Depression in COPD: Benefits of Treating Both Conditions

Depression in COPD: Treatments Reduce Visits to Emergency Department

Background: Depression is common in any chronic illness, including COPD. For example, in a three year study of 1,589 individuals with COPD about 1 in 4 individuals with COPD had persistent symptoms of depression over a three year period (CHEST 2016; volume 149: pages 916-926). Those with persistent or new-onset depression experienced more flare-ups (exacerbations) and a reduced walking distance.

Dr. Albrecht wrote about depression in COPD

Jennifer S. Albrecht, Ph.D., Assistant Professor at the University of Maryland School of Medicine

Study: Dr. Albrecht and colleagues from the University of Maryland School of Medicine reported on adherence to medications prescribed to treat both COPD and depression in the same individuals. Adherence refers to whether  you are taking the medications on schedule as prescribed by your health care professional.

The authors examined a random sample of those receiving Medicare who had two or more prescriptions filled for both COPD maintenance medications and anti-depressants. These individuals were followed for 12 months.

The study was published on-line in the journal Respiratory Medicine.

Results: Of the 16,075 individuals receiving Medicare, only 21% took their medications at least 80% of the time for COPD, and only 55% took their  anti-depressants at least 80% of the time. Compared to no use of medication and controlling for adherence to anti-depressants, higher levels of taking COPD medications were associated with a decreased risk of going to the Emergency Department (ED) and hospitalization. Also, higher levels of taking anti-depression medications led to fewer visits to the ED and hospitalizations compared to no use.

Depression in COPD in a woman

Woman with depression

Conclusions: Depression in COPD is common. Taking prescribed daily medications for both conditions – COPD and depression – can reduce the need for emergency visits and hospitalizations.

My Comments: There are many different reasons why someone does not take medications as prescribed even to help relieve symptoms (COPD → difficulty breathing; depression → feeling bad).

Some of the common reasons shared by patients in my practice for not taking medications are: cost (“It is very expensive”), lack of efficacy (“It doesn’t seem to work”), “I forget to take it,” and concern of side effects (“The TV add says that it may cause death”).

However, I often explain why I prescribe a particular medication, and review how to use a specific inhaler correctly. I ask the person to try the inhaler for 2-3 weeks (I usually give a sample), and that I will prescribe a different inhaler if it does not help with shortness of breath and/or reduce flare-ups (exacerbations).

Correct Inhaler Use: Study Shows Poor Adherence in Many Patients with COPD

Correct Inhaler Use: Factors of Poor Adherence

Background: Many studies show that correct inhaler use is poor in those with COPD. The technique of using inhalers can be challenging because there are four different kinds of ways that inhaled medications can be delivered. These include metered-dose inhalers, dry-powder inhalers, soft mist inhalers, and by a nebulizer.

In my practice, I always ask the patient, “Does the inhaler help your breathing?” If the person answers, “No,” or “I don’t know,” then I ask – “How are you using the inhaler?” Certainly, if the medication does not get deep into the lungs, it can not relax the muscle that wraps around the breathing tubes to open up the airways.

Advair was used in a study to assess correct inhaler use

Advair Diskus is a dry powder inhaler

Study: Dr. Sulaiman and colleagues at the Royal College of Surgeons in Dublin, Ireland, evaluated the correct use of the Advair Diskus in patients after discharge from the hospital for either a flare-up of COPD or for another reason. The reason for the study was to ask the question, “Why inhalers may not help?” for those with COPD. While in the hospital, patients were repeatedly shown how to use the inhaler each time the medication was taken, and a check list was used to make sure that the person was using the inhaler correctly.

Patients were instructed to use the inhaler as they had been shown in the hospital twice per day, and that someone would collect the inhaler between 26 to 30 days later. An electronic recording device was

Device to check correct inhaler use

Example of electronic audio recording device compared with size of a paper clip

attached to the Diskus at discharge from the hospital.  Each time that the person opened the inhaler, electronic recordings were made to calculate the time of use, the time period between doses, and whether the person used it correctly.

The study was published in the May 15, 2017, issue of the American Journal of Respiratory & Critical Care Medicine (volume 195; pages 1333-1343).

Results: There were 244 patients in the study; their mean age was 71 years. The authors calculated adherence which means whether someone is using the inhaler exactly as instructed. Actual adherence was 23% of expected if the doses were taken correctly and on time. Analyses showed three different patterns among the subjects: 1. 34% had low inhaler use and high error rates; 2. 25% had high inhaler use and high error rates; and 3. 36% had overall good adherence. Older age, mental impairment, and poor lung function on breathing tests were common in those with poor adherence and frequent errors.

 Conclusions: This study demonstrates that many patients with COPD fail to follow instructions for correct inhaler use despite repeated instructions. The results also help health care professionals understand why a inhaler may not be effective.

My Comments: These results are disappointing. It appears that some or many patients have physical and/or mental limitations that prevent correct inhaler use. This emphasizes that a spouse, family member, or caregiver should supervise their loved one when he/she uses the inhaler. In some cases, it is reasonable to try a different delivery system for the bronchodilator medications.