ANXIETY AND DEPRESSION IN ADVANCED LUNG-DISEASE

Patients with advanced lung disease face innumerable challenges to the ir functional independence, self-esteem, and quality of life. Capacity for work and social interaction is diminished severely. Sleep, eating , and sexual intimacy are disrupted. Ordinary activities require extra planning and time. Coughing becomes a dreaded ordeal. Minor exacerbat ions spoil anticipated events, and each new symptom reawakens fear of respiratory crisis or death. The young man unable to father a child, t he husband who can no longer walk with his wife, and the grandmother w ho lacks the strength to lift her newborn grandson are all too aware t hat life has changed. Considering the many stresses they face, patient s with advanced lung disease appear at high risk for development of an xiety or depression. Limited evidence suggests that both disorders are , indeed, exceptionally common in this patient population. One recent study suggests that 45% of patients with moderate to severe chronic ob structive pulmonary disease (COPD) suffer from depression.(24) That ra te is higher than that reported for chronically ill populations in gen eral(19), (23,) (35, 36, 38) and substantially higher than the 6% to 1 7% prevalence of depression observed in adult primary care settings.(2 0) Anxiety and panic disorders are also common in COPD13, 33, 49, 51 a nd severe asthma.(49, 51) Yellowlees and his colleagues,(50) for examp le, found chronic anxiety or panic in 34% of 50 patients with COPD adm itted consecutively to an inpatient respiratory unit in Australia.(50) Although little is documented about the prevalence of anxiety or depr ession in advanced lung diseases other than chronic airflow obstructio n, high rates for those groups might be expected as well.(24) Untreate d anxiety or depression can have devastating effects on patients with severe, chronic medical illnesses.(33) In addition to increasing the r isk of suicide, such disorders commonly cause or amplify somatic sympt oms and often lead to further loss of physical or social function. Sym ptoms attributable to anxiety and depression include dyspnea, neurocog nitive deficits, fatigue, pain, insomnia, sexual inactivity, and weigh t loss or gain.(10,) (21), (27) Social or behavioral manifestations in clude restricted emotional responses, irritability, anger, substance a buse, isolation, and marital discord.(42) The patient's quality of lif e is reduced and medical care may be adversely affected. Both anxiety and depression have been associated with excessive utilization of medi cal services,(2 8) delayed evaluation or treatment,(6, 48, 49) and poo r compliance with suggested medical regimens. Common although both con ditions may be, neither anxiety nor depression is inevitable in patien ts with advanced lung disease, and both are highly amenable to treatme nt.(27) This article presents an approach to the diagnosis of anxiety, panic, and depression in patients with advanced lung disease. Recomme ndations are offered for drug treatment of those conditions and the ro le of adjunctive therapy is reviewed.