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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 10  |  Issue : 2  |  Page : 110-115

Risk of depression in patients with chronic obstructive pulmonary disease and its determinants


Department of Pulmonary Medicine, J.N. Medical College, Belagavi, Karnataka, India

Date of Web Publication30-May-2017

Correspondence Address:
Sujeer Khan
Department of Pulmonary Medicine, J.N. Medical College, Belagavi - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.ijhs_453_16

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  Abstract 

Background and Objectives: Depression is an important comorbid condition of chronic obstructive pulmonary disease (COPD). There is a risk of undertreatment for depression in patients with COPD as depressive symptoms, including suicidal tendencies, can erroneously be conceptualized as an understandable reaction to COPD and not as signs of an independent depressive disorder. The exact prevalence of depression in COPD patients among the Indian population is unknown.
Aim: This study aims to know the prevalence of depression in COPD patients attending tertiary care hospital.
Materials and Methods: A total of 120 COPD patients were enrolled in the study according to Global initiative for COPD (GOLD) criteria 2015. They were screened for depression as per Beck's depression score.
Results: Eighteen patients in stage 1, 66 patients in stage 2, 29 patients in stage 3, and 7 patients in stage 4 of the COPD were enrolled. The prevalence of depression in the study population was 55%.
Conclusion: The prevalence of depression in COPD is very high. The factors associated with depression in COPD patients were the duration of the disease, body mass index, GOLD stage, and smoking. Duration of the disease and smoking was the most significant factors associated with depression in COPD. Patients with COPD should be screened for depression and those with higher depression score should undergo further evaluation. Further studies involving larger number of subjects from several centers are required to study the prevalence of depression in Indian patients with COPD.

Keywords: Beck's depression score, chronic obstructive pulmonary disease, depression


How to cite this article:
Khan S, Patil BB. Risk of depression in patients with chronic obstructive pulmonary disease and its determinants. Indian J Health Sci Biomed Res 2017;10:110-5

How to cite this URL:
Khan S, Patil BB. Risk of depression in patients with chronic obstructive pulmonary disease and its determinants. Indian J Health Sci Biomed Res [serial online] 2017 [cited 2017 Oct 18];10:110-5. Available from: http://www.ijournalhs.org/text.asp?2017/10/2/110/207263


  Introduction Top


Chronic obstructive pulmonary disease (COPD) is the fourth largest cause of death in the world, which kills more than 3 million people every year.[1] According to the World Health Organization, COPD will become the third biggest cause of death by the year 2030, and it is anticipated that mortality rates due to COPD will increase by over 160% over the next 2 decades.[2] Most COPD patients die because of other comorbid conditions that accompany COPD rather than the pulmonary disease. These include ischemic heart disease, diabetes, hypertension, renal disease, skeletal muscle dysfunction, osteoporosis, and depression.[3]

Many studies reported that the prevalence of depression in COPD is higher than that in other advanced chronic diseases. The presence of these comorbidities is related to decreased exercise capacity and health-related quality of life, poor adherence to pulmonary rehabilitation and COPD-related medications, functional disability and risk of exacerbation and mortality, loss of productivity and increased health resource use.

Although depression is a significant comorbid conditions in chronic illness, little is known about the prevalence or risk factors for depressive symptoms in patients with COPD in India. The prevalence rates of depression in COPD patients in India showed a wide variation, and there is little data available about the factors which contribute significantly for the development of depression in this chronic respiratory disease.

Despite their impact on the morbidity associated with COPD, these psychological consequences are rarely addressed.[4] The majority of the cases go undiagnosed either due to lack of awareness among treating physicians or due to overlapping of symptoms. Untreated depressive symptoms may increase physical disability, morbidity, and pressure on health-care facilities.[5] Depression can lead to nonadherence and reduced efforts to follow medical advice, which will further accelerate the disease progression. Hence, it is important to identify those who have clinically significant depressive symptoms.

There is a risk of under treatment for depression in patients with COPD as depressive symptoms including suicidal tendencies can erroneously be conceptualized as an independent depressive disorder.

Detection of depression in patients with COPD by a simple questionnaire will help respiratory physicians to diagnose it and appropriate treatment or referral. The exact prevalence of depression in COPD patients among Indian population is unknown. Hence, the present study was conducted to assess the risk of depression in patients with COPD using Beck depression inventory scale (BDI-S) and to find the association between disease-related factors and depression.


  Materials and Methods Top


This cross-sectional study was carried out on consecutive patients with COPD during their routine out- and in-patient visits in KLE's Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi from January 2015 to December 2015. The subjects were recruited on the basis of a written informed consent. The study was approved by the Institutional Ethics Committee.

Patients diagnosed as COPD based on the Global initiative for COPD (GOLD) criteria 2015 (postbronchodilator ratio of forced expiratory volume in 1 s [FEV1]/forced vital capacity [FVC] <0.70) with age >40 years were included in the study.

Patients with other chronic respiratory diseases such as bronchial asthma, bronchiectasis, and interstitial lung disease already diagnosed with behavioral abnormalities, pulmonary tuberculosis, HIV patients, patients with neurological deficit, and patients who are not able to participate in the study and did not give consent were excluded from the study.

All the participants diagnosed as a case of COPD as per GOLD will be subjected to a detailed evaluation of their personal information, present symptoms, history of cardiovascular diseases, diabetes mellitus, systemic hypertension, history of smoking, and other addictions. COPD diagnosis was confirmed as per GOLD criteria 2015. According to GOLD criteria 2015, spirometric criterion for the diagnosis of COPD is postbronchodilator value FEV1/FVC < 0.70. Further based on FEV1% predicted COPD is classified into four stages as follows [Table 1].
Table 1: Staging of chronic obstructive pulmonary disease

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Kannada translation of BDI-2 scale was self-administered to literate patients. For illiterate patients, help was sought from either relative or paramedical workers to read out the questionnaire and to record the responses. The BDI-2 is scored by summing the ratings for the 21 items. Each item is rated on a four-point scale ranging from 0 to 3. Add up the score for each of the 21 questions by counting the number to the right of each question marked. The highest possible total score for the whole test would be 63 and lowest possible score for the test would be 0. The levels of depression can be evaluated according to the score below. Depending on the total score, the severity of depression was classified as follows normal (0–10), mild (11–16), borderline (17–20), moderate (21–30), severe (31–40), and extreme depression (>40).

Statistical analysis

The data obtained was coded and entered into the Microsoft Excel spreadsheet. The categorical data were expressed as rates, ratios, and percentages. Continuous data were expressed as mean ± standard deviation (SD). The categorical data were analyzed using Chi-square test and continuous data were analyzed using independent t-test. A P < 0.05 was considered as statistically significant. Quantitative analyses were performed using Karl Pearson's correlation coefficient, comparison of GOLD stage with depression was performed using one-way ANOVA.

In this model, the dependent variable was the score on the BDI-2, and the independent variable was age, sex, occupation, body mass index (BMI) and comorbidities, smoking, duration of the disease and GOLD stage. The relationship between demographic and clinical variables and depression in patients with COPD was assessed by performing multiple logistic regression analyses with the score on the BDI-2 as the dependent variable. All analyses were carried out using SPSS 8.0.2 for Windows (SPSS Inc. Released 2009. PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc.).


  Results Top


A total of 120 patients were included in the study. Out of these, 104 patients (86.67%) were males and 16 patients (13.3%) were females. The mean age of the study population was 63.77 ± 9.00 years (mean ± SD). The demographic characteristics of the patients and spirometric values are summarized in [Table 2].
Table 2: Demographics, spirometry data, and mean depression of the study population

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Among the 120 patients of COPD 54 (45%) were found to be without depression and 66 (55%) were found to have depression using BDI-2 score. Of the 120 patients, 6 (5%) had mild depression, 18 (15%) had moderate depression, 42 (35%) had severe depression, and none of the patients were having borderline and extreme depression [Figure 1].
Figure 1: Depression wise distribution

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The factors which were found to have a significant association (P < 0.05) with depression in COPD patients were the duration of the disease, BMI, GOLD stage, and smoking [Table 3] and [Table 4]. Multiple regression analysis was done to find out the most significant factor associated with depression. It showed that duration of the disease (P = 0.0011) and smoking (P = 0.0435) were the most significant factors associated with depression [Table 5].
Table 3: Association of various factors with depression in chronic obstructive pulmonary disease patients

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Table 4: Association of Socioeconomic status and Global Initiative for COP with depression in chronic obstructive pulmonary disease patients

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Table 5: Multiple regression analysis of depression scores by other variables

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  Discussion Top


COPD is a major cause of disability and death worldwide. In contrast to the marked decline in mortality and morbidity observed with other major chronic diseases, trends for COPD are continuously increasing.[6]

One area that has advanced is the recognition of the psychosocial impacts of COPD, in particular, the psychiatric diagnoses of depression and anxiety. Several studies done in the past proved that COPD is associated with increased prevalence of depression, but studies analyzing the prevalence of depression in COPD and its determinants in the Indian population are very few. Hence, the current study is undertaken to know the risk of depression and its determinants in COPD patients in a tertiary care hospital.

In the present study, we investigated the prevalence of undiagnosed depression in COPD patients. The prevalence of depression in the present study is 55%. In a review of three studies, Solano et al.[7] had observed the prevalence of depression ranged from 37% to 71% of COPD patients and the cumulative prevalence rate of depression in our study is comparable with their results.

The prevalence of depression varies widely in different populations, which could be attributed to different ethnicity, different cultural backgrounds and heterogeneous demography of the study populations and different screening tools.

There is no standardized approach for the diagnosis of depression in COPD patients because of the differences in the methodology and variability of the screening questionnaires in cutoff points to determine a diagnosis of depression. Hence, the wide range that is observed among different studies.

The prevalence of depression as observed by earlier studies was 13.2%.[7],[8] However, studies from other countries reported the prevalence of depression in patients with COPD varying from 6% to 56%.[9],[10],[11] The study by Negi et al. found a prevalence of depression of 33%.[12]

The prevalence rates of depression in the general population of India varies from 21% to 83%, and one large study from the urban area of south India had reported the prevalence of depression is 25.7% among a population of more than 60 years of age.[13] In a group of 13 inpatients with chest diseases, Singh et al. had observed the prevalence of depression as 53.8%.[14]

Wagena et al. failed to show any significant association between the severity of COPD and the level of depression.[15] Whereas, Manen et al. observed that the patients with mild to moderate COPD severity are not at increased risk for depression but patient with severe COPD had 2.5 times (95% confidence interval, 1.2–5.4) higher risk of depression.[16] The present study showed that the prevalence of depression increases with the severity of COPD (P = 0.0054).

An Indian study which looked into the prevalence and risk factors for depressive symptoms in 126 stable patients concluded that educational and occupational status, BMI, FEV1, respiratory symptoms, physical impairment, and dyspnea were the potential predictors of depression in COPD patients.[12] Similarly, in this study, the factors which were found to have a significant association (P < 0.05) with depression in COPD patients were the duration of the disease, BMI, GOLD stage, and smoking. A number of studies have demonstrated that patients with COPD who also suffer from depression or anxiety are more likely to be smokers. The primary association appears to be between depression and smoking. The association of smoking and depression is due to nicotine dependency rather than smoking index.[17] The population in the present study did not participate in any smoking cessation program.

Neither comorbidities nor occupational status showed any significant association with depression in COPD patients in this study. When the correlation between depression score with other variables was calculated GOLD stage (P =0.0004) and duration of the disease (P =0.0001) showed a positive correlation and FEV1 (P =.0007), BMI (P =.0005), and socioeconomic status (P =.0425) showed a negative correlation with depression which were statistically significant.

In the present study, the comparison of GOLD stages with mean depression showed that as the severity of stages of COPD increases the prevalence of depression also increases, hence those patients who falls in GOLD Stage 3 and 4 should be screened for depression. The present study also showed that the duration of the disease and smoking were the most significant factors associated with depression in COPD.

The available evidence suggests that less than one-third of COPD patients with comorbid depression are receiving appropriate treatment for this. To address these barriers, an integrated treatment approach is required from the health-care professionals, patients, and caregivers. In addition, the health-care providers should be ready to provide appropriate resources to improve the quality of service provision and clinical practice. The strength of the study is we utilized a structured analytical tool for the estimation of the frequency of psychiatric comorbidities in COPD patients.

The limitations of the present study need to be mentioned. In this study, the samples were selected from a single center and percentage of female patients was less. In our study population, female patients with obstruction had a history of exposure to other risk factors, but none were current or ex-smoker. Hence in this study, in females, the risk factors of COPD other than smoking could not be compared for the development of depression in females. Furthermore, the impact of treatment of depression on COPD was not covered as part of the study. The role of pulmonary rehabilitation in the treatment of COPD and depression is questionable as the patients did not have the pulmonary rehabilitation program. Similarly, the role of smoking cessation in treating COPD with depression could not be elicited as none of the patients were under smoking cessation program.


  Conclusion Top


This study gives the prevalence of depression in COPD is very high. The factors associated with depression in COPD patients were the duration of the disease, BMI, GOLD stage, and smoking. Duration of the disease and smoking were the most significant factors associated with depression in COPD. Patients with COPD should be screened for depression and those with higher depression score should undergo further evaluation. Further studies involving a larger number of subjects from several centers are required to study the prevalence of depression in Indian patients with COPD.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Salvi S. COPD: The neglected epidemic. In: Jindal SK, editor. Textbook of Pulmonary and Critical Care Medicine. New Delhi: Jaypee Brothers Medical Publishers; 2011. p. 971-4.  Back to cited text no. 1
    
2.
The Global Burden of Disease, WHO; October, 2008. Available from: http://www.who.int/healthinfo/global_burden_disease/projections/en/. [Last accessed on 2015 Sep 17].  Back to cited text no. 2
    
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Limaye S, Salvi S. Risk factors for COPD. In: Jindal SK, editor. Textbook of Pulmonary and Critical Care Medicine. Vol. 2. New Delhi: Jaypee Publications; 2011. p. 987-92.  Back to cited text no. 3
    
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Hill K, Geist R, Goldstein RS, Lacasse Y. Anxiety and depression in end-stage COPD. Eur Respir J 2008;31:667-77.  Back to cited text no. 4
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6.
Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet 1997;349:1436-42.  Back to cited text no. 6
    
7.
Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage 2006;31:58-69.  Back to cited text no. 7
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Kahraman H, Orhan FO, Sucakli MH, Ozer A, Koksal N, Sen B. Temperament and character profiles of male COPD patients. J Thorac Dis 2013;5:406-13.  Back to cited text no. 8
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Fan VS, Ramsey SD, Giardino ND, Make BJ, Emery CF, Diaz PT, et al. Sex, depression, and risk of hospitalization and mortality in chronic obstructive pulmonary disease. Arch Intern Med 2007;167:2345-53.  Back to cited text no. 9
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Cinciripini PM, Wetter DW, Fouladi RT, Blalock JA, Carter BL, Cinciripini LG, et al. The effects of depressed mood on smoking cessation: Mediation by postcessation self-efficacy. J Consult Clin Psychol 2003;71:292-301.  Back to cited text no. 11
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Negi H, Sarkar M, Raval AD, Pandey K, Das P. Presence of depression its risk factors in patients with chronic obstructive pulmonary disease. Indian J Med Res 2014;139:402-8.  Back to cited text no. 12
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Poongothai S, Pradeepa R, Ganesan A, Mohan V. Prevalence of depression in a large urban South Indian population – The Chennai Urban Rural Epidemiology Study (CURES-70). PLoS One 2009;4:e7185.  Back to cited text no. 13
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Singh G, Sachdev JS, Kaur H. Prevalence of depression among medical in-patients. Indian J Psychiatry1979;21:274-8.  Back to cited text no. 14
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Wagena EJ, Arrindell WA, Wouters EF, van Schayck CP. Are patients with COPD psychologically distressed? Eur Respir J 2005;26:242-8.  Back to cited text no. 15
    
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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