COPD patients in a COVID-19 society: depression and anxiety

KEYWORDS:

• COPD
• depression
• anxiety
• Covid-19
• hospitalization
• mortality
• pandemic
• fear
• worry

1. Introduction

Chronic obstructive pulmonary disease (COPD) is a major cause of physical disability and morbidity in old age. Worldwide over 174 million people suffer from COPD [1]. In the United States (US) alone, over sixteen million people live with physician-diagnosed COPD [2]. To date over 128, 000 people died in the United States from the coronavirus (COVID-19). Furthermore, about 90% of hospitalized patients identified through the COVID-19-Associated Hospitalization Surveillance Network had one or more underlying conditions, the most common being obesity, hypertension, chronic lung disease, diabetes mellitus, and cardiovascular disease [3].

A recent report from the Centers for Disease Control and Prevention suggests that over one third of adult patients who were hospitalized with COVID-19 were respiratory related such as COPD [3]. The reason behind why COVID-19 disproportionally affects COPD patients is uncertain. It may be partly due to the majority of COPD patients having one or more comorbidities [4]. In addition, the chronic nature of COPD, the severity of lung function impairment, and concomitant low-grade inflammation may compromise immune mechanisms and predispose to acquiring acute respiratory infections. Without adequate and prompt treatment, COVID-19 infection may progress to intolerable dyspnea, hypoxia, and tenacious dry cough, excessive fatigue, and with or without sputum production from the underlying COPD. Some may develop pneumonia, leading to a hospital admission, requirements for intensive care, and eventually for some, death might occur. This brief overview highlights the emotional impact of COVID-19 on patients with COPD as well as other chronic respiratory diseases, to provide clinical tips and suggestions for health-care professionals as the pandemic progresses worldwide.

2. Impact of coronavirus on psychological well-being

We live in an unprecedented time. Because of the coronavirus pandemic worldwide, some COPD patients will likely be more susceptible to intensified symptoms and disorders of mental illness such as post-traumatic distress disorder, fear, anxiety, depression and vulnerable to suicidal ideation. Even under normal circumstances, approximately 40% of patients with COPD experience clinically relevant depressive symptoms (e.g. excessive fatigue, loss of interest in pleasurable activities), and 36% exhibit anxiety symptoms (e.g. nervousness, fear, and panic) that may warrant medical intervention [5]. The causes of increased anxiety and depression in patients with COPD are multifactorial (Table 1). Furthermore, COPD patients with comorbid anxiety and depression might exhibit worsening symptoms, culminating in fear of self-isolation, excessive worry, loss of social support, and physical distancing (superimposed on current, worldwide social distancing measures) [6]. Financial stressors, unemployment, and ‘bad news aired’ by social media daily discourage and demoralize, especially among older COPD patients. Such older COPD patients, often with preexisting mobility limitations, now find themselves trapped in their own homes, potentially triggering hopelessness and even suicidal ideation. The current pandemic and post COVID-19 crisis begs for urgent consideration of the mental health of COPD patients, to alleviate their concerns, and treat their fear, distresses, and chronic nature of depression and anxiety [7]. Because of social isolation and lock-downs, few data are available to inform us whether COPD patients are adopting adverse social behaviors such as excessive drinking, active smoking, and substance misuse disproportionately compared to other chronic diseases. These adverse social behaviors and frequent acute exacerbations may have a deleterious impact on the emotional health status and physical well-being of patients with COPD. Thus, social isolation, entrapment, and loneliness may instigate self-harm and suicide risk. Unlikely to abate during the pandemic, these adverse social behaviors may be exacerbated for bereaved patients with COPD who lose a confidante or family member [6,8].

Table 1. Causes for increased anxiety and depressive symptoms in patients with chronic respiratory diseases with COVID-19 pandemic

Fear

Loneliness

Stress

Excessive worry

Physical disability

Substance misuse

Physical disability

Lack of social support

Unemployment

Bereavement e.g. loss of loved ones

Life events (related with the COVID-19)

Social isolation

Severe respiratory impairment and acute exacerbations

Co-morbidities

Lockdown

3. What is the best way forward to support this patient group?

Telemedicine to communicate with patients with chronic respiratory diseases can alleviate their current symptoms and give hope. Remotely delivering psychological intervention using a telephone or social media platform can help during this pandemic period. However, this requires both the availability of psychological services and the willingness of patients to participate in an online, virtual environment intervention. The available evidence suggests personal support, relaxation therapy, and counseling services using online media may reduce anxiety and depression in patients with mental health issues as well as in the general population [6]. Unfortunately, mental health concerns may not represent a high priority in health-care systems over-whelmed trying to manage new COVID-19 patients. Thus, it is advisable where appropriate and available to provide community support for those living alone (e.g., shopping for groceries and essential amenities) and encouraging families and friends to engage regularly by phone. Such community support can reduce emotional distancing and might help ease some of the current, unparalleled stresses.

4. Role of health-care professionals in this pandemic

Health-care professionals should be actively engaged in developing psychological interventions and self-management exercises that are easily and freely available (accessible) online for COPD patients with comorbid depression and anxiety. The unimaginable impact of an economic recession on mental health of COPD patients may be equally overwhelming to a healthcare system as the impact of those directly afflicted by the COVID-19 and their concerned caregivers. Thus, the front-line caregivers for patients with COPD (including nurses, general practitioners, and respiratory therapists) should actively engage to detect the impact of COVID-19 by administering simple psychological screening tools such as the Hospital Anxiety Depression scale [9] or the Depression Anxiety Stress Scale [10]. Patients with elevated symptoms need to be monitored periodically, and where appropriate referred to a psychologist and/or psychiatrist for further treatment. Tracing lonesomeness and treating patients timely are essential priorities in dealing patients with respiratory diseases and comorbid depression and anxiety [11]. Importantly, reducing persistent thoughts of solitude and fostering positive attitudes are essential to shield and combat the impact of hopelessness and self-harm.

Outside organizations can also reduce the impact and scope of COVID-19. Spiritual leaders and community support groups can engage actively to connect with chronic respiratory diseases. This type of collaborative partnership [6,9] under the auspices of physicians may be therapeutic for some patients and provide a welcome diversion from worry, fear, and anxiety for others [12]. All contacts with COPD patients, including family and friends, can promote healthy habits such as quitting cigarette smoking, eating a balanced diet, drinking in moderation, engagement in regular physical activities, exercise and self-management of COPD. Table 2 shows interventions that are most likely to benefit of patients with chronic respiratory diseases with comorbid anxiety and depressive symptoms. In conclusion clinicians, researchers, community organizations, families, and friends of patients with COPD can work together to overcome the impact of the COVID-19 pandemic and alleviate mental health disorders in patients with chronic respiratory diseases.

Table 2. Interventions to alleviate anxiety and depressive symptoms in patients with COPD

Online freely available psychological mobile applications

Cognitive behavioral therapy

Pharmacological intervention e.g. Selective Serotonin Receptive Inhibitors

Exercise therapy

Relaxation therapy

Counseling

Yoga exercise

Mindfulness

Music, e.g. dancing

Psychotherapy

5. Expert opinion

As severe COPD patients are prone to excessive dyspnea on exertion which may lead to shortness of breath and subsequently to hypoxemia and exacerbate to ischemic changes in the brain that may contribute to cognitive dysfunction, elevated anxiety, and depression. Thus, COPD patients with severe respiratory impairment and active smokers need to be encouraged to stop smoking. Developing interventions that may alleviate the impact of post COVID-19 on physicial activities, brain function and improve mental health in COPD patients are worthwhile enterprise. The role of multidisciplinary team is crucial in the management of COPD patients with comorbid anxiety and depression. Continuing monitoring hospitalization rates of COPD patients and who were discharged from the hospital with COVID-19 is worthy endeavor.

Declaration of interest

A Yohannes discloses receiving an honorarium for consultation fees from AstraZeneca. The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.