Editorials
Age and Ageing 2006; 35: 457–459 © The Author 2006. Published by Oxford University Press on behalf of the British Geriatrics Society.
doi:10.1093/ageing/afl011 All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Published electronically 25 April 2006
Depression and anxiety in elderly patients with
chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD) is a major
cause of morbidity, disability and mortality in old age [1]. It
has been predicted that COPD will be the world’s fifth-
ranking cause of disability by 2020 [2]. Co-morbid psycho-
logical impairments (depression and anxiety) are common
in COPD and are often associated with increased disability
and morbidity. They also impair quality of life in COPD and
are often not fully explored in the clinical management of
COPD patients.
In the UK, the National Institute of Clinical Excellence
COPD Guidelines [1] estimates the prevalence of depres-
sion in COPD to be 40% (36–44%) and suggests that anx-
iety symptoms may have a prevalence of 36% (31–41%)
[3]. With such a high prevalence, why is depression so
often undetected and untreated? First, recognition of
co-morbid depression is difficult, because some of the
physical symptoms of COPD may mimic the core symp-
toms of depression, for example, poor sleeping pattern,
anorexia and loss of enjoyment due to breathlessness. Sec-
ond, screening tools for depression and anxiety symptoms
are not routinely employed by health care professionals
caring for COPD patients. Third, patients often deny that
they are suffering from anxiety and depression, perhaps
because of perceptions of the stigma attached to these
problems [4].
Unrecognised and untreated depression has major
implications in compliance with medical treatment and
may increase the frequency of consultation with health
services, for example, in primary care [5]. In COPD, it
increases the likelihood of hospital admission in those
most severely disabled [4].
Anxiety is common in patients with COPD. It is often
associated with clinical depression, and a study from our
centre identified that 37% of depressed COPD patients had
clinical anxiety compared with 5% of non-depressed COPD
patients [4].
COPD is among a number of medical disorders associ-
ated with a high rate of depression. The wide range of con-
ditions suggest that the aetiology is multifactorial. Suggested
mechanisms include cerebrovascular and microangiopathy
(heart disease, diabetes), localised disruption to fronto-
striatal brain circuits (stroke), social adversity (diabetes) and
neurodegenerative brain disease (Alzheimer’s disease, idio-
pathic Parkinson’s disease), pain (arthritis, cancer) and
oncological therapy (cancer) [6]. Furthermore, there is
robust evidence that depression worsens the outcome and
mortality of many of these conditions [6], and this has been
demonstrated for COPD too [7]. There is little data regard-
ing aetiological mechanisms leading to depression in
Downloaded from https://academic.oup.com/ageing/article-abstract/35/5/457/9724 by guest on 03 March 2020
COPD. However, disability and handicap are powerful pre-
dictors of depression and are likely to be the major determi-
nants in COPD [8]. Whether biological mechanisms play a
significant role has not been clarified.
Is it feasible to screen COPD patients for
anxiety and depression?
Routine screening for depression in patients with COPD
would be justified if (i) there was an adequately tested
and validated tool available that was simple and user-
friendly and (ii) treatment of psychological difficulties in
this situation was effective and acceptable to the patient
population. The evidence base at present suggests that
the former condition is satisfied but the latter is probably
not.
We have recently validated the Brief Assessment
Schedule Depression Cards [BASDEC] [4] to diagnose
depression in this patient group. The BASDEC per-
formed with a sensitivity of 100% and a specificity of
90% when compared against the Geriatric Mental State
Schedule which is a research benchmark for the diagno-
sis of clinical depression. The BASDEC is simple to use,
takes about 5 min to administer at the bedside and can be
done by any health care professional following brief
training.
Before employing a screening tool, it is important to
explain the purpose and relevance of assessment to patients.
In our experience, many patients with elevated depression
scores tend to deny that they are suffering from depression
and refuse to accept either treatment or referral to a mental
health care specialist [9].
After diagnosing co-morbid anxiety or depression, it is
also important to explain why seeking treatment for depres-
sion is potentially worthwhile. Health care professionals
should be aware of patients’ misgivings and be prepared to
help the patient come to a decision about treatment. Having
a choice of interventions may help this process. A recent
study of depressed patients in a primary care setting that
investigated patients’ preferred choice of treatment (anti-
depressant medication versus counselling) reported a better
response and compliance with treatment in patients who
had a choice of treatment compared with a non-choice
comparison group [10].
457
A. M. Yohannes et al.
It is also worth exploring how family and friends may
be involved in supporting the patient and to encourage
social interaction. Educating the spouse, family members
and friends about depression may help them to understand
the consequences of the disease and to develop coping
strategies and in turn may reduce the likelihood of isola-
tion. A very recent study [11] that investigated the bene-
fits of emotional support by family and friends and of
spiritual beliefs in patients with major depression showed
that those with higher perceived emotional support had
better outcomes.
Treatment of depression in COPD
Evidence for the benefit of antidepressant therapy for older
COPD patients with depression is sparse and inconclusive.
A single-blinded study in our department using the selective
serotonin reuptake inhibitor fluoxetine in older COPD
patients was unsuccessful [9]. This trial failed because
majority of the patients refused to participate in the study,
and one-third of the patients withdrew from the trial because
of side-effects. Those who refused the treatment reported
that they could not understand the relevance of antidepres-
sant therapy to their condition. Similar findings were also
reported by Lacasse et al. [12] in a 12-week, randomised
double-blind placebo-controlled trial of paroxetine in end-
stage COPD using the Chronic Respiratory Questionnaire
(CRQ) as an outcome measure. Although a small sample
size, the intention-to-treat analysis did not show improve-
ment in CRQ scores. Again, this study identified the diffi-
culties of treating patients with antidepressant therapy in the
frail and elderly with COPD.
Kunik and co-workers [13] found a significant
improvement in anxiety and depression scores in a group
of depressed patients given a single 2-h session of cogni-
tive behavioural therapy (CBT) compared with education
alone. This is an interesting and potentially cost-effective
approach.
Withers et al. [14] and Emery et al. [15] have reported
that pulmonary rehabilitation (PR) improves depression
and anxiety in some COPD patients. The PR programmes
combined both depressed and non-depressed patients and
included exercise and educational therapy and (in some)
relaxation therapy. It is unclear why depression scores
improved in some patients in a given PR programme but
not others. It may be an artefact of the statistical analysis
and the fact that the trials were not designed with depres-
sion as a dependent variable. Not all PR programmes
employ a substantial amount of psychological therapy for
those with high levels of depression and anxiety symptoms.
Future studies should focus on an individually tailored pro-
gramme with emphasis on psychological therapy to quan-
tify which aspects of therapy are effective for this patient
group.
Undetected and untreated depression in COPD patients
is common and is often associated with increased disability
and health care usage and impaired quality of life. Further
studies are required to examine the benefits of CBT and
antidepressant therapy in the treatment of depression and
458
anxiety in elderly patients with COPD. Whether depression
depends on the level of disability independent of age is
unclear, because there are no studies that have investigated
whether anxiety and depression are more common in elderly
patients with COPD than younger ones with the same level
of disability.
ABEBAW MENGISTU YOHANNES1*,
R. C. BALDWIN2, M. J. CONNOLLY3
1
Department of Physiotherapy, Manchester Metropolitan
University, Manchester, UK
2
Department of Old Age Psychiatry, University of Manchester,
Manchester, UK
3
Downloaded from https://academic.oup.com/ageing/article-abstract/35/5/457/9724 by guest on 03 March 2020
Department of Geriatric Medicine, University of Auckland,
Auckland, New Zealand
*To whom correspondence should be addressed at:
Senior Lecturer, Department of Physiotherapy,
Manchester Metropolitan University,
Elizabeth Gaskell Campus, Hathersage Road,
Manchester M13 0JA, UK
Tel: (+44) 161 247 2943
Fax: (+44) 161 247 6571
Email: a.yohannes@mmu.ac.uk
References
1. National Institute for Clinical Excellence. National clinical
guidelines on management of chronic obstructive pulmonary
disease in adults in primary and secondary care. Thorax 2004;
59 (Suppl. 1): 1–232.
2. Murray CJ, Lopez AD. Alternative projections of mortality
and disability by cause 1990–2020: global burden of disease
study. Lancet 1997; 349: 1498–504.
3. Yohannes AM, Baldwin RC, Connolly MJ. Mood disorders in
elderly patients with chronic obstructive pulmonary disease.
Rev Clin Gerontol 2000; 10: 193–202.
4. Yohannes AM, Baldwin RC, Connolly MJ. Depression and
anxiety in elderly outpatients with chronic obstructive pulmo-
nary disease: prevalence, and validation of the BASDEC
screening questionnaire. Int J Geriatr Psychiatry 2000; 15:
1090–6.
5. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk
factor for non-compliance with medical treatment: meta-
analysis of the effects of anxiety and depression on patient
adherence. Arch Intern Med 2000; 160: 2101–7.
6. Evans DL, Charney DS, Lewis L et al. Mood disorders in the
medically ill: scientific review and recommendations. Biol Psy-
chiatry, 2005; 58: 175–89.
7. Yohannes AM, Baldwin RC, Connolly MJ. Predictors of 1-
year mortality in patients discharged from hospital following
acute exacerbation of chronic obstructive pulmonary disease.
Age Ageing 2005; 34: 491–6.
8. Prince MJ, Harwood RH, Thomas A, Mann AH. A prospective
population-based cohort study of the effects of disablement
and social milieu on the onset and maintenance of late-life
depression. The Gospel Oak Project VII. Psychol Med 1998;
28: 337–50.
9. Yohannes AM, Connolly MJ, Baldwin RC. A feasibility of
antidepressant drug therapy in depressed elderly patients with
chronic obstructive pulmonary disease. Int J Geriatr Psychia-
try 2001; 16: 451–4.

10. Lin P, Campbell DG, Chaney EF et al. The influence of patient
preference on depression treatment in primary care. Ann
Behav Med 2005; 30: 3002–9.
11. Nasser EH, Overholser JC. Recovery from major depression:
the role of support from family, friends, and spiritual beliefs.
Acta Psychiatr Scand 2005; 111: 125–32.
12. Lacasse Y, Beaudoin L, Rousseau L, Maltais F. Randomized
trial of paroxetine in end-stage COPD. Monaldi Arch Chest
Dis 2004; 61: 140–7.
13. Kunik ME, Braun U, Stanley MA et al. One session cogni-
tive behavioural therapy for elderly patients with chronic
Age and Ageing 2006; 35: 459–460 © The Author 2006. Published by Oxford University Press on behalf of the British Geriatrics Society.
doi:10.1093/ageing/afl069 All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Published electronically 14 July 2006
Palliative care for older people
Do older people have equitable access to specialist palliative
care? A number of studies addressing this question have
been published in recent years; however, all have methodo-
logical flaws limiting the generalisation of their findings.
Therefore, the systematic review by Burt and Raine [1] on
the effect of age on referral to and use of specialist palliative
care services in adult cancer patients is particularly welcome.
They find some evidence that older cancer patients are less
likely to be referred to or use specialist palliative care serv-
ices, but emphasise the failure of all studies to consider vari-
ations in the need for such services. Consideration of need
is crucial when evaluating equity of access to health services.
The authors conclude that ‘Sensitive and flexible prospec-
tive methods should be developed to examine the extent to
which the use of specialist palliative care is fair’. This is true.
However, is it the most urgent question to be asked now
regarding palliative care for older people?
The need for comprehensive and high-quality palliative
care provision for all patients regardless of age, diagnosis
and geography is now a given [2, 3]. There is also the wide-
spread recognition that the palliative care needs of the eld-
erly require specific attention [4–10]. Unusually in the field
of palliative care, central funding in support of service
development has become available in recent years [11–14].
Such monies have financed more equitable spread of serv-
ices across networks and specific initiatives in end of life
care. Such initiatives, including the Gold Standards Frame-
work, Liverpool Care Pathway for the Dying and the Pre-
ferred Place of Care Document, aim to improve provision
of general palliative care for all and to prompt referral to
specialist palliative care services as necessary [15].
These end-of-life initiatives are based on existing spe-
cialist palliative care expertise. However, new knowledge
and models are required to shape services to meet the needs
of older people at the end of their lives [5–8]. Work is in
progress to explore the values, attitudes and needs of the
older population in relation to dying, death and bereave-
ment [see for example 6, 16, 17]. Policy groups have been
established to evaluate the evidence base for palliative care
Editorials
obstructive pulmonary disease. Psychol Med 2001; 31:
599–606.
14. Withers NJ, Rudkin ST, White RJ. Anxiety and depression in
severe chronic obstructive pulmonary disease: the effects of
pulmonary rehabilitation. J Cardiopulm Rehabil 1999; 19:
362–5.
15. Emery CF, Schein RL, Hauck ER, MacIntyre NR.
Psychological and cognitive outcomes of a randomised
trial of exercise among patients with chronic obs-
tructive pulmonary disease. Health Psychol 1998; 17:
232–40.
Downloaded from https://academic.oup.com/ageing/article-abstract/35/5/457/9724 by guest on 03 March 2020
service provision, needs and service models for specific
conditions prevalent in the elderly, such as dementia [5].
Any model of palliative care provision for the elderly must
also address cross-cutting factors relevant to the older
population in general, for example increasing frailty, comor-
bidities, increased psychosocial vulnerability and altered
physiology [5–7]. Most people say that they want to die at
home but few do. Service-based research is under way to
explore the reasons why this is the case and to develop or
redesign services to facilitate home deaths for those who
choose this [18].
There can be no doubt that new models are needed for
end-of-life care. Nationally, there are 2,674 specialist palliative
care (hospice) inpatient beds [19] and a shortfall of specialist
palliative care professionals. Such specialist resources are
unlikely to expand significantly. Therefore, we do need to
establish and monitor how best to use these services. Mean-
while, there is a pressing need to improve palliative and
terminal care for patients in their current locations and to
promote patient choice regarding place of care and death.
Specifically, palliative care for patients in hospitals and care
homes needs to be improved, and the number of people
enabled to die at home needs to be increased [3, 8, 18]. For
this to happen, a system-based approach is required, with
collaboration among patients, carers and providers and
commissioners of services at all levels. The context includes
societal attitudes and practices, in relation to advance care
planning, willingness to provide care for family and friends
to enable them to remain at home, the legality or otherwise
of assisted dying and how much we are prepared to pay per-
sonally and as a society for health and social care. The
framework incorporates the network of health and social
professionals and informal carers, with consideration of
who is best placed to meet needs without unnecessary
duplication or gaps [5, 6]. Necessary processes include
advance care planning regarding individual preferences for
place and goals of care; the development of competencies in
palliative care for different professionals, with appropriate
training in symptom management, psychosocial care and
459