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Outcomes of Depressed Patients Undergoing Inpatient Pulmonary Rehabilitation
Outcomes of Depressed Patients Undergoing Inpatient Pulmonary Rehabilitation George S. Alexopoulos, M.D., Jo Anne Sirey, Ph.D., Patrick J. Raue, Ph.D., Dora Kanellopoulos, B.S., Timothy E. Clark, M.T.S., Richard S. Novitch, M.D.
Objective: Approximately 30% of patients with chronic obstructive pulmonary disease (COPD) experience depression. Pulmonary rehabilitation for COPD focuses on physical conditioning, but includes behavioral interventions that may address depressive symptoms. This study tested the hypothesis that brief inpatient pulmonary rehabilitation is followed by improvement in both depressive symptoms and function in patients with COPD with major depression. Methods: The subjects, who were recruited from the pulmonary rehabilitation unit of the Burke Rehabilitation Hospital in White Plains, NY, who had COPD and major depression were consecutively admitted patients to a pulmonary rehabilitation unit. Symptoms of depression, disability, medical burden, the experience of support, and satisfaction with treatment were systematically ascertained on admission and before discharge. Results: Three hundred sixty-one patients were screened and 63 met criteria for COPD and major depression. Depressive symptoms improved by discharge (z ⫽ ⫺6.785, p ⬍0.0001); median length of stay was 16 days. Approximately 51% of subjects met criteria for response (50% or greater reduction in depressive symptoms scores from baseline), and 39% met criteria for remission (final Hamilton Depression scale score equal to or less than 10). History of treatment for depression was associated with limited change in depressive symptoms, whereas social support and satisfaction with treatment were predictors of improvement. All disability domains were lower at discharge compared to baseline (z⫽⫺3.928, p ⬍0.0001). Subjects with pronounced disability at baseline had the greatest improvement if their depression improved by discharge. Conclusions: Acute inpatient rehabilitation is followed by improvement of depressive symptoms and disability in older patients with COPD and major depression. Improvement of depression may be the result of behavioral interventions rather than the use of antidepressant drugs. (Am J Geriatr Psychiatry 2006; 14:466–475) Key Words: Geriatric depression, pulmonary rehabilitation, treatment adherence, COPD
Received June 22, 2005; revised November 14, 2005; accepted November 23, 2005. From the Departments of Psychiatry (GSA, JAS, PJR, DK, TEC), Clinical Psychology, and Medicine (RSN) Weill Medical College of Cornell University; and the Department of Pulmonary Rehabilitation (RSN), Burke Rehabilitation Hospital. Send correspondence and reprint requests to Dr. Patrick J. Raue, 21 Bloomingdale Road, White Plains, NY 10605. e-mail: [email protected] © 2006 American Association for Geriatric Psychiatry
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Alexopoulos et al. The sorrow that has no vent in tears may make other organs weep. –Sir Henry Maudsley, M.D. (1835–1918) Chronic obstructive pulmonary disease (COPD) afflicts approximately 17% of men and 13% of women and is a major contributor to disability and utilization of health services.1 As of 1990, COPD has been the fourth most frequent cause of death in the United States and the only major chronic disease for which death rates have not declined over the past 30 years.2 Moreover, COPD is a major contributor to disability and utilization of health services.1–3 More than 25% of persons with COPD have depressive disorders.4 The ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel has pointed out that, although it affects a substantial number of patients with COPD, depression is not a necessary consequence of lung disease and the resultant disability.1 Indeed, some patients with COPD have few, if any, psychiatric symptoms.5 These observations suggest that depression is a distinct syndrome in a significant minority of patients with COPD. Depression accelerates the spiral of deterioration in patients with COPD. Depressive disorders worsen the outcomes of most medical disorders, including COPD.6 Depressive symptoms have been found to predict the functional capacity of patients with COPD more than physiological indicators in COPD.7–9 Moreover, depressive symptoms such as hopelessness, helplessness, suicidal ideation, and psychomotor retardation compromise participation in treatment and rehabilitation. Because the cornerstone of COPD rehabilitation is exercise and adherence to medical procedures, depression can paralyze patients with COPD and contribute to their early death. Treatment services offered by inpatient pulmonary rehabilitation units have the potential to address some of the patients’ psychologic needs and thus improve depressive symptoms. Although their focus is on physical conditioning and on disability induced by pulmonary diseases, rehabilitation units offer a multilevel treatment program that includes respiratory therapy, physical therapy, occupational therapy, and speech therapy, but also relaxation classes, support groups, and help with the patients’ psychosocial needs. Diagnosing depressive disorders and adding an antidepressant to the patients’ regimen can offer additional benefit in depressed patients with COPD.
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To assess the effectiveness of a comprehensive intervention on the short- and long-term outcomes of older patients with COPD with major depression, we are conducting a 26-week controlled treatment study of consecutive admissions to a short-term pulmonary rehabilitation unit. This is the first report of this study and focuses on the impact of pulmonary rehabilitation on depression and disability. It tests the hypothesis that both depressive symptoms and overall function improve by the time of discharge in patients with COPD with major depression. In addition, this report seeks to identify predictors of poor response to treatment.
METHODS Subjects The participants were consecutively admitted patients to the acute pulmonary rehabilitation unit of the Burke Rehabilitation Hospital, a university-affiliated hospital, and were recruited between April 2002 and June 2004. Approval was obtained from the Weill Cornell Medical College and Burke Rehabilitation Hospital Institutional Review Boards. All participants received a complete description of the study and signed informed consent. The Burke pulmonary rehabilitation unit accepts patients with impairment in ambulation and other functions resulting from respiratory diseases or patients who require respiratory support, including oxygen, nebulizers, bilevel nasal positive pressure (BiPAP; Respironics Inc., Murrysville, PA), and/or tracheostomy. Medically unstable or demented patients, patients requiring isolation because of staphylococcus or tuberculosis pneumonia, and patients requiring renal dialysis are not admitted to this unit. The participants were required to have the diagnosis of COPD, meet Diagnostic and Statistical Manual of Mental Disorders (DSM–IV) criteria for unipolar major depressive disorder (MDD),10 and have a score of 17 or greater on the 24-item Hamilton Depression Rating Scale (HAM-D).11 Reasons to exclude potential participants included significant cognitive impairments (i.e., Mini Mental State Examination12 score lower than 24), aphasia interfering with rating
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Depressed Patients Undergoing Inpatient Pulmonary Rehabilitation procedures, inability to complete study interviews because of severe medical burden, or permanent placement in a nursing home. Systematic Clinical Assessment The diagnosis of COPD was made by a pulmonary specialist according to American Thoracic Society Guidelines13 after review of history and medical records, physical examination, and laboratory workup, including blood gases and pulmonary function tests. Psychiatric diagnosis relied on the Structured Clinical Interview for DSM–IV (SCID-R) administered within 1–2 days of admission. Assessment was conducted by trained research assistants. Depressive symptoms were quantified with the interviewer-rated 24-item HAM-D. Disability was assessed with the 12- item World Health Organization Disability Assessment Schedule II (WHODAS II).14 The WHODAS form is compatible with the international classification system of disability, is crossculturally applicable, and treats all disorders at parity when determining level of functioning. The WHODAS II assesses six domains: 1) understanding and communicating, 2) getting around, 3) self-care, 4) getting along with others, 5) household and work activities, and 6) participation in society. Each domain has a factor loading of at least 0.70, and the items also load on a general disability factor. The functional independence measure (FIM) was also used to quantify disability.15 The FIM measures what a person actually does, not what he or she should be able to do or might be able to do under different circumstances. The FIM includes a seven-level scale that designates major gradations from dependence to independence and evaluates six domains of function, i.e., communication, locomotion, self-care, social cognition, sphincter control, and transfers. Medical burden was quantified with the Charlson Comorbidity Index (CCI), an instrument that predicts mortality and service use.16 Cognitive impairment was documented with the Mini Mental State Examination.12 The experience of subjective support was rated with the subjective support subscale of the Duke Social Support Index (DSSI).17 During the last two hospital days, severity of depression (HAM-D) and disability (WHODAS-II, FIM) were assessed again, as was satisfaction with treatment received in the hospital (three-item
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Client Satisfaction Questionnaire).18 After discharge, participants were randomly assigned either to a comprehensive intervention by a health specialist encouraging adherence to medical and rehabilitative recommendations or to usual care. Depression and disability were assessed over a period of 26 weeks after discharge. Because the follow-up part of the study is still in progress, the analysis of this report is limited to comparisons between admission and discharge data. Treatment After a comprehensive assessment, treatment is offered by a multidisciplinary team led by a pulmonologist. A treatment regimen is tailored for each patient, but pulmonary rehabilitation patients typically attend five 45-minute classes each day Monday through Saturday. Respiratory therapists administer medications through nebulizers, offer and monitor supplemental oxygen, assist with tracheostomy care when appropriate, and perform pulmonary function tests. Physical therapists engage patients in exercises aimed to improve ambulation and increase flexibility, strength, and range of limb motion while monitoring oxygen saturation. Occupational therapists instruct patients in techniques for improving the ability to dress, groom, change position, transfer, and perform homemaking tasks while conserving energy. Speech therapists ensure that meals are compatible with the patients’ swallowing capacity and assess vocalization ability. Finally, social workers help the rest of the staff match their treatment strategies to the patients’ functional needs imposed by their respective home environments. Moreover, social workers plan postdischarge support services, including services by visiting nurses, home health aids, in-home and outpatient therapy, and medical care. The rehabilitation program combines active rehabilitation with a positive, encouraging approach. In addition to the interventions to improve functioning, patients receive attention, encouragement, and activation designed to increase their self-efficacy in managing COPD. This combination of increased functioning and psychologic support and activation may play an important role in improving depression in adults with depression. Because evidence-based guidelines indicate that use of antidepressant drugs is the standard of care in
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Alexopoulos et al. the acute treatment of MDD, all participants were offered treatment with 10 mg escitalopram during their inpatient stay. This antidepressant was selected because of its limited drug– drug interactions.19 Participants already receiving antidepressants on admission continued treatment with their antidepressant unless they had failed to improve after exposure to therapeutic dosages over a period longer than 12 weeks. In such cases, the pulmonologist recommended that they switch to escitalopram. Data Analysis The primary outcome for depression was change in total HAM-D score. Secondary analyses on depression data focused on treatment response (defined as 50% reduction in HAM-D since admission) because this outcome is often the focus of U.S. Food and Drug Administration pivotal studies. Another secondary outcome for depression was remission (defined as a final HAM-D score of equal to or less than 10) because remission is associated with a lower relapse rate and higher functioning during the well period.20 The primary outcomes for disability were change in both total WHODAS score and total FIM score, because these measures assess somewhat different aspects of disability. Initially, we conducted bivariate comparisons using paired Wilcoxon tests to compare measures of depression and disability on admission and discharge. To identify predictors of change in depression and disability, we used regression with backward elimination to arrive at a parsimonious model of baseline demographic and clinical characteristics associated with change in HAM-D, WHODAS, and FIM. We used logistic regression with backward elimination to identify predictors of the categorical outcomes response and remission of depression.
these, 88 (24.4ü received the diagnosis of major depression. Of the 88 patients with major depression and COPD, 63 entered the study and 25 were excluded. The reasons for exclusion included severe medical burden requiring treatment beyond that offered by the study (N ⫽9), discharge to a nursing home before completion of the rehabilitation program (N⫽4), refusal to participate (N⫽ 11), and need for complex psychiatric care (N⫽1). The excluded patients had a mean age of 73.7 years (standard deviation [SD]: 10) and a ratio of men to women 1.3:1. The mean education of the excluded patients was 12.8 years (SD: 2.2). Of the excluded patients, 96% were non-Hispanic and 96% were white. The participants’ (N⫽ 63) mean age was 71.3 years (SD: 7.9), and the ratio of women to men was 2:1. Their mean education was 13.4 years (SD: 3.2); 98.5% were non-Hispanic and 89% were white. Of the 63 participants, 37 were started on antidepressants after they entered the rehabilitation center and remained on antidepressants throughout their stay. Twelve participants were receiving antidepressants on admission and remained on these agents throughout their hospitalization. Another 14 participants were discharged on no antidepressants either because they refused treatment or developed side effects and were reluctant to reinitiate treatment. Profile of Depression On admission, interviewer-rated 24-item HAM-D (mean: 23.59, SD: 3.18) indicates that many participants had moderate to severe depression. The most prominent depressive symptoms were depressed mood; early, middle, and late insomnia; psychic and somatic anxiety; fatigue and other somatic symptoms; and ideational disturbances such as helplessness, hopelessness, and worthlessness.
Improvement of Depression
RESULTS A total of 469 consecutively admitted patients to the rehabilitation unit were available for screening. Of these, 66 patients were excluded from screening as a result of severe medical illness, and another 42 patients who were approached refused to be screened. The remaining 361 patients were screened, and of
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The median length of stay in the rehabilitation unit was 16 days (mean: 17.94 days, SD: 8.23). Depressive symptoms improved by the time of discharge. Improvement occurred across all depressive symptoms with high baseline values. Of the 63 participants, 32 (51%) met criteria for response defined as 50% or greater reduction in HAM-D scores from baseline, and 25 (39%) met criteria for remission
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Depressed Patients Undergoing Inpatient Pulmonary Rehabilitation defined as a final HAM-D score equal to or less than 10. Change in HAM-D scores since admission was not associated with length of stay in the rehabilitation center (Spearman: r⫽0.03, N⫽63, p⫽0.85). Change in HAM-D depressive symptoms did not differ for subjects who 1) initiated and remained on an antidepressant at the rehabilitation center, 2) entered the rehabilitation center on an antidepressant, or 3) did not receive or could not tolerate an antidepressant (Kruskal-Wallis 2 ⫽2.65, df⫽2, p⫽0.27). We examined the bivariate relationships between the following baseline variables and each outcome variable: age, gender, education, medical burden (Charlson Comorbidity score), disability (WHODAS total score), functioning (FIM total score), subjective support (subscale of the DSSI), cognitive impairment (MMSE score), and overall treatment satisfaction (Client Satisfaction Questionnaire). Using regression with backward elimination, we constructed a parsimonious model of baseline demographic and clinical characteristics associated at the bivariate level with
TABLE 1.
change in HAM-D scores since baseline. The model predicted 28.9% of the variance in HAM-D score change since baseline (Table 1). Following the same process, we constructed a model, which predicted 29.2% of the variance in the occurrence of treatment response (Table 1). Younger age (Figure 1) and the subjective experience of social support (Figure 2) were associated with high response rates, whereas history of treatment for previous depressive episodes was a predictor of poor response. Like with prediction of response, a model consisting of age (Figure 1) and the subjective experience of social support (Figure 2) was associated with high remission rates and predicted 24.9% of the variance (Table 1). Improvement of Disability By the time of discharge, there was a significant reduction in disability. All disability domains of both WHODAS and FIM were significantly lower on discharge compared with baseline (Table 2). There was
Predictors of Improvement of Depression in 63 Older Adults With Major Depressive Disorder Receiving Inpatient Pulmonary Rehabilitation
Predictor Variables
df
Parameter Estimate (SE)
t
p
1 1 1 1
⫺14.82 (8.31) ⫺3.89 (1.86) 0.67 (0.24) 1.16 (0.55) (model F ⫽ 6.92, df ⫽ [4,51], p ⬍0.0005)
⫺1.78 ⫺2.10 2.77 2.13
0.080 0.041 0.008 0.038
Wald 2
p
a
Change in Severity of Depression Intercept History of antidepressantsb Baseline HAM-Dc Treatment satisfactiond Predictor Variables Response
df
Parameter Estimate (SE)
e
Intercept Age Subjective supportf History of antidepressantsb
1 1 1 1
2.77 (3.67) ⫺0.11 (0.05) 0.33 (0.16) ⫺1.67 (0.84) (likelihood ratio 2 ⫽ 13.85, df ⫽ 3, p ⬍0.0031)
0.57 5.87 4.33 3.93
0.451 0.015 0.037 0.048
0.35 5.79 7.11
0.550 0.016 0.008
Remissiong Intercept Age Subjective supportf
1 1 1
⫺2.00 (3.39) ⫺0.09 (0.04) 0.45 (0.17) (likelihood ratio 2 ⫽ 12.78, df ⫽ 2, p ⬍0.0017)
a
Change in total of 24-item Hamilton Depression Rating Scale (HAM-D) from admission to discharge. Prior use of antidepressants assessed by the Barriers to Medication scale. c Twenty-four-item Hamilton Depression Rating Scale total. d Client Satisfaction Questionnaire total. e Fifty percent decrease in HAM-D. f Duke Social Support Index subscale. g HAM-D total of ⱕ10 at discharge. SE: Standard error. b
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FIGURE 1.
Relationship of Age to Response and to Remission of Depression After Controlling for Social Support
no significant association between length of stay in the rehabilitation center and change in either WHODAS (Spearman: r⫽⫺0.11, N⫽58, p⫽0.39) or FIM (Spearman: r⫽0.11, N⫽62, p⫽0.38) scores since admission. Change in WHODAS and FIM scores did not differ for subjects who 1) initiated and remained on an antidepressant at the rehabilitation center, 2) entered the rehabilitation center on an antidepressant, or 3) did not receive or could not tolerate an antidepressant (Kruskal-Wallis 2 ⫽ 0.35, df⫽ 2, p⫽ 0.84; 2 ⫽0.29, df⫽2, p⫽0.86). After examination of bivariate relationships, a parsimonious multivariate model following regression with backward elimination model predicted 86.8% of the variance in WHODAS change from baseline (Table 3). A similar model predicted 46.7% of the variance in FIM change from baseline (Table 3). The interaction of baseline disability and severity of depression at discharge was significantly associated with change in disability assessed with both WHODAS and FIM. Subjects with significant disability at baseline had the greatest improvement in
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disability if they had low severity of depression at the time of discharge.
DISCUSSION The principal finding of this study is that brief inpatient pulmonary rehabilitation is followed by improvement of depressive symptoms and disability in older patients with COPD with MDD. Improvement occurred in a broad range of depressive symptoms and on all domains of disability. These favorable outcomes were noted regardless of the use of antidepressant drugs. To our knowledge, this is the first study documenting improvement in depressive symptoms and disability in older patients with COPD with MDD during brief pulmonary rehabilitation. The findings of this study are consistent with observations suggesting that pulmonary rehabilitation improves psychosocial outcomes of patients with
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Depressed Patients Undergoing Inpatient Pulmonary Rehabilitation
FIGURE 2.
Relationship of Subjective Supports to Response and Remission of Major Depressive Disorder After Controlling for Age
COPD, although prior investigations did not focus on MDD. Nonetheless, symptoms of depression and anxiety as well as quality of life improve after inpatient pulmonary rehabilitation in patients with COPD with a broad range of anxiety and depression symptoms.21–25 Similarly, outpatient pulmonary rehabilitation may lead to improvement of depression and anxiety symptoms and quality of life in the minority of patients with COPD with such symptoms before treatment.26,27 Improvement in depression and anxiety may lead to decreased perception of breathlessness even when pulmonary function tests and physical disability remain unchanged.22,28 There is some evidence that the beneficial effects on emotional functions endure over a period of three months to two years.29 However, negative findings have also been reported.30 Improvement of depressive symptoms occurred regardless of whether patients with COPD were started on an antidepressant at the Burke Rehabilita-
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tion Hospital, were already on an antidepressant before admission, or were not treated with antidepressants. The short length of stay (median: 16 days) suggests that many patients who were started on antidepressants did not have the opportunity to improve as a result of this treatment. This view is supported by findings suggesting that older adults derive the most benefit from antidepressants after two weeks of treatment.31 Thus, nonpharmacologic interventions of the rehabilitation program may have been the principal contributor to changes in depressive symptoms. Although not specifically designed as a treatment for depression, most interventions of the rehabilitation program offer support and promote behavioral activation, treatment elements with known efficacy in MDD.32 These observations are encouraging because a considerable number of patients with COPD refuse antidepressant drug treatment.33 The larger study will provide the opportunity to examine the sustainability of the im-
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TABLE 2.
Change in Disability in 63 Older Adults With Major Depressive Disorder Receiving Inpatient Pulmonary Rehabilitation
Disability Variables
Admission
Discharge
Mean
Mean
WHODAS Getting around 8.86 Life activities 3.92 Understanding and communicating 4.98 Participation in society 6.40 Self-care 6.08 Getting along with people 3.38 Work 2.98 Total WHODAS 36.06 FIM Communication Locomotion Self-care Social cognition Sphincter control Transfers Total FIM
13.13 3.44 27.97 17.87 10.94 11.02 85.10
SD
SD
Z
p
8.08 1.78 ⫺2.958 2.81 1.32 ⫺4.188
0.003 0.001
2.19
3.96 1.80 ⫺3.168
0.002
2.10 2.25
4.98 2.33 ⫺3.292 5.36 2.34 ⫺2.038
0.001 0.042
1.84 1.21 7.45
2.78 1.52 ⫺2.026 2.33 1.06 ⫺3.316 30.52 7.97 ⫺3.928
0.043 0.002 0.001
⫺3.388 ⫺6.858 ⫺6.860 ⫺4.162 ⫺4.768 ⫺6.858 ⫺6.850
0.001 0.001 0.001 0.001 0.001 0.001 0.001
0.79 2.93 2.54 1.74 1.74 1.85 8.10
SD: Standard deviation; WHODAS: World Health Organization Disability Assessment Schedule; FIM: Functional Independence Measure.
provements in depression and disability. We will be able to explore the effect of the rehabilitation on longer-term outcomes and account for the impact of continued use of antidepressant therapy. The experience of support and satisfaction with treatment was associated with favorable outcomes of depression. This observation is consistent with studies documenting that a positive experience during treatment is a predictor of good treatment response.34 History of treatment for depression and advanced age were associated with limited change in depressive symptoms. History of chronic depression and depressive recurrences predict adverse outcomes of geriatric depression.35 Advanced age has been associated with slow change in depressive symptoms.36 Moreover, there is some evidence that old-old patients with COPD achieve smaller gains in psychologic well-being than younger-old patients undergoing rehabilitation.37 Patients with greater disability on admission and lower depressive symptomatology on discharge had the greatest improvement in disability. The course of disability parallels the course of depression. In
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Predictors of Improvement of Disability in 63 Older Adults With Major Depressive Disorder Receiving Inpatient Pulmonary Rehabilitation
Wilcoxon Test
1.40 1.13
1.56 13.79 2.43 9.79 3.83 35.63 2.15 19.15 2.63 12.79 3.87 17.26 9.98 108.40
TABLE 3.
Predictor Variables
df
Parameter Estimate (SE)
t
Change in WHODAS II scores Intercept 1 ⫺31.86 (2.84) ⫺11.19 Baseline WHODAS 1 1.02 (0.06) 15.54 Discharge HAM-D 1 1.98 (0.21) 9.36 Baseline WHODAS ⫻ discharge HAM-D 1 ⫺0.06 (0.01) ⫺13.04 (model F ⫽ 118.64, df ⫽ [3, 54], p ⬍0.0001) Change in FIM scores Intercept 1 13.94 (16.5) 0.85 BaselineFIM 1 0.06 (0.19) 0.35 Discharge HAM-D 1 3.78 (1.25) 3.03 Baseline FIM ⫻ discharge HAM-D 1 ⫺0.04 (0.01) ⫺2.90 (model F ⫽ 16.93, df ⫽ [3, 58], p ⬍0.0001)
p
0.001 0.001 0.001 0.001
0.400 0.728 0.004 0.005
SE: Standard error; WHODAS: World Health Organization Disability Assessment Instrument II; FIM: Functional Independence Measure.
community-residing individuals, residual depressive symptoms covary with disability over time.38,39 Reduction in level of depression was shown to result in approximately 50% reduction in days burdened by disability one year later.39 Depression may lead to disability in elderly individuals directly40 and by increasing the impact of medical burden.41 In patients with COPD, the antidepressant nortriptyline was superior to placebo in improving both depression and day-to-day function, although it did not influence physiological measures of pulmonary insufficiency.42 Thus, improvement of depression is critical for improving disability in patients with COPD. This study has several limitations. The lack of control group does not allow definitive conclusions on the impact of the rehabilitation program on depression and disability. However, the reduction of depressive symptoms and the response and remission rates were remarkable, and in many ways similar, to those occurring during randomized, controlled trials of antidepressants.43 Although the study implemented an algorithm for administration of antidepressant treatment, it included patients who refused to take antidepressants as well as patients who continued on antidepressants started before hospitalization. Thus, the study cannot offer definitive in-
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Depressed Patients Undergoing Inpatient Pulmonary Rehabilitation formation on the efficacy of antidepressant drug use. Finally, the study did not control the treatment offered by the rehabilitation center. Although the treatment package was associated with reduction of depression and disability, this effect may not be generalized to centers with less intense treatment.
CONCLUSIONS Brief inpatient pulmonary rehabilitation is followed by improvement of depressive symptoms and disability in older patients with COPD with MDD. Improvement of depression may be the result of behavioral interventions of the rehabilitation program rather than use of antidepressant drugs. Satisfaction with treatment and the experience of support were predictors of favorable outcomes of MDD, whereas
advanced age and history of treatment for depression were associated with limited improvement of depressive symptoms. Most gains in disability occurred in patients experiencing significant disability on admission and had limited depressive symptoms by the time of discharge. Because depression is a relapsing illness, patients discharged from inpatient pulmonary rehabilitation units should have vigilant follow up, including continuation and maintenance treatment for depression, to maintain the gains made during their hospitalization. The National Heart, Lung, and Blood Institute (RO1 HLB71992), the National Institute of Mental Health (P30 MH68638), the Sanchez Foundation, and Forest Pharmaceuticals, Inc., supported this research. The authors thank the study Health Specialists Allison Rieger, C.S.W., and Susan Friedman, C.S.W.
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Alexopoulos et al. 26. Boueri FM, Bucher-Bartelson BL, Glenn KA, et al: Quality of life measured with a generic instrument (Short Form-36) improves following pulmonary rehabilitation in patients with COPD. Chest 2001; 119:77–84 27. Withers NJ, Rudkin ST, White RJ: Anxiety and depression in severe chronic obstructive pulmonary disease: the effects of pulmonary rehabilitation. J Cardiopulm Rehabil 1999; 19:362–365 28. De Godoy DV, de Godoy RF: A randomized controlled trial of the effect of psychotherapy on anxiety and depression in chronic obstructive pulmonary disease. Arch Phys Med Rehabil 2003; 84:1154–1157 29. Guell R, Casan P, Belda J, et al: Long-term effects of outpatient rehabilitation of COPD: a randomized trial. Chest 2000; 117:976– 983 30. Ries AL, Kaplan RM, Limberg TM, et al: Effects of pulmonary rehabilitation on physiologic and psychosocial outcomes in patients with chronic obstructive pulmonary disease. Ann Intern Med 1995; 122:823–832 31. Thomas L, Mulsant BH, Solano FX, et al: Response speed and rate of remission in primary and specialty care of elderly patients with depression. Am J Geriatr Psychiatry 2002; 10:583–591 32. Arean PA, Cook BL: Psychotherapy and combined psychotherapy/pharmacotherapy for late life depression. Biol Psychiatry 2002; 52:293–303 33. Yohannes AM, Connolly MJ, Baldwin RC: A feasibility study of antidepressant drug therapy in depressed elderly patients with chronic obstructive pulmonary disease. Int J Geriatr Psychiatry 2001; 16:451–454
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34. Bosworth HB, McQuaid DR, George LK, et al: Time-to-remission from geriatric depression: psychosocial and clinical factors. Am J Geriatr Psychiatry 2002; 10:551–559 35. Cole MG, Bellavance F: The prognosis of depression in old age. Am J Geriatr Psychiatry 1997; 5:4–14 36. Alexopoulos GS, Meyers BS, Young RC, et al: Recovery in geriatric depression. Arch Gen Psychiatry 1996; 53:305–312 37. Emery CF: Effects of age on physiological and psychological functioning among COPD patients in an exercise program. J Aging Health 1994; 6:3–16 38. Ormel J, Von Korff M, Van den Brink W, et al: Depression, anxiety, and social disability show synchrony of change in primary care patients. Am J Public Health 1993; 83:385–390 39. Von Korff M, Ormel J, Katon W, et al: Disability and depression among high utilizers of health care. A longitudinal analysis. Arch Gen Psychiatry 1992; 49:91–100 40. Bruce ML, Seeman TE, Merrill SS, et al: The impact of depressive symptomatology on physical disability: MacArthur Studies of Successful Aging. Am J Public Health 1994; 84:1796–1799 41. Bruce ML: Psychosocial risk factors for depressive disorders in late life. Biol Psychiatry 2002; 52:175–184 42. Borson S, McDonald GJ, Gayle T, et al: Improvement in mood, physical symptoms, and function with nortriptyline for depression in patients with chronic obstructive pulmonary disease. Psychosomatics 1992; 33:190–201 43. Thase ME: Evaluating antidepressant therapies: remission as the optimal outcome. J Clin Psychiatry 2003; 64:18–25
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Objective: Approximately 30% of patients with chronic obstructive pulmonary disease (COPD) experience depression. Pulmonary rehabilitation for COPD focuses on physical conditioning, but includes behavioral interventions that may address depressive symptoms. This study tested the hypothesis that brief inpatient pulmonary rehabilitation is followed by improvement in both depressive symptoms and function in patients with COPD with major depression. Methods: The subjects, who were recruited from the pulmonary rehabilitation unit of the Burke Rehabilitation Hospital in White Plains, NY, who had COPD and major depression were consecutively admitted patients to a pulmonary rehabilitation unit. Symptoms of depression, disability, medical burden, the experience of support, and satisfaction with treatment were systematically ascertained on admission and before discharge. Results: Three hundred sixty-one patients were screened and 63 met criteria for COPD and major depression. Depressive symptoms improved by discharge (z ⫽ ⫺6.785, p ⬍0.0001); median length of stay was 16 days. Approximately 51% of subjects met criteria for response (50% or greater reduction in depressive symptoms scores from baseline), and 39% met criteria for remission (final Hamilton Depression scale score equal to or less than 10). History of treatment for depression was associated with limited change in depressive symptoms, whereas social support and satisfaction with treatment were predictors of improvement. All disability domains were lower at discharge compared to baseline (z⫽⫺3.928, p ⬍0.0001). Subjects with pronounced disability at baseline had the greatest improvement if their depression improved by discharge. Conclusions: Acute inpatient rehabilitation is followed by improvement of depressive symptoms and disability in older patients with COPD and major depression. Improvement of depression may be the result of behavioral interventions rather than the use of antidepressant drugs. (Am J Geriatr Psychiatry 2006; 14:466–475) Key Words: Geriatric depression, pulmonary rehabilitation, treatment adherence, COPD
Received June 22, 2005; revised November 14, 2005; accepted November 23, 2005. From the Departments of Psychiatry (GSA, JAS, PJR, DK, TEC), Clinical Psychology, and Medicine (RSN) Weill Medical College of Cornell University; and the Department of Pulmonary Rehabilitation (RSN), Burke Rehabilitation Hospital. Send correspondence and reprint requests to Dr. Patrick J. Raue, 21 Bloomingdale Road, White Plains, NY 10605. e-mail: [email protected] © 2006 American Association for Geriatric Psychiatry
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Alexopoulos et al. The sorrow that has no vent in tears may make other organs weep. –Sir Henry Maudsley, M.D. (1835–1918) Chronic obstructive pulmonary disease (COPD) afflicts approximately 17% of men and 13% of women and is a major contributor to disability and utilization of health services.1 As of 1990, COPD has been the fourth most frequent cause of death in the United States and the only major chronic disease for which death rates have not declined over the past 30 years.2 Moreover, COPD is a major contributor to disability and utilization of health services.1–3 More than 25% of persons with COPD have depressive disorders.4 The ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel has pointed out that, although it affects a substantial number of patients with COPD, depression is not a necessary consequence of lung disease and the resultant disability.1 Indeed, some patients with COPD have few, if any, psychiatric symptoms.5 These observations suggest that depression is a distinct syndrome in a significant minority of patients with COPD. Depression accelerates the spiral of deterioration in patients with COPD. Depressive disorders worsen the outcomes of most medical disorders, including COPD.6 Depressive symptoms have been found to predict the functional capacity of patients with COPD more than physiological indicators in COPD.7–9 Moreover, depressive symptoms such as hopelessness, helplessness, suicidal ideation, and psychomotor retardation compromise participation in treatment and rehabilitation. Because the cornerstone of COPD rehabilitation is exercise and adherence to medical procedures, depression can paralyze patients with COPD and contribute to their early death. Treatment services offered by inpatient pulmonary rehabilitation units have the potential to address some of the patients’ psychologic needs and thus improve depressive symptoms. Although their focus is on physical conditioning and on disability induced by pulmonary diseases, rehabilitation units offer a multilevel treatment program that includes respiratory therapy, physical therapy, occupational therapy, and speech therapy, but also relaxation classes, support groups, and help with the patients’ psychosocial needs. Diagnosing depressive disorders and adding an antidepressant to the patients’ regimen can offer additional benefit in depressed patients with COPD.
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To assess the effectiveness of a comprehensive intervention on the short- and long-term outcomes of older patients with COPD with major depression, we are conducting a 26-week controlled treatment study of consecutive admissions to a short-term pulmonary rehabilitation unit. This is the first report of this study and focuses on the impact of pulmonary rehabilitation on depression and disability. It tests the hypothesis that both depressive symptoms and overall function improve by the time of discharge in patients with COPD with major depression. In addition, this report seeks to identify predictors of poor response to treatment.
METHODS Subjects The participants were consecutively admitted patients to the acute pulmonary rehabilitation unit of the Burke Rehabilitation Hospital, a university-affiliated hospital, and were recruited between April 2002 and June 2004. Approval was obtained from the Weill Cornell Medical College and Burke Rehabilitation Hospital Institutional Review Boards. All participants received a complete description of the study and signed informed consent. The Burke pulmonary rehabilitation unit accepts patients with impairment in ambulation and other functions resulting from respiratory diseases or patients who require respiratory support, including oxygen, nebulizers, bilevel nasal positive pressure (BiPAP; Respironics Inc., Murrysville, PA), and/or tracheostomy. Medically unstable or demented patients, patients requiring isolation because of staphylococcus or tuberculosis pneumonia, and patients requiring renal dialysis are not admitted to this unit. The participants were required to have the diagnosis of COPD, meet Diagnostic and Statistical Manual of Mental Disorders (DSM–IV) criteria for unipolar major depressive disorder (MDD),10 and have a score of 17 or greater on the 24-item Hamilton Depression Rating Scale (HAM-D).11 Reasons to exclude potential participants included significant cognitive impairments (i.e., Mini Mental State Examination12 score lower than 24), aphasia interfering with rating
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Depressed Patients Undergoing Inpatient Pulmonary Rehabilitation procedures, inability to complete study interviews because of severe medical burden, or permanent placement in a nursing home. Systematic Clinical Assessment The diagnosis of COPD was made by a pulmonary specialist according to American Thoracic Society Guidelines13 after review of history and medical records, physical examination, and laboratory workup, including blood gases and pulmonary function tests. Psychiatric diagnosis relied on the Structured Clinical Interview for DSM–IV (SCID-R) administered within 1–2 days of admission. Assessment was conducted by trained research assistants. Depressive symptoms were quantified with the interviewer-rated 24-item HAM-D. Disability was assessed with the 12- item World Health Organization Disability Assessment Schedule II (WHODAS II).14 The WHODAS form is compatible with the international classification system of disability, is crossculturally applicable, and treats all disorders at parity when determining level of functioning. The WHODAS II assesses six domains: 1) understanding and communicating, 2) getting around, 3) self-care, 4) getting along with others, 5) household and work activities, and 6) participation in society. Each domain has a factor loading of at least 0.70, and the items also load on a general disability factor. The functional independence measure (FIM) was also used to quantify disability.15 The FIM measures what a person actually does, not what he or she should be able to do or might be able to do under different circumstances. The FIM includes a seven-level scale that designates major gradations from dependence to independence and evaluates six domains of function, i.e., communication, locomotion, self-care, social cognition, sphincter control, and transfers. Medical burden was quantified with the Charlson Comorbidity Index (CCI), an instrument that predicts mortality and service use.16 Cognitive impairment was documented with the Mini Mental State Examination.12 The experience of subjective support was rated with the subjective support subscale of the Duke Social Support Index (DSSI).17 During the last two hospital days, severity of depression (HAM-D) and disability (WHODAS-II, FIM) were assessed again, as was satisfaction with treatment received in the hospital (three-item
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Client Satisfaction Questionnaire).18 After discharge, participants were randomly assigned either to a comprehensive intervention by a health specialist encouraging adherence to medical and rehabilitative recommendations or to usual care. Depression and disability were assessed over a period of 26 weeks after discharge. Because the follow-up part of the study is still in progress, the analysis of this report is limited to comparisons between admission and discharge data. Treatment After a comprehensive assessment, treatment is offered by a multidisciplinary team led by a pulmonologist. A treatment regimen is tailored for each patient, but pulmonary rehabilitation patients typically attend five 45-minute classes each day Monday through Saturday. Respiratory therapists administer medications through nebulizers, offer and monitor supplemental oxygen, assist with tracheostomy care when appropriate, and perform pulmonary function tests. Physical therapists engage patients in exercises aimed to improve ambulation and increase flexibility, strength, and range of limb motion while monitoring oxygen saturation. Occupational therapists instruct patients in techniques for improving the ability to dress, groom, change position, transfer, and perform homemaking tasks while conserving energy. Speech therapists ensure that meals are compatible with the patients’ swallowing capacity and assess vocalization ability. Finally, social workers help the rest of the staff match their treatment strategies to the patients’ functional needs imposed by their respective home environments. Moreover, social workers plan postdischarge support services, including services by visiting nurses, home health aids, in-home and outpatient therapy, and medical care. The rehabilitation program combines active rehabilitation with a positive, encouraging approach. In addition to the interventions to improve functioning, patients receive attention, encouragement, and activation designed to increase their self-efficacy in managing COPD. This combination of increased functioning and psychologic support and activation may play an important role in improving depression in adults with depression. Because evidence-based guidelines indicate that use of antidepressant drugs is the standard of care in
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Alexopoulos et al. the acute treatment of MDD, all participants were offered treatment with 10 mg escitalopram during their inpatient stay. This antidepressant was selected because of its limited drug– drug interactions.19 Participants already receiving antidepressants on admission continued treatment with their antidepressant unless they had failed to improve after exposure to therapeutic dosages over a period longer than 12 weeks. In such cases, the pulmonologist recommended that they switch to escitalopram. Data Analysis The primary outcome for depression was change in total HAM-D score. Secondary analyses on depression data focused on treatment response (defined as 50% reduction in HAM-D since admission) because this outcome is often the focus of U.S. Food and Drug Administration pivotal studies. Another secondary outcome for depression was remission (defined as a final HAM-D score of equal to or less than 10) because remission is associated with a lower relapse rate and higher functioning during the well period.20 The primary outcomes for disability were change in both total WHODAS score and total FIM score, because these measures assess somewhat different aspects of disability. Initially, we conducted bivariate comparisons using paired Wilcoxon tests to compare measures of depression and disability on admission and discharge. To identify predictors of change in depression and disability, we used regression with backward elimination to arrive at a parsimonious model of baseline demographic and clinical characteristics associated with change in HAM-D, WHODAS, and FIM. We used logistic regression with backward elimination to identify predictors of the categorical outcomes response and remission of depression.
these, 88 (24.4ü received the diagnosis of major depression. Of the 88 patients with major depression and COPD, 63 entered the study and 25 were excluded. The reasons for exclusion included severe medical burden requiring treatment beyond that offered by the study (N ⫽9), discharge to a nursing home before completion of the rehabilitation program (N⫽4), refusal to participate (N⫽ 11), and need for complex psychiatric care (N⫽1). The excluded patients had a mean age of 73.7 years (standard deviation [SD]: 10) and a ratio of men to women 1.3:1. The mean education of the excluded patients was 12.8 years (SD: 2.2). Of the excluded patients, 96% were non-Hispanic and 96% were white. The participants’ (N⫽ 63) mean age was 71.3 years (SD: 7.9), and the ratio of women to men was 2:1. Their mean education was 13.4 years (SD: 3.2); 98.5% were non-Hispanic and 89% were white. Of the 63 participants, 37 were started on antidepressants after they entered the rehabilitation center and remained on antidepressants throughout their stay. Twelve participants were receiving antidepressants on admission and remained on these agents throughout their hospitalization. Another 14 participants were discharged on no antidepressants either because they refused treatment or developed side effects and were reluctant to reinitiate treatment. Profile of Depression On admission, interviewer-rated 24-item HAM-D (mean: 23.59, SD: 3.18) indicates that many participants had moderate to severe depression. The most prominent depressive symptoms were depressed mood; early, middle, and late insomnia; psychic and somatic anxiety; fatigue and other somatic symptoms; and ideational disturbances such as helplessness, hopelessness, and worthlessness.
Improvement of Depression
RESULTS A total of 469 consecutively admitted patients to the rehabilitation unit were available for screening. Of these, 66 patients were excluded from screening as a result of severe medical illness, and another 42 patients who were approached refused to be screened. The remaining 361 patients were screened, and of
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The median length of stay in the rehabilitation unit was 16 days (mean: 17.94 days, SD: 8.23). Depressive symptoms improved by the time of discharge. Improvement occurred across all depressive symptoms with high baseline values. Of the 63 participants, 32 (51%) met criteria for response defined as 50% or greater reduction in HAM-D scores from baseline, and 25 (39%) met criteria for remission
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Depressed Patients Undergoing Inpatient Pulmonary Rehabilitation defined as a final HAM-D score equal to or less than 10. Change in HAM-D scores since admission was not associated with length of stay in the rehabilitation center (Spearman: r⫽0.03, N⫽63, p⫽0.85). Change in HAM-D depressive symptoms did not differ for subjects who 1) initiated and remained on an antidepressant at the rehabilitation center, 2) entered the rehabilitation center on an antidepressant, or 3) did not receive or could not tolerate an antidepressant (Kruskal-Wallis 2 ⫽2.65, df⫽2, p⫽0.27). We examined the bivariate relationships between the following baseline variables and each outcome variable: age, gender, education, medical burden (Charlson Comorbidity score), disability (WHODAS total score), functioning (FIM total score), subjective support (subscale of the DSSI), cognitive impairment (MMSE score), and overall treatment satisfaction (Client Satisfaction Questionnaire). Using regression with backward elimination, we constructed a parsimonious model of baseline demographic and clinical characteristics associated at the bivariate level with
TABLE 1.
change in HAM-D scores since baseline. The model predicted 28.9% of the variance in HAM-D score change since baseline (Table 1). Following the same process, we constructed a model, which predicted 29.2% of the variance in the occurrence of treatment response (Table 1). Younger age (Figure 1) and the subjective experience of social support (Figure 2) were associated with high response rates, whereas history of treatment for previous depressive episodes was a predictor of poor response. Like with prediction of response, a model consisting of age (Figure 1) and the subjective experience of social support (Figure 2) was associated with high remission rates and predicted 24.9% of the variance (Table 1). Improvement of Disability By the time of discharge, there was a significant reduction in disability. All disability domains of both WHODAS and FIM were significantly lower on discharge compared with baseline (Table 2). There was
Predictors of Improvement of Depression in 63 Older Adults With Major Depressive Disorder Receiving Inpatient Pulmonary Rehabilitation
Predictor Variables
df
Parameter Estimate (SE)
t
p
1 1 1 1
⫺14.82 (8.31) ⫺3.89 (1.86) 0.67 (0.24) 1.16 (0.55) (model F ⫽ 6.92, df ⫽ [4,51], p ⬍0.0005)
⫺1.78 ⫺2.10 2.77 2.13
0.080 0.041 0.008 0.038
Wald 2
p
a
Change in Severity of Depression Intercept History of antidepressantsb Baseline HAM-Dc Treatment satisfactiond Predictor Variables Response
df
Parameter Estimate (SE)
e
Intercept Age Subjective supportf History of antidepressantsb
1 1 1 1
2.77 (3.67) ⫺0.11 (0.05) 0.33 (0.16) ⫺1.67 (0.84) (likelihood ratio 2 ⫽ 13.85, df ⫽ 3, p ⬍0.0031)
0.57 5.87 4.33 3.93
0.451 0.015 0.037 0.048
0.35 5.79 7.11
0.550 0.016 0.008
Remissiong Intercept Age Subjective supportf
1 1 1
⫺2.00 (3.39) ⫺0.09 (0.04) 0.45 (0.17) (likelihood ratio 2 ⫽ 12.78, df ⫽ 2, p ⬍0.0017)
a
Change in total of 24-item Hamilton Depression Rating Scale (HAM-D) from admission to discharge. Prior use of antidepressants assessed by the Barriers to Medication scale. c Twenty-four-item Hamilton Depression Rating Scale total. d Client Satisfaction Questionnaire total. e Fifty percent decrease in HAM-D. f Duke Social Support Index subscale. g HAM-D total of ⱕ10 at discharge. SE: Standard error. b
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FIGURE 1.
Relationship of Age to Response and to Remission of Depression After Controlling for Social Support
no significant association between length of stay in the rehabilitation center and change in either WHODAS (Spearman: r⫽⫺0.11, N⫽58, p⫽0.39) or FIM (Spearman: r⫽0.11, N⫽62, p⫽0.38) scores since admission. Change in WHODAS and FIM scores did not differ for subjects who 1) initiated and remained on an antidepressant at the rehabilitation center, 2) entered the rehabilitation center on an antidepressant, or 3) did not receive or could not tolerate an antidepressant (Kruskal-Wallis 2 ⫽ 0.35, df⫽ 2, p⫽ 0.84; 2 ⫽0.29, df⫽2, p⫽0.86). After examination of bivariate relationships, a parsimonious multivariate model following regression with backward elimination model predicted 86.8% of the variance in WHODAS change from baseline (Table 3). A similar model predicted 46.7% of the variance in FIM change from baseline (Table 3). The interaction of baseline disability and severity of depression at discharge was significantly associated with change in disability assessed with both WHODAS and FIM. Subjects with significant disability at baseline had the greatest improvement in
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disability if they had low severity of depression at the time of discharge.
DISCUSSION The principal finding of this study is that brief inpatient pulmonary rehabilitation is followed by improvement of depressive symptoms and disability in older patients with COPD with MDD. Improvement occurred in a broad range of depressive symptoms and on all domains of disability. These favorable outcomes were noted regardless of the use of antidepressant drugs. To our knowledge, this is the first study documenting improvement in depressive symptoms and disability in older patients with COPD with MDD during brief pulmonary rehabilitation. The findings of this study are consistent with observations suggesting that pulmonary rehabilitation improves psychosocial outcomes of patients with
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Depressed Patients Undergoing Inpatient Pulmonary Rehabilitation
FIGURE 2.
Relationship of Subjective Supports to Response and Remission of Major Depressive Disorder After Controlling for Age
COPD, although prior investigations did not focus on MDD. Nonetheless, symptoms of depression and anxiety as well as quality of life improve after inpatient pulmonary rehabilitation in patients with COPD with a broad range of anxiety and depression symptoms.21–25 Similarly, outpatient pulmonary rehabilitation may lead to improvement of depression and anxiety symptoms and quality of life in the minority of patients with COPD with such symptoms before treatment.26,27 Improvement in depression and anxiety may lead to decreased perception of breathlessness even when pulmonary function tests and physical disability remain unchanged.22,28 There is some evidence that the beneficial effects on emotional functions endure over a period of three months to two years.29 However, negative findings have also been reported.30 Improvement of depressive symptoms occurred regardless of whether patients with COPD were started on an antidepressant at the Burke Rehabilita-
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tion Hospital, were already on an antidepressant before admission, or were not treated with antidepressants. The short length of stay (median: 16 days) suggests that many patients who were started on antidepressants did not have the opportunity to improve as a result of this treatment. This view is supported by findings suggesting that older adults derive the most benefit from antidepressants after two weeks of treatment.31 Thus, nonpharmacologic interventions of the rehabilitation program may have been the principal contributor to changes in depressive symptoms. Although not specifically designed as a treatment for depression, most interventions of the rehabilitation program offer support and promote behavioral activation, treatment elements with known efficacy in MDD.32 These observations are encouraging because a considerable number of patients with COPD refuse antidepressant drug treatment.33 The larger study will provide the opportunity to examine the sustainability of the im-
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TABLE 2.
Change in Disability in 63 Older Adults With Major Depressive Disorder Receiving Inpatient Pulmonary Rehabilitation
Disability Variables
Admission
Discharge
Mean
Mean
WHODAS Getting around 8.86 Life activities 3.92 Understanding and communicating 4.98 Participation in society 6.40 Self-care 6.08 Getting along with people 3.38 Work 2.98 Total WHODAS 36.06 FIM Communication Locomotion Self-care Social cognition Sphincter control Transfers Total FIM
13.13 3.44 27.97 17.87 10.94 11.02 85.10
SD
SD
Z
p
8.08 1.78 ⫺2.958 2.81 1.32 ⫺4.188
0.003 0.001
2.19
3.96 1.80 ⫺3.168
0.002
2.10 2.25
4.98 2.33 ⫺3.292 5.36 2.34 ⫺2.038
0.001 0.042
1.84 1.21 7.45
2.78 1.52 ⫺2.026 2.33 1.06 ⫺3.316 30.52 7.97 ⫺3.928
0.043 0.002 0.001
⫺3.388 ⫺6.858 ⫺6.860 ⫺4.162 ⫺4.768 ⫺6.858 ⫺6.850
0.001 0.001 0.001 0.001 0.001 0.001 0.001
0.79 2.93 2.54 1.74 1.74 1.85 8.10
SD: Standard deviation; WHODAS: World Health Organization Disability Assessment Schedule; FIM: Functional Independence Measure.
provements in depression and disability. We will be able to explore the effect of the rehabilitation on longer-term outcomes and account for the impact of continued use of antidepressant therapy. The experience of support and satisfaction with treatment was associated with favorable outcomes of depression. This observation is consistent with studies documenting that a positive experience during treatment is a predictor of good treatment response.34 History of treatment for depression and advanced age were associated with limited change in depressive symptoms. History of chronic depression and depressive recurrences predict adverse outcomes of geriatric depression.35 Advanced age has been associated with slow change in depressive symptoms.36 Moreover, there is some evidence that old-old patients with COPD achieve smaller gains in psychologic well-being than younger-old patients undergoing rehabilitation.37 Patients with greater disability on admission and lower depressive symptomatology on discharge had the greatest improvement in disability. The course of disability parallels the course of depression. In
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Predictors of Improvement of Disability in 63 Older Adults With Major Depressive Disorder Receiving Inpatient Pulmonary Rehabilitation
Wilcoxon Test
1.40 1.13
1.56 13.79 2.43 9.79 3.83 35.63 2.15 19.15 2.63 12.79 3.87 17.26 9.98 108.40
TABLE 3.
Predictor Variables
df
Parameter Estimate (SE)
t
Change in WHODAS II scores Intercept 1 ⫺31.86 (2.84) ⫺11.19 Baseline WHODAS 1 1.02 (0.06) 15.54 Discharge HAM-D 1 1.98 (0.21) 9.36 Baseline WHODAS ⫻ discharge HAM-D 1 ⫺0.06 (0.01) ⫺13.04 (model F ⫽ 118.64, df ⫽ [3, 54], p ⬍0.0001) Change in FIM scores Intercept 1 13.94 (16.5) 0.85 BaselineFIM 1 0.06 (0.19) 0.35 Discharge HAM-D 1 3.78 (1.25) 3.03 Baseline FIM ⫻ discharge HAM-D 1 ⫺0.04 (0.01) ⫺2.90 (model F ⫽ 16.93, df ⫽ [3, 58], p ⬍0.0001)
p
0.001 0.001 0.001 0.001
0.400 0.728 0.004 0.005
SE: Standard error; WHODAS: World Health Organization Disability Assessment Instrument II; FIM: Functional Independence Measure.
community-residing individuals, residual depressive symptoms covary with disability over time.38,39 Reduction in level of depression was shown to result in approximately 50% reduction in days burdened by disability one year later.39 Depression may lead to disability in elderly individuals directly40 and by increasing the impact of medical burden.41 In patients with COPD, the antidepressant nortriptyline was superior to placebo in improving both depression and day-to-day function, although it did not influence physiological measures of pulmonary insufficiency.42 Thus, improvement of depression is critical for improving disability in patients with COPD. This study has several limitations. The lack of control group does not allow definitive conclusions on the impact of the rehabilitation program on depression and disability. However, the reduction of depressive symptoms and the response and remission rates were remarkable, and in many ways similar, to those occurring during randomized, controlled trials of antidepressants.43 Although the study implemented an algorithm for administration of antidepressant treatment, it included patients who refused to take antidepressants as well as patients who continued on antidepressants started before hospitalization. Thus, the study cannot offer definitive in-
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Depressed Patients Undergoing Inpatient Pulmonary Rehabilitation formation on the efficacy of antidepressant drug use. Finally, the study did not control the treatment offered by the rehabilitation center. Although the treatment package was associated with reduction of depression and disability, this effect may not be generalized to centers with less intense treatment.
CONCLUSIONS Brief inpatient pulmonary rehabilitation is followed by improvement of depressive symptoms and disability in older patients with COPD with MDD. Improvement of depression may be the result of behavioral interventions of the rehabilitation program rather than use of antidepressant drugs. Satisfaction with treatment and the experience of support were predictors of favorable outcomes of MDD, whereas
advanced age and history of treatment for depression were associated with limited improvement of depressive symptoms. Most gains in disability occurred in patients experiencing significant disability on admission and had limited depressive symptoms by the time of discharge. Because depression is a relapsing illness, patients discharged from inpatient pulmonary rehabilitation units should have vigilant follow up, including continuation and maintenance treatment for depression, to maintain the gains made during their hospitalization. The National Heart, Lung, and Blood Institute (RO1 HLB71992), the National Institute of Mental Health (P30 MH68638), the Sanchez Foundation, and Forest Pharmaceuticals, Inc., supported this research. The authors thank the study Health Specialists Allison Rieger, C.S.W., and Susan Friedman, C.S.W.
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