Treatment of Mood Disorders: Pulmonary Diseases
The occurrence of depression in patients with chronic obstructive pulmonary disease (COPD) has been found to be approximately 45%. The selection of an antidepressant for the patient with pulmonary disease is often decided based on the drug’s adverse effects of possibly leading to a decrease in ventilatory drive and dyspnea. In uncontrolled case reports, TCAs have been shown to lessen depression, anxiety, and disability in depressed patients with COPD but to have essentially no effect on dyspnea. Medications such as the TCAs are often sedating and lead to concern of decreased ventilatory drive and worsening hypoxemia.
The SSRIs offer a helpful alternative. Sertraline is one SSRI of which several case studies demonstrating some success have been published. Papp and colleagues (1995) examined the effects of sertraline in six consecutive patients with COPD with and without comorbid anxiety and mood disorders. Diagnosis of a psychiatric disorder was made in three patients by psychiatric interview. Treatment was initiated at 12.5 mg/day and increased to a final average of 100 mg/day over a 2-week period. Patients remained at this dose for 6 weeks. At week 6, all patients reported improved quality of life measures. The three patients with active psychiatric diagnoses also reported improvement in their symptoms. No significant changes were noted in their spirometric indices or arterial blood gas levels. Further support for the use of sertraline in particular came in a case series in 1998. Smoller et al. reproduced the results of Papp et al. and also suggested that the medication had some effect on dyspnea by an unspecified neurobiological effect on respiratory control mechanisms. This observation does have some support from laboratory biochemical research, but the results of these very small studies have yet to be confirmed in larger clinical trials.
One should be aware of both the potential drug interaction between fluvoxamine and theophylline on CYP1A2, leading to toxic theophylline levels, and the influence of fluvoxamine and nefazodone on corticosteroid metabolism. The use of buspirone and benzodiazepines is not indicated for depression per se but clearly can be of use in the treatment of anxiety. It has been suggested in a case report that the augmentation of an SSRI with methylphenidate might be beneficial, but definitive clinical research is necessary to support this. One particular clinical trial now in the planning phase will examine the effect of citalopram on depression, anxiety, and pulmonary function indices and might shed more light on improving treatment and function in these patients.
Psychotherapy, in particular CBT, can be of great benefit to patients with chronic lung disease. A study in Europe revealed improved exercise tolerance in a group of 10 patients using CBT. This study primarily examined anxiety scales instead of depression scales, but theoretically one would believe the same methods would apply to mood disorders as well. A case study supports this issue, but further well-designed studies proving effectiveness are needed.
Revision date: June 20, 2011
Last revised: by Sebastian Scheller, MD, ScD