite mental health treatment, and had complex relationships with both health and life events. [30]. COPD patients with depression had 13.6- and 10.0-fold higher risks of suicidal attempts and suicidal drug overdose, respectively, than did controls, in a Taiwanese study. The risk was more pronounced in patients aged less than 50 years [31]
In a Korean study, based on data from the Fourth Korean National Health and Nutrition Examination Survey (KNHANES IV & V), suicidal ideation was reported by 16.0% of patients in stages I and II, by 23.8% of those in stages III and IV and by 15.7% of controls. The suicidal attempts were reported by 0.6% of patients in stages I and II, by 2.6% of those in stages III and IV and by 1.0% of controls [32]. It should be a matter of serious concern that an association between history of hospitalization and increased suicidal risk has been reported. In a Nested case–control study, based on data from five Danish national, medical, and administrative registries/databases, it was found that patients with a history of hospitalization with COPD were at a significantly increased risk of suicide compared with individuals without such a history. The association was more pronounced in women than in men and in individuals aged 61–95 years than the younger group and in persons with no history of psychiatric illness [33].
The epidemiological and clinical studies reveal that inadequately treated malady is associated with worse outcomes. The deleterious effects include sub-optimal adherence to pharmacotherapy, repeated episodes of AECOPD, increased hospitalization, prolonged length of stay, re-admissions and subsequently increased burden to healthcare system, more pronounced in resource limited countries where the budget is already over-run. Moreover, despite significantly higher toll of depressive disorders in patients with COPD than controls, the low percentage of such patients seeking psychiatric consultation suggests that there is an unmet need in the psychiatric care of COPD patients [34]. While the background information that the psychological status plays an intrinsic role in the overall well- being is ignored, such patients are regularly overlooked, often remain undiagnosed and rarely get access to adequate treatment [35]. In view of the severity of the problem, early detection and prompt intervention is crucial. Of imp, the UK NICE Guidelines for COPD advise that patients should be offered psychological therapies before they are prescribed anti-depressants [36]. Interestingly, “Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) Study” found a 30
In the context of the COVID-19 pandemic, it appears likely that there will be substantial increases in depression associated COPD equilateral is dire need to search for an effective interventional strategy. Following are the suggestions:
(a)—The Psychological First Aid Guidance
Mental Health UK has described the “The 6 Ways to Boost One’s Well-being While Staying Indoors” [52] which are easily doable and really well-rewarding.
(b)—WHO’s Unique Contribution: The “Living with the Times” toolkit containing illustrated posters with key messages for older adults on how to maintain their well-being during the COVID-19 pandemic, is a unique potentially beneficial approach [53].
(c)—Novel Add-ons: Dance Movements Therapy (DMT) and Musical Engagement Therapy have emerged as promising effective Add-ons in the management of COPD and depression and are worth trial in the prevailing situation. [54, 55].
DMT has aesthetic expression, attractive to both genders irrespective of age, tempting to those with disabilities, and a fruitful tool in developing self-confidence. [54]. Certain Organizations of National and International Disability, provide ample opportunities for disabled and would be of special interest to COPD patients, with disabilities, planning to avail the benefits of DMT. Solo dancing, while restricted to home, is a highly accessible, doable, feasible, sustainable and beneficial alternative. Online group-sessions for dance are available for those, willing to join.Interestingly, The Bezmialem Vakif University Istanbul Turkey has championed to initiate “The First Interventional (Clinical Trial) Study to Apply Dance-based Exercise Training in COPD” - with the goal to “to investigate the effect of creative dance-based exercise training on respiratory, balance and cognitive functions, respiratory and peripheral muscle strength and functional capacity in COPD patients”.
Music therapy (singing and listening), an inexpensive and readily accessible resource, has emerged as promising interventional strategy, with acceptance on wider scale, because of its unique link to the emotions and powerful soothing effect [55]. In a systematic review and meta-analysis of 26 studies, a statistically significant reduction in depression levels was found over time in the experimental (music intervention) group compared to a control / comparison group. In particular, elderly participants showed impressive improvements when they listened to music or participated in music therapy projects [56]. Of imp, in the Clinical Trials. gov entitled “Active and Passive Music Therapy Interventions”, sponsored by University of North Carolina Chapel Hill United States, it has been argued that: “Music therapy (MT) interventions are a cost-effective, accessible, and holistic treatment option with social, rhythmic, creative, sensorimotor, and respiratory components, giving them the potential to improve the quality of life for a diverse array of disorders”.
“COPD is an individual disease, I have yet to meet any two people with COPD would have the exact same symptoms and have reacted exactly the same to this horrible disease”.
Mary Clara Ultes (1946-2018)-- "Same Devil - Different Levels, Same Level - Different Devils"
Prevalence studies show that patients who have COPD are four times as likely to develop depression compared to those without COPD. Regrettably, this dual burden is under-recognized and under-treated. Pumar et al have argued that, in daily practice, the presence of psychological manifestations in patients with COPD is often regarded as a complication caused by the physical ailments [57]. Whereas it is known that pulmonary rehabilitation (PR) alleviates depression in patients with COPD and a reduction of depressive symptoms makes PR more effective, and patient are more motivated to cooperate actively with the therapist in the rehabilitation process [11],they are still under- referred, by the health care providers. A tailored, cognitive behavioral approach (CBA) intervention has been developed for patients with COPD and co- morbid anxiety and/or depression. This has been named TANDEM (Tailored intervention for Anxiety and Depression Management in COPD): Protocol for a Randomized Controlled Trial), and has been sponsored by Queen Mary, University of London. This trial would, most hopefully, optimize the unrealized synergy between a psychological intervention and PR. [58]. The fittest closing sentence is from"COPD Makes Things Harder, But Life is Fun"--
“Don’t despair. Life is not over. It is just more challenging”.
The authors are highly grateful to Prof. Nicolino Ambrosino Respirologist (Italy) and Prof. Amin Muhammad Gadit Clinical Professor of Psychiatry (Canada) for their scholarly advice to improve the manuscript.
The authors express great appreciation to Dr. Murad Ahmad Khan (Vancouver, BC) for his insightful suggestions and stimulating discussions, throughout the conduct of this study.
The authors declare that they have no direct and indirect financial, commercial, personal/career affiliation with the article, counting any individually held viewpoint that are relevant to their work, to disclose.
The authors received no financial support, from any quarter, for the research, authorship, and/or publication of this article.
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