Prevalence of Anxiety and Depression in Patient with Chronic Obstructive Pulmonary Disease

Anxiety and depression are very common comorbidities in patients with chronic obstructive pulmonary disease (COPD). This study was aimed at documenting the prevalence anxiety and depression in COPD patient attending tertiary level hospital. A quantitative cross sectional analytical study was carried out in 221 patients with previously diagnosed COPD. Participants were recruited from respiratory OPD at Tribhuvan University Teaching Hospital, Nepal. Anxiety and depression were screened using previously validated Nepalese version of Hospital Anxiety and Depression Scale (HADS) and dyspnea was assessed using the modified Medical Research Council Dyspnea Scale (mMRC). COPD Assessment Test (CAT) was used to measure the impact of COPD on daily life. Data was analyzed using SPSS version 16. Out of 221, 140 patients (63.3%) had anxiety and 153 patients (69.2%) had depression and 133 (60.2%) had both psychiatric symptoms. Factors associated with anxiety and depression in COPD patients were age, ethnicity, educational status, marital status, current working status, duration of illness, history of previous hospitalization, number of hospitalization in previous year, domiciliary oxygen therapy comorbidities along with dyspnea, CAT score. In conclusion, the study findings suggest that anxiety and depression are highly prevalent in COPD patients. 1Neuro Cardio and Multispeciality Hospital, Biratnagar, Nepal, 2Innovative college of health sciences, Kathmandu, Nepal, 3Lecturer, Nepal Institute of Health Sciences, Kathmandu, Nepal, 4Institute of Medicine, Biratnagar Nursing Campus, Biratnagar, Nepal


INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is defined as a disease state characterized by the presence of airflow obstruction due to chronic bronchitis or emphysema; the airflow obstruction is generally progressive, may be accompanied by airway hyperactivity, and may be partially reversible. 1 Globally around 65 million people are reported to suffer from moderate to severe COPD. Furthermore, COPD is currently fifth leading cause of death word wide and expected to rise to third by 2020. 2 Therefore, it is evident that increasing number of people is suffering from this disease and psychosocial consequences. 3 Persons with COPD have a high prevalence of psychological disorders and may function at a reduced level of efficiency due to neuropsychological impairments. Psychological status is independently related to all dimensions of health-related quality of life. Anxiety and depression are very common comorbidities in COPD and have significant impact on patients, their families, society, and the course of the disease. [4][5][6] Estimates of prevalence of anxiety and depression in COPD are generally higher than those reported in some other advanced chronic diseases. Screening for depression and anxiety may help to identify patients with poor quality of life and an urgent need for intervention in order to improve their health status. 7 Untreated and undetected anxiety and depressive symptoms may increase physical disability, morbidity, and health-care utilization. 8 While few published studies demonstrate that these disorders associated with COPD respond well to appropriate pharmacologic and non-pharmacologic therapy, only a small proportion of COPD patients with these disorders receive effective treatment. 7,9 Anxiety and depression are challenging to identify and treat because their symptoms often overlap with those of COPD. The causes of depression and anxiety symptoms are multifactorial and include behavioral, social and biological factors. 10 It has been argued that family may play a significantly important role in COPD given the higher prevalence of depression and anxiety in these patient populations and their association with important clinical features such as dyspnea. It has also been documented that unsupportive family relationships were associated with psychological distress. 11 A cross-sectional population-based postal survey of COPD patients revealed association of depression and anxiety with demographic, health-related quality of life and clinical characteristics of COPD patients seen in UK primary care. 12 Depression is also associated with lower patient-reported generic health status. The data suggest that assessment and treatment for depression and anxiety should be considered for all COPD patients, not just those with more severe clinical levels of disease. 13 Though anxiety and depression are significant comorbid conditions in chronic illnesses, little is known about the prevalence or risk factors for anxiety or depressive symptoms in patient with COPD. Thus it is important to identify those who have clinically significant anxiety or depressive symptoms and its associated factors.

MATERIALS AND METHODS
This was a cross-sectional analytical study conducted on 221 patients diagnosed with at the Outpatient department of Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal. Data was collected following an ethical approval from the Research Committee Maharajgunj Nursing Campus and Institutional Review Board of Tribhuvan University; Institute of Medicine. The sample size for this study was calculated based on similar study by our group. 14 After obtaining the formal permission from the hospital, purpose of the study was explained to the patient and they were explained about the study. Following this, an informed consent was obtained from each participant who met the inclusion criteria. Participant's confidentiality was maintained by using coding their personal identity information in all forms, and the information obtained was solely used for research purpose. The average time required to complete the interview was about 15-20 minutes following the familiarization. A structured interview based questionnaire was use to collect the information regarding the sociodemographic and disease and treatment related variables of the patient such as age, sex, address, ethnicity, religion, educational status, marital status, type of family, working status, smoking status, type of fuel used for cooking, and history of COPD in family, duration of illness, history of previous hospitalization, status of hospitalization in last year, currently used medicine, domiciliary oxygen therapy and other comorbidities. Anxiety and depression were screened using hospital anxiety depression rating scale. Dyspnea level was measured using modified Medical Research Council Dyspnea Scale. Impact of COPD on activities of daily living was assessed using COPD assessment Test (CAT).

Data Analysis Procedure
The collected data were checked daily and organized for completeness and accuracy. The collected data were then edited, coded, classified and then entered into Excel spreadsheet, which was later transferred to SPSS (Statistical Package for Social Science) version 16. Descriptive statistics such as frequency and percentages were used for categorical variables and mean and standard deviation was used for continuous variables. The relationship of various factors with anxiety and depression was analysed using chi-square test. Logistic regression was done to find out the most significant associated factor to anxiety and depression. The significance level (alpha) was set at 0.05 and a p value <0.05 was considered to be statistically significant.

RESULTS
221 patients diagnosed with COPD were included in the study. The mean age of patients was 68.16±10. 16 years and their age ranged from 44 to 90 years. Less than half of the patients (46.2%) were male. Regarding the ethnic group more than half (54.7%) of patient were from upper caste. Similarly, majority of patients 143 (64.7%) COPD were illiterate and most of the COPD patients (67.4%) were married. Regarding occupation, only 51 (23.1%) was involved in occupation currently. Likewise, 15.4% COPD patients were current smokers, less than half (42.5%) COPD patients had history of exposure to passive smoking. The mean duration of illness was 6.99±6.34 Years, 57% had previously hospitalized and 27.8 % had no any history of hospitalization in last year. Among COPD patients majority of patients 79.2% weren't dependent on domiciliary oxygen and only 53 patients had other comorbidities.

DISCUSSION
The study aimed to describe prevalence of anxiety and depression among COPD patients. The study demonstrated out of 221 patients, 140 patients (63.3%) had anxiety and 152 patients (69.2%) had depression. The mean HADS (±SD) anxiety score was 11.37 (± 6.894) and mean HADS (±SD) depression score was 11.18 (± 6.013). This finding is nearly consistent with the findings of the study including 60 COPD patients which show the mean scores for anxiety and depression were 8.2 ± 4.6 and 7.9 ± 4.3 respectively. Likewise in their study, 41.7% patients  A cross-sectional association was observed for anxiety/depression with different sociodemographic and clinical variables. Both anxiety and depression were associated with age (p=0.003, p=0.001) and were more prevalent in age group ≤70 years. This finding was supported by the study from Ray et al. VAT is a relatively common problem but in comparison to ventilator-associated pneumonia (VAP where age is associated with anxiety and depression. 17 In contrast, the age of the patient did not appear to be associated with both anxiety and depression in a study by Jose et al 18 Similarly in another study, compared with the oldest group (≥70 years old), the risk of anxiety and depression was 15% higher for those aged ≤ 50 years of age; those aged 51-70 also had an excess risk of 11%. Furthermore, in the present study higher number females score both in anxiety and depression scale than males, however there was no statistical significant relation between the scores of anxiety/ depression and gender. In a study by Xiao et al, it was reported that after adjustment for covariates, female patients were more likely to suffer from anxiety (aOR = 6.41, 95% CI: 1.73-23.80) than male patients. 19 Likewise, we found anxiety was associated with ethnicity (p=0.002), educational status (p=0.014), marital status (p=0.002) and occupational status (p=0.015) whereas depression was associated with marital status (p=0.001), working status (p=0.015) and smoking status (p=0.034). Balcells et al, 2010 also found that strong association between the working  20 A Korean study on the prevalence of depression and anxiety noted that smoking history were independent risk factors for depression in patients with COPD. 21 Further current smokers had a higher prevalence of both anxiety (54% vs. 37%) and depression (43% vs. 23%) than nonsmokers. 22 Some studies also found that living alone and low education levels were related to anxiety and depression in COPD. 23,24 A cross-sectional study from India gave a strong relationship with low level of education, poor socio-economic conditions and advanced age to depression. 25 Likewise Tsai et al., population-based studies on the association between chronic obstructive pulmonary disease (COPDfound in their study that age, gender, monthly income and hospitalization were significantly related to the risk of depression in COPD patients. Compared with the oldest group (≥70 years old), the risk of depression was 15% higher for those aged ≥ 50 years of age; those aged 51-70 also had an excess risk of 11%. 26 In another study, depression was related to the severity of pulmonary obstruction and anxiety was related to marital status and satisfaction with income. 22 Further anxiety was more common in women than in men (47% vs. 34 %) and current smokers had a higher prevalence of both anxiety (54% vs. 37%) and depression (43% vs. 23%) than non-smokers. 22 A cross sectional study among 121 COPD patients in Aligarh, India to assess the presence of anxiety and depression in COPD client attending OPD using Hospital anxiety and depression scale to examine depression and anxiety respectively showed that 69 (57.02%) and 44 (36.37%) patients out of 121 had depression and anxiety respectively. In addition, depression was more common in male gender, and this prevalence was also found to be positively associated with lower education class, social class, single marital status and cases residing urban locality. Likewise, prevalence of anxiety was more in female gender, rural locality, higher education and upper socioeconomic and marital status being single. 27 The present study showed that the age, current working status, use of domiciliary oxygen and mMRC Dyspnea score were the most significant factors associated with anxiety and depression in COPD. The factors associated with anxiety and depression in COPD patients were found same in the findings reported by Jose et al. These include duration of disease, number of hospitalizations in the previous year MMRC grade, oxygen therapy, and presence of other comorbodities. 18 Another study also reported that comorbidity, increased duration of disease diagnosis, increased dyspnea, increases the risk of depression in COPD patients. 23,26 The major limitations were absence of specialist evaluation for anxiety/depression and it was difficult to assume causality for anxiety and depression as it was a cross-sectional study.
In conclusion, the prevalence of anxiety and depression in chronic obstructive pulmonary disease is very high and a significant number of patients have both the co-morbidities. Age, current working status, use of domiciliary oxygen and dyspnea score were the most significant factor associated with anxiety and depression in COPD.
Considering the high prevalence of anxiety and depression among COPD patients, management of the psychiatric symptoms should be incorporated in the treatment of COPD. A routine screening test is recommended to detect the psychiatric morbidities among the COPD patients.