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Published ahead of print on August 28, 2008, doi:10.1164/rccm.200804-619OC

Am. J. Respir. Crit. Care Med., Volume 178, Number 9, November 2008, 913-920

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Submitted on April 27, 2008
Accepted on August 28, 2008

Independent Effect of Depression and Anxiety on COPD Exacerbations and Hospitalizations

Wanning Xu1, Jean-Paul Collet2, Stanley Shapiro3, Yingxiang Lin4, Ting Yang4, Robert Platt3, Chen Wang4*, and Jean Bourbeau3

1 Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada; Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University Health Center, Montreal, QC, Canada, 2 Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada; Centre for Applied Health Research and Evaluation, Children's and Women's Health Centre, University of British Columbia, Vancouver, BC, Canada, 3 Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada, 4 Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China

* To whom correspondence should be addressed. E-mail: cyh-birm{at}263.net.

Rationale: Depression and anxiety are significant co-morbid and potentially modifiable conditions in COPD but their effects on exacerbations are not clear. Objectives: To investigate the independent effect of depression and anxiety on the risk of COPD exacerbations and hospitalizations. Methods: A multi-center prospective cohort study in 491 stable COPD patients in China. Multivariate Poisson and linear regression was used, respectively, to estimate adjusted incidence rate ratios (IRR) and adjusted effects on duration of events. Measurements: Depression and anxiety were measured using Hospital Anxiety and Depression Scale (HADS) at baseline. Other measurements included socio-demographic, clinical, psychosocial and treatment characteristics. Patients were then followed monthly for 12 months to document the occurrence and characteristics of COPD exacerbations and hospitalizations. Exacerbation was determined using both symptom-based (worsening of ≥1 key symptoms) and event-based definition (≥1 symptom worsening plus ≥1 change in regular medications). Main Results: A total of 876 symptom-based and 450 event-exacerbations were recorded, among which 183 led to hospitalization. Depression (HADS depression score≥11) was associated with an increased risk of symptom-based exacerbations (adjusted IRR=1.51, 95%CI: 1.01-2.24), event-based exacerbations (adjusted IRR=1.56, 1.02-2.40) and hospitalization (adjusted IRR=1.72, 1.04-2.85) compared to non-depression (score≤7). The duration of event-based exacerbations was 1.92 (1.04-3.54) times longer for patients with probable anxiety (HADS anxiety score≥11) than those with no anxiety (≤7). Conclusions: This study suggests a possible causal effect of depression on COPD exacerbations and hospitalizations. Further studies are warranted to confirm this finding and test the effectiveness of antidepressants and psychotherapies on reducing exacerbations and improve health resource utilizations.
Key words: Chronic Obstructive Pulmonary Disease (COPD), exacerbation, depression, anxiety, risk factor.




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