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Original Research: COPD |

Bidirectional Associations Between Clinically Relevant Depression or Anxiety and COPDCOPD Prognosis with Depression or Anxiety: A Systematic Review and Meta-analysis

Evan Atlantis, PhD; Paul Fahey, MMedStat; Belinda Cochrane, MD; Sheree Smith, PhD
Author and Funding Information

From the School of Nursing and Midwifery (Drs Atlantis, Cochrane, and Smith), the School of Science and Health (Dr Fahey), and the School of Medicine (Dr Cochrane), University of Western Sydney, Campbelltown Campus, NSW, Australia; Campbelltown Hospital (Dr Cochrane), Department of Medicine, SLHD/SWSLHD, Campbelltown, NSW, Australia; and the Centre for Pharmacology and Therapeutics (Dr Smith), Division of Experimental Medicine, Imperial College, South Kensington, London, England.

Correspondence to: Evan Atlantis, PhD, Family and Community Health Research Group, School of Nursing and Midwifery, University of Western Sydney, Bldg 17, Room 17.1.14, Campbelltown Campus, Locked Bag 1797, Penrith, NSW 2751 Australia; e-mail: e.atlantis@uws.edu.au


For editorial comment see page 726

Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(3):766-777. doi:10.1378/chest.12-1911
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Background:  The longitudinal associations between depression or anxiety and COPD, and their comorbid effect on prognosis, have not been adequately addressed by previous reviews. We aimed to systematically assess these associations to inform guidelines and practice.

Methods:  We searched electronic databases for articles published before May 2012. Longitudinal studies in adult populations that reported an association between clinically relevant depression or anxiety and COPD, or that reported their comorbid effect on exacerbation and/or mortality, were eligible. Risk ratios (RRs) were pooled across studies using random-effects models and were verified using fixed-effects models. Heterogeneity was explored with subgroup and metaregression analyses.

Results:  Twenty-two citations yielded 16 studies on depression or anxiety as predictors of COPD outcomes (incident COPD/chronic lung disease or exacerbation) and/or mortality, in 28,759 participants followed for 1 to 8 years, and six studies on COPD as a predictor of depression in 7,439,159 participants followed for 1 to 35 years. Depression or anxiety consistently increased the risk of COPD outcomes (RR, 1.43; 95% CI, 1.22-1.68), particularly in higher-quality studies and in people aged ≤ 66 years. Comorbid depression increased the risk of mortality (RR, 1.83; 95% CI, 1.00-3.36), particularly in men. Anxiety (or psychologic distress) increased the risk of COPD outcomes/mortality in most studies (RR, 1.27; 95% CI, 1.02-1.58). Finally, COPD consistently increased the risk of depression (RR, 1.69; 95% CI, 1.45-1.96).

Conclusions:  Depression and anxiety adversely affect prognosis in COPD, conferring an increased risk of exacerbation and possibly death. Conversely, COPD increases the risk of developing depression. These bidirectional associations suggest potential usefulness of screening for these disease combinations to direct timely therapeutic intervention.

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