Antidepressant therapy may offer benefit in COPD

Abstract

We share Barnes’ concern [1] about the neglect of this common and burdensome condition. As treatment to alter the progression of COPD is still lacking, current clinical management focuses on palliation of breathlessness, treatment of infections, and optimisation of function. The latter goal has been modestly but successfully achieved with pulmonary rehabilitation [2], which improves clinical outcomes without affecting the underlying disease mechanism. Another approach to improving the dismal quality of life of COPD sufferers is suggested by their high rates of anxiety and depression. These psychological symptoms exacerbate the misery of COPD and, if present before lung damage, may contribute to its usual aetiology by fostering nicotine dependence and impairing attempts to quit. We thus became interested in examining the usefulness of antidepressant treatment in COPD patients with co-morbid anxiety or depression. Limited trial evidence indicates that selective serotonin reuptake inhibitor (SSRI) treatment may be of benefit [3]. The North East Wales Local Research Ethics Committee approved our double-blind, randomized controlled trial of three months treatment with the SSRI citalopram (10-20 mg/day) v placebo. The St Georges Respiratory Questionnaire (SGRQ), used to measure health status in airways disease, was our primary outcome; reductions of four points or more are considered clinically significant. Of 22 patients screened, 8 were randomised, and 7 completed the three month trial. Of 5 patients randomised to citalopram, one withdrew due to insomnia and restlessness (‘activation syndrome’), 3 had striking improvements in health status as measured by reductions in SGRQ total score [11, 12.6, 8.2, 0.5]; the fourth experienced psychological symptom relief according to our secondary measures, the Hospital Anxiety and Depression Scale and the Depression in Medical Illness scale. None of the 3 patients completing three months of placebo showed changes in SGRQ [0.8, 1, 2.3] or the other two measures. Neither treatment affected spirometry. Our small trial indicates dramatic changes in health status are possible for COPD patients with prominent psychological symptoms. The magnitude of health status gains with successful antidepressant treatment appears more striking than that typically observed with optimised conventional therapy for COPD [3,4]. Although a difficult population to study, focused treatment of psychological disturbance in COPD warrants a carefully-designed, large-scale trial.