Psychosocial Concomitants to Rehabilitation in Chronic Obstructive Pulmonary Disease

SPECIAL

REPORT

Psychosocial

Concomitants

in Chronic 3.

Dealing

Obstructive with

Distinguished

M.D.;#{176}#{176} Edward M.S.W.4 and

S

obstructive

chronic

quire

patients

treatment

certain

number

with same

M. Glaser, Ph.D.;t Daniel L. Logan, Ph.D.

is biologic

greater

than

perienced

with

or only

that

of the

a similar

patients

who

disease,

wim

disease

than in patients distinction between problems issue.

signfficant The

treatment

of the

often

be by various psychotherapies, therapies, and social support systems, tion as adjuncts when necessary, while

Psychiatry

Behavioral

fPresident, Angeles. Psychiatric §Clinical Reprints

Medicine, Human Social

Psychologist, consisting

available from Angeles 90024. are

and

Behavioral

Sciences;

and

Worker

Research

Institute,

Dr.

CHEST, 77: 5, MAY, 1980

and 3 of 10889

this

series

Wilshire

of Blvd.,

reality

with

Los

articles

Los

necessarily In

states

prob-

little

in alveolar

the patient with (that is, one who

hope

with

(c) for

This

cop-

clinical of the

but

disease, often

does

not

changes

associated

progresses increases

it

in oxygen

production

that

for physiologically ventilation. Even

ventilation

With

in with

in severity, in emotional

elevations

dioxide

be compensated patient’s impaired

changes

those

probability

produce

carbon

to accommodate.

(b)

diagnosis.

disease where

difficult

pulmo-

or no response

problem

are

type

and

of pulmo-

marked

problems.

the

minimal tion, tem,

feel

of pulmonary

of any

be

incapacitated;

an increased

activation

readily of the

all;

are

a psychiatric

consumption cannot because

serious

have

at

and

dyspnea only. As the may reach a point activation

and

to

who

concomitant

confirm

early

psychiatric

disease

overreact

having

psychologic

the

suggests

patients’

can

textbooks

without such combinations. A for possible psychiatric disease

disease

the

information

diseases

current

likely

and pharm-

for anxiety above three

with

of

who

types),

patients with (a) no complaints

but

pulmonary

ing

Chief,

patients to screen

be condepres-

Specific available in the

the

more

to identify

patients

Dallas. 1,2 Glaser,

the

of

combined

are

disease

to

Cerritos.

of Parts

than way

little

Seattle.

Interaction

lems good be

any

with

disease

fre-

#{176}Fromthe Harborview Medical Center, University of Washington, Seattle; the Human Interaction Research Institute, Los Angeles; the Department of Psychiatry, Southern California Permanente Medical Group, Cerritos, CA; and the Timberlawn Psychiatric Center, Dallas.

o*professor,

A review from

nary

can

behavioral with medicatreatment of

bipolar

syndromes).

of psychiatric

nary

former

and

brain

are also classified

af-

dis-

of medications.

acologic treatments and depression not obtained

in the

be no recovery

(unipolar (acute

psychiatry.

psychiatric

will

illness

ex-

disease. and psy-

medica-

needed

sive

not

no more

without pulmonary psychophysiologic

and

is a critical

is probably

use

the

likely

be

the psychiatric diseases to are the schizophrenias, manic

categories.

psychophysiologic emotions that severe pulmonary

there

with

may

general, about

psybe

DISEASE

but

without

be primarily

of therapy

period,

Patients

PsYcmA’riuc

initially

types

In cerned

problem.

psychiatric

chosocial

recovery

will

have

should

Other

delirium

the psythat the

for continued psychiatric! and psychotherapy

latter

tions. period

psychi-

significant

In contrast to psychosocial and problems and their accompanying ffict many or most patients with

can

A

from psychosocial can be managed

management apply. Once is under control, it is likely

DEALING

ease

the re-

or pharmacologic.

distinguished problems),

need of these patients chological evaluation

The

disease

the help of psychoactive medications. At the time, however, the guidelines for psychosocial

and psychologic chiatric disease

quent

disease

psychiatric

of patients (as

(as

or

pulmonary

with

that

atric disease, psychophysiologic

Disease*

Problems)

Donald L. Dudley, Betty N. Jorgenson,

(COPD)

Disease

Psychosocial

Psychophysiologic

ome

Pulmonary

Psychiatric

from

to Rehabilitation

then

psychologic

an unimpaired is not paralyzed

become activa-

muscular and thus

syscan

PSYCHOSOCIALCONCOMITANTS IN REHABILITATION OF COPD 677

muscles),

contract

and possible in psychologic amount

of air

the

When there

patient

drop in oxygen of the skeletal

emotional

arousal

be

becomes The cough,

the

fear, as another

than these

than

uncom-

system

is required symptoms

the

patient’s

and

avoid

logical

understandable

these interpersonal contact because stress involved. They thereby

chological they

that

stressors.

The

lessen the psychological

organ

system,

By using

more

chronic

however,

inappropriate, as rejecting,

preceding

problems

patients

with

repression,

interact

do

add

not

regarded

since the patient bland, and unresponsive. can

be magnified

psychiatric

many

times

in

siderable

therapy addition,

medications

proach

to treating psychiatric

justment

that

Failure edgeably cantly

lack

the

ability

In

disease, may

increase

in contrast

morbidity

with

with

and

pulmonary

practical

increase the

patient

may

and

work

information

and lack on

his

should

review of therapeutic and psychoactive medicaflons.1

678 DUDLEY El AL

if improve

the

the

energy

other concomitant and reactions to

greater

the

the

age

lower

and

the

one

to

ap-

In

In addition,

and

do not center,

pulmonary

medicaments,

pulmonary have

patients

facilities

for

probmeasur-

medications.

dosage is the precombined psychi-

with COPD.

Fortunately,

have

with

most

high

a

degree

disease

awareness

is a compromise

medication appetite. and

how

are

safe

and

when

when

between

the

indications.

not

As

to prescribe for

These

1)

are

their

potent

(that or

antidepressant or and particularly

pulmonary

disease

impression,

problems

problems. The be supplemented

following by

nontherapeutic

effects

a of

are

pulmonary

unclear. them

who may not of medication

neuroleptic),

can

dangerous

Without that the

patients.

it is likely

of may

disease.

it is

if clinical

prescribing

is, to patients some other type

can

with

medication,

and

such as an antitherapeutic

need

of someoverused.

agents

administration

compounds,

be sedation, and potentiation havioral disorganization that

to

often

posbeneof the

for the patients’ them rather than

any

with

and to

stamina

are

anxiolytic

indiscriminately, need them

nostic

Other-

the hands to use them.

in

(Table

agents

specific

indications

also can be For example,

agents

knows

of

used of contraindica-

pulmonary

and with cases.

Anxiolytic

malad-

in

or adand

cardiac

They tend to be given in sympathy condition and our inability to cure

to social

mortality

be to

depress do not

or

psychoactive

severe

medication

better

knowlsignifi-

of

many

it is important

doses that respiratory

compounds

who

for

psychotherapy.

a

the

dose

advisable.8’9

individualized in

psychoactive

disease.

interventions levels

disease, needs

of major

in patients

signifi-

with severe sleep, energy, may be more responsive

energy

levels

disease

with

possibly

addition, psychoactive medication as an adjunct to psychotherapy.

psychotherapeutic

examine

only

associated

be treatable

a depressed patient appetite impairment

wise,

the

to utilize these types of medications and with discriminating care can

the patient useful

are symptoms

the

now

treatment

Any

many

of

sible toxic side effects and the possible clinical fits. However, even the potentially most toxic

MEDICATIONS

since

and the

discriminately tions for given

disorders.

importance,

age

the

of psychoactive medication wifi than that normally prescribed

hospitals

blood

safety

other treatment techniques, and psychois often contraindicated or not effective. In

utilize

to

In such a setting, the optimal clinical response can be associated with a specific blood level, and that blood level can then be maintained. This method of

atric

be The

are

related

agent

psychoactive

may

this

disease,

with

determining

by others

for

the

to existing

Some

extent

reasons

disease.

versely

ferred

events. a failing

role of psychoactive medications in the treatof patients with pulmonary disease is of con-

ment

cant

often

are

PSYCHOACTiVE

The

and

the

psychiatric

lems.

people tend to of the psychodecrease psy-

denial

be

a rule,

As

to select agents overly stimulate

emotional

impact of emotionally loaded defenses used to protect

as socially perceived

general

drug.

ing is

to

The

chronicity of the and individual

given

treat

state. It

seem

in COPD

to a greater

practiced.

patients, the dose one third or less

that in turn further com-

physiological

but

agents

individualized

psychopharmacologic

to are

treatment,

depression stimulus,

be

is generally

patient, diseases,

reall

of psychopharmacologic must

varied

is no

pulmonary

psychosocial

and!or emotional

anxiety,

promising

with

use

patients

or impossible to accomplish. reaction to dyspnea, wheezing, production, and pain that occurs can

difficult

secondary sputum

serves

there

and nutritional Thus, any and

oxygen Until

eg,

nonmeclical,

The

hypoxia

but

associated

because

tends to deliver less metabolic demand.

relieved,

be

need muscles.

may

symptoms

then meet

develop

there is a decrease is a drop in the

breathes,

equivalent quirements fortable

to then

is likely

hypercarbia. activation,

in

be the

a clear diagonly effect will

depression further The

or beaggravate

use

of these

agents should be limited to the attainment of shortterm goals, such as overcoming an acute situational problem. Giving them over long periods of time can lead to significant problems with habituation and depression. tered

If an

in significant

anxiolytic dosage

agent over

has

been

an appreciable

adminis-

pe-

CHEST, 77: 5, MAY, 1980

1-Examples

Table

of Anxiolytic

Agents

(Minor

Tranquilizers)

*

Daily

Dose

Moderate

Specific

Medication

Indications

Special

Usual Dose

Properties

Daily (Oral),

Severe (Oral),

mg

in to

COPD mg

BENZODIAZEPINES Chlordiazepoxide

Anxiety

(Librium)

ing

which

specific

is imped-

Poor

behaviors

absorption

by the

intramuscular

such as sleep, exercise, social interactions, Some cases of insomnia,

For many the drug choice in alcohol withdrawal.

Same as for chlordiazepoxide

Poor absorption the intramuscular

Diazepam (Valium)

Clorazepate (Tranxene)

10-200

10-100

5-50

5-10

3.75-45

3.75-15

route.

of

by route.

Good

muscular

relaxant.

Same as for chlordiazepoxide.

Wide

dose

Not recommended. If used, same as chiordiazepoxide.

May have low safety factor with overdose as compared to other anxiolytic agents.

400-1600

200-800

Same as for chlordiazepoxide.

Antihistamine Low abuse with other Atropine-like

25-200

10-100

selection.

GLYCEROL DERIVATIVES Meprobamate (Miltown,

Equanil)

DIPHENYLMETHANE DERIVATIVES Hydroxyzine (Atarax, Viataril)

5Barbiturates

produce

unacceptable

central

nervous

system

potential compared anxiolytic agents. side effects.

depression,

sedation,

dependency

and

addiction

risk

safety margin compared to the medications listed above, with the exception of meprobamate. For all anxiolytics or lack of attention may make operation of machinery dangerous. This is particularly so during initial treatment. may need the usual daily dose. Respiratory depression with aggravation or onset of hypoxia and hypercarbia complication when the anxiolytic agents are used in the COPD population. COMMON SIDE Drowsiness Ataxia Confusion Slurred speech

EFFECTS:PRECAUTIONS

Hepatic

Dizziness Impaired visual accomodation Dependency Dry mouth Difficulty handling secretions

Pregnancy Withdraw slowly when used long term to avoid problems such as convulsions Breast feeding mothers-medication may be transferred via milk May occasionally produce paradoxical rage or anxiety or depression

nod

of time,

withdrawal reduction of

gradual

withdrawal

Abrupt

nervousness, most of the is taken to many

anxiety, symptoms

one severe

long-term not

used

just

who

be

CHEST, 77: 5, MAY, 1980

such

as

from with

with the effects for anxiolytic year.

Unlike

these cause

medications significant

of these compounds the

have

a low

use

or

agents, writes prescriptions only several times

neuroleptics in low respiratory

and

per

antidepressants,

to moderate doses depression.1#{176}

may

abrupt reference

Neuroleptics

anxiolytics. agents

are

(a)

treats and

is well

The

diaze-

(c) hydroxyzine, interesting to note

frequently disease

occur

by

and in fact, an alcoholic

resulting

anxiolytic

(b) chlordiazepoxide, oxazepam. It may pulmonary

in symptoms

use

impairment

carried out than abruptly.

tremors, insomnia, that occur when

medications,

psychiatrist

result

Problems

from

Commonly pam, (d)

will

off alcohol.

withdrawal

should be dosage rather

CONTRAINDICATIONS: Hypersensitivity Porphyria (do not meprobamate) Comotose states Severe dependency addiction

WITH: Glaucoma Anticoagulants Renal impairment Respiratory depression

Headache

and

listed, drowsiness Selected patients is always a possible

patients acquainted

neuroleptics

and that

quilizers)

with

chotic reactions In common with

diseases

are such

(formerly used as

in the

called treatment

schizophrenia, and the

sometimes antidepressants

major

tran-

of psychiatric mania,

acute

delirium (Table (Table 3),

psy2). they

PSYCHOSOCIALCONCOMITANTS IN REHABILITATIONOF COPD 679

Table

2-Examples

of

TVeuroleptics

(Major

Tranquilizers)

*

Daily

Dose

Moderate Specific

Medication

PHENOTHIAZINES Thioridazine (Mellaril)

Usual Dose

Indications

Special

Properties

Same as for chlorpromazine. When anticholinergic

Strongly compared on this Inhibition

anticholinergic to other neuroleptics chart. of ejaculation.

activity are

plus sedation

desired.

Chlorpromazine

Hyperactive

(Thorazine)

in association

behavior

Daily (Oral),

Severe (Oral),

mg

50-800

5-200

Sedating.

50-2000

5-200

Available in depot form (Prolixin Decanoate or Enanthate) which can be administered to patients who are unreliable or who prefer the convenience of

2-20

Depot form 12.5 to 75 mg every ito 3 weeks intramuscular

not taking

injection.

Pigmented

retinitis

doses

800

over

in to

COPD mg

in daily

mg.

with

schizophrenia, mania or other definable psychiatric

disease.

Need to attenuate turbing sensory When Fluphenazine

sedation

dis-

stimuli. is desirable.

Same as for chlorpromazine with less sedation.

(Prolixin)

DIHYDROLINDOLONES Molindone (Mobane)

Same

(Navane)

as for chiorpro-

Low

May

mazine.

anticholinergic have significant

depressant BUTYROPHENONES Haloperidol (Haldol)

*As

you

Same as for chiorpromazine. When sedation and cardiovascular side effects need to be avoided.

move

from

thioridazine

to

haloperidol,

medications.

Apparent low cardiovascular toxicity as compared with chlorpromazine. Does not block guanethidine. Little or no experience with the drug in COPD.

Same as for chlorpromazine.

THIOTHANXENES Thiothixene

daily

Depot form 6.25 to 37.5 mg every 1 to 3 weeks intramuscular injection.

30-100

10-30

5-80

2-20

2-40

1-10

effect.

The least

sedating

The most Parkinson

likely type

neuroleptic. to produce

symptoms. Low toxicity. Low activity.

cardiovascular anticholinergic

extrapyramidal

activity. anti-

1-10 (oral)

(oral)

symptoms

increase,

and

moving

backward,

alpha

adrenergic

blocking, allergic responses, sedation, atropine like effects, seizures and orthostatic hypotension generally increase. For all neuroleptics listed, drowsiness or lack of attention may make operation of machinery dangerous. This is particularly so during initial treatment. Selected patients may need the usual daily dose. Respiratory depression with aggravation or onset of hypoxia and hypercarbia is always a possible complication when the neuroleptics are used in the COPD population. Neuroleptics in general can alter sexual function and drive. Each medication in this class can produce specific types of problems. For example, thioridazine may contribute to delayed or inhibited ejaculation and chlorpromazine may contribute to a simple reduction in sexual drive. On the other hand, both may increase sexual drive and performance in specific patients. In addition, sexual dysfunction is so common in patients who need to be treated with neuroleptics that it is often difficult to know what the cause

of the

change

COMMON

in sexual

SIDE

EFFECTS:

is secondary

to. PRECAUTIONS

Blurred vision Dysuria Constipation

Seizures Depression

Nasal congestion Postural hypotension Photosensitivity

Respiratory

Fatigue Weight gain Extrapyramidal

Respiratory Potential handling

DUDLEY

WITH:

CONTRAINDICATION5:

Comatose Central

disease

Cardiac disease Respiratory depression May reverse the hypertensive action

side

depression

effects

states nervous

system

depression

Pregnancy

Drowsiness

680

function

of medications

epinephrine, antihypertensive guanethidine

and

block effect

such the of

as

Bone marrow depression Subcortical brain damage Seriously impaired liver function Hypersensitivity Uncontrolled Severe retarded

epilepsy depression

difficulty secretions

El AL

CHEST, 77: 5,MAY, 1980

Table

3-Examples

of

Tricyclic

Antidepressants

Daily

Dose

Moderate

Specific

Medication

Indications

Amitriptyline

Agitated

(Elavil)

prophylactic

depression

of panic

Doxepin (Adapin

Special or

Strongly

anticholinergic.

Usual

Daily

Dose

(Oral),

.Severe

mg

COPD

(Oral),

50-300

10-100

50-300

10-100

50-300

10-100

50-200

10-100

5-60

2.5-20

mg

Strongly sedating. Reportedly high incidence of cardiac complications. Administer near bedtime.

treatment attacks.

Same as amitriptyline plus severe insomnia.

or Sinequan)

Properties

in to

Compared with it is moderately

but equally cardiac

sedating.

Low

toxicity.

Little tory

amitriptyline anticholinergic

or no effect

on

respira-

center.

Unlikely

to inhibit

guanethedine

in doses under 150 mg. Administer near bedtime. Imipramine (Presamine

or Tofranil)

Depression

which

between

the agitated

retarded

categories.

Prophylactic panic attacks.

falls

and

treatment

of

Moderately

anticholinergic.

be sedating. complications. Administer during the

Potential

Same

as imipramine.

bedtime

or

day depending of sedation.

degree Despiramine

near

May cardiac

Weakly

anticholinergic

on

compared

to amitriptyline. Tends to be more activating than imipramine. Lower incidence of potential cardiac complications compared to imipramine. Generally administer during the day unless sedating effect predominates.

(Pertofrane, Norpramin)

Protriptyline

Retarded depression depression associated with loss of energy.

(Vivactil)

or

Moderately

anticholinergic.

Potential cardiac complications. May be used in combination with amitriptyline or doxepin. Give the sedating antidepressant for sleep

and

protriptyline

in the

morning for energy. Administer in the morning at noon.

you go from amitriptyline to protriptyline, from antidepressant effect which will follow therapeutic and demonstrates to the patient antidepressant during the day or to a patient lead to noncompliance with therapy.

As

For

all antidepressants

listed,

so during initial treatment. A beneficial side effect of these usual daily dose. COMMON

SIDE

Dry mouth Potential difficulty Blurred

vision

Constipation Nausea

medications

effect

apparent

in hours.

activation effect generally increases. Initial effects should Initial sedation or activation is present in hours. However,

that

condition

with

or lack

the

is responsive

a retarded

in COPD

secretions

to medications.

depression.

of attention

may

patients

Urinary

handling

be

initial in days.

The

make

may

PRECAUTIONS

EFFECTS:

should

operation

be mild WITH:

retention

initial

sedation

In

general, may

of machinery

bronchodilation.

avoid

be distinguished initial giving

incapacitate dangerous.

Selected

the This

patients

effect

is

a sedating patient

and

is particularly

may

need

the

CONTRAINDICATIONS: Acute myocardial infarction Hypersensitivity

Cardiovascular Narrow angle

disorders glaucoma

Acute

Organic brain Schizophrenia

syndrome

Mania

schizophrenia

Monoamine

oxidase

inhibitors

Mania

Heartburn Hypotension

Weight

drowsiness

Activating

and

gain

Convulsive Thyroid

disorders Disease

Pregnancy Potentiation amines Blocking

CHEST,

77: 5, MAY, 1980

of sympathomimetic guanethidine

PSYCHOSOCIALCONCOMITANTS IN REHABILITATIONOF COPD 681

are

not

habit-forming

tolerated conditions.

or

if prescribed Neuroleptics

generally

seen

while

the

ocuous. effects

as being

those

from

agents

that

provide

the

and

problems

medications

vantage of haloperidol pure, central blockade blockade

produces

decreased

activity

with

minimal

if the cardiac

may

lem

with

strictions

in

peridol

is safe

patients

of

be

and that

be

noted

or no

From

by

the

both

in

blood

antinuclear

antibodies.1’

implicated

in

phorylation,

pressure is

sensory

uncoupling

(ATP).12 useless

heat

of the

This

It been

and

a

subsequent

treat-

and

peripheral

blockade hypotension.

is also

by the cations, and

682

alpha-adrenergic associated

The

with

In

the

hypotension

beta-adrenergic

DUDLEY El AL

action.

To

to

sants

for

blood

reac-

procainamide if the

medica-

antidepressants

a general rule, the and antiparldnany given patient,

As

antidepressants prescribed for probability

are

of hyperthermia. central hypothalmic

of

clinically

medialphapres-

steroids

significant

is

to

sedative

effect

the

of

antidepres-

purposes:

sedating,

illustrated illustrated

compounds

also

are

by proby imi-

potentiate

compatible

As

little

with

characteristics, reduce

or

the

with

is apparent

effect

with

other

or no effect

Protriptyline

is

depressed

motivation.

An

but

may not appear Imipramine

the

in minutes

or agito

in

In addition is

sufficiently

agitation.

The

or hours,

while

may not appear for several antidepressants, it appears to on the respiratory center, and bronchodilator.10”3

the

of

antidepressant

patients activating

as with

choice

it

eliminate

to act as a mild

retarded,

of COPD.

antidepressant

patients

antidepressant

hours,

use

bronchodilators.

antidepressant

it seems of

these

to

it is helpful

clinical three

and

depressed

have

depression,

the

following

In general, of

sedating

the

This

of

on

by doxepin; activating, and intermediate,

Doxepin

its

howmuscle

both

the

action.

the

triptyline;

tated,

the

the production may be aggravated

support

The

to the

and

permanent

that

treatment

information

of been phos-

blockade.

concomitant use of sympathomimetic such as epinephrine, that have

noted

the

potentiate

hyper-

reaction to chiorpromazine, related to decreased

identical

the production to be related to

have

weeks.

A more common ever, is hypothermia

de-

will

syndrome.

Antidepressants

action

thermia.

tone

anticholinergic

pramine.

Less

lead

and

more

illustrated

of adeno-

can

patient

it in may

input,

oxidative

formation

of

develop

hyperthermia.

desirable.

has

a rare

to be

is not

can

to 50 percent may

in

higher

of chlorpromazine and the formation

blocking

triphosphate of

and

be

implicated appears

the

in which

clinically

should

also This

surgical

route!

situations

up

hydrochloride and

son

data,

Chiorpromazine

the

thus

in

therapy

erythematosis-type

of halo-

have

and

of

diphenhydramine the antiparkinson mesylate or pro-

daily,

appears

initially

is withdrawn.

It

bronchoconstriction.’#{176}

is useful

antibodies,

neuroleptics, medications

emergencies medication

butyrophenones

with

chlor-

unimpaired

maintenance

chlorpromazine

and

production

initial

intravenous

occasional

coupled with sedation, well known complications ment include hyperthermia

production

little

and

Oral

or

mg

tion

reactions with

administration

1 mg,

with any of as benztropine

treated

hydrochloride

extra-

intravenous

patients

serious

effects

use

medical

in

is very

that

Chlorpromazine

sine

intravenous

be

recom-

reactions

cyclidine hydrochloride. In doses above 400

toxicity A prob-

These

50 mg.

to hydralazine

of

is

in maintaining

with

be accomplished medications, such

tion

side

may

stimulant

norepinephrine)

mesylate,

lupus

oral

the

These

that during psychiatric surgical patients, this

to produce

reduction

the

effective

given

treated

be

a lupus syndrome

to patients with reto move air. Several recent

there

when

should found

by

development

problems.

appear and

safer

the

that

movements.

velop

brain of choice

pressure.

given

it

alpha

of extrapyramidal haloperidol than

respiratory

antinuclear

and

input in the

neuroleptic

symptoms.

ability

shown

and

sensory

blood

ad-

relatively

distressing

extrapyramidal

would medical

on

is

and

the

have

of

dopamine

centers

when

particularly

studies

in

It is the

route signs

be

class

in its

or

is important

hydrochloride,

exam-

this

This

emotional

effect

dopamine

promazine) should

anxiolytic

hypotension or potentially because it has low cardiac

no

intramuscular can

a decrease

haloperidol

pyramidal

lies

of dopamine.

sedation.

have

of

seemingly

of

patient has problems

and

than

reasonable

that

of a strong

Rapid treatment (more common with

in-

(haloperidol (a butyrophenone) (a phenothiazine). The

are

chiorpromazine

as

circumstance

addition

benztropine

neuroleptics benefits

unusual the

(such

dangerous,

of

the

mended.

counteract

administration dosage.

of

and

to

in

necessary,

can have side side effects of the

difficult

long-term

sure

well

disease are

and

medication but the

less

are

considered

are

in significant

Two ples

and

appropriate antidepressants

agents

Both types of in some patients, are

the and

too powerful

anxiolytic

neuroleptics

addicting

for

doxepin,

for days falls in

with

low may

effect

the

choice drive appear

antidepressant

or weeks. between

doxepin

CHEST,

in and in effect

and

pro-

77: 5, MAY, 1980

and

triptyline

activation

should

is not

will

not

the

day,

adapt

be used

needed. well

to doxepin

or to protriptyline optimal therapeutic

obtain be taken

of the

acteristics

by

or activation

life.

It should

similar

initial

may

A review

not

immediate

both,

the

of the cardiovascular

these

medications,

have

a quinidine-like

one

ficial

for

patients

with

therapeutic

may

premature

0.2

the

fact

that

well

be bene-

once

auricu-

In

utilizing

is

important

have

the

antidepressants

to

little

relationship

ticularly

to

the

the

desired

a setting, ciated

with

This

one

disease increased have medications

determining

asso-

the

is the

combined

and

pre-

given

cardiac problems when within a reasonable

Understanding creasingly

lithium important

therapy

has

as clinical

studies

demonstrate its effectiveness mania, depression, or cyclic

in controlling swings from

depression.

treated

Mania

neuroleptic, However,

and lithium

The

starting

900

mg

if the since tion may

kept CHEST,

dose

per

day.

patient theophylline of lithium,

excretion

may depression should of lithium This

dose

is taking

to

vary with salt intake stable during lithium

5, MAY, 1980

with

a

from

is generally

addition,

to

rier,

require

will

a diuretic,

lithium

excredecrease excretion

the of

lead

an use of

with

warm

skin,

the 1

to

4

respiratory

of

the

or inis rec-

mg,

simply action.

produce Meth-

intramuscularly), effects

an

this is of the

(in minutes). bloodbrain bar-

use of neostigmine will peripheral cholinergic to 1.0 mg

and that dose

severity

is rapid cross the

peripheral

signs mild

increased

mydriasis,

intramuscular

the

the

including

with

(0.5 avoid

to

Again, the the probability

increase

scopolamine to block

properties amitrip-

It is important increasing the

used

can

be

of physostigmine

problems

when

necessary.

SUMMARY

The treatment chophysiologic or associated

and evaluation and psychosocial with pulmonary

accomplished

from

treatment

thereby be A fasting

car-

control.

associated ingestion,

Reversal wifi

to

modification or

which should administration.

300

lithium

flushed,

Treatment physostigmine,

symptoms

to help

with

occasionally

syndrome. early, since agents

and

it is treat

sweating,

antidepressant. concomitantly.

theophylline

In

recurrent mania

initially

with an be started may

in-

continue

tends to cause an increased and most diuretics will

of lithium.

77:

be

become

occurs, and

(delirium). increases

elevation,

ommended.16’11 Only physostigmine

Lithium

this

of

Lithium depression

high anticholinergic agents, thioridazine,

decreased

psychosis. travenous

window.

If

signs alternate

neuroleptic

is under

This will be of atropine

rate,

offending

advance. a severe

combined

depression

psychosis medications

acute brain recognized

these thera-

for and

in

the

hydroxyzine

reaction. symptoms

heart

disease. In addition to the of the treatment, it is unusual

significant

and

temperature

psychiatric

informa-

Problems

anticholinergic of multiple

maintained.

dosage

with

tyline,

of may

contemplat-

carefully

control.

Medications with such as antiparkinson

lev-

be

the

This

physicians

planned produces

antidepressant until

levels

lithium

hyperthermia),

discontinue

Anticholinergic

is par-

can

then

level,

an

patients

blood that

is

usual-

patients.

is under to

bonate

In such

response

blood

patients

are

with

blood This

antidepressants.

clinical

and pulmonary effectiveness

to

peutic

tricyclic

of

in

optimal

medications.

a specific

method

ferred

to maintain

psychoactive

so for

neuroleptics,

related to either. Since these a therapeutic window, above will be no positive clinical

it is essential

of major

els

and

that blood levels may oral dose, and cellular

remember

levels may be poorly compounds may have or below which there effects,

mania

from

be monitored

should be occasionally

necessary

COPD

problems.’5 by

(particularly

treatment carbonate

they

renal

should

toxicity

dose can

some

indicate

reviewed

a seven and the

has

maintenance

effects data

in COPD

Patients

of

may

therapeutic

signfficant

its use

that

disat a

of therapy

or antidepressant Note

be

lung

usually

onset the

the

thera-

to equilibrate

Lithium

the

after

to severe days

When

L. Recent

should

ing

lar contractions. it

good

tion

hours is usually

moderate

neuroleptic

withdrawn.

mEq/

to ten

to ten

three

response.

produce

is the the

ventricular

be

with

take

the

obtain

be

action

with that

ly

(nine

of 0.5 to 1.0 mEq/L

blood level. lag between

reached,

effects of the anti-

is left action

sedaa

of lithium

in patients

It may

therapeutic to ten day

apparent.

sympathomimetic

dose)

ease.

antipsychotic

doxepin considering

level

evening

char-

have

to become

morning

peutic

patient’s

effect

but

or weeks

and

the

neuroleptics

depressants is essential.14 In general, least cardiotoxic. However, after anticholinergic

during

when

with

the

The or

days

or

patients

activating

at times

interfere that

effect.

take

and

them

will

sedating,

sedation rule,

if it is given

sedative

be noted

biphasic

calming,

clear

if it is given at night. To effect, advantage should

prescribing

tion

effect

when

As a general

psychotherapy failure.

a

approaches

per

It is essential

broad (eg,

Se)

of psychiatric, psyproblems related to disease need to be

are

clinical

base.

certain

to recognize

Single

per

biofeedback to be the

met

limitations

se or with

of

PSYCHOSOCIALCONCOMITANTSIN REHABILITATIONOF COPD 683

psychiatric gree

treatment

of

with

specific

psychiatric In

tempted

until

trol

sometimes

and

techniques morbidity and

psychiatric

not

comfortable

should

(usually

be

the

Readiness

meet

when

either

feels

the

the

by who

to

patient

the care of COPD can serve as the

coordinating

However,

since

such

centers

not available in most parts of the United States, primary physician often must act as treatment

coordinator. patient may

coordination unreceptive

If this

become

private

practitioner

community in local

hospitals,

tions,

Visiting

Nurse

contacted

physician

treatment and

may by

be

aware

care

problems,

the

pa-

needs, or whether resources referred

to try the

patient,

and

to consolidate

patient’s

he may wish to elicit the to above. The physician

684

DUDLEY El AL

suggests

he

aid of the can have

attitude toward and psychotherathat

serious

HI, Sadock II.

NN:

Cain

BJ:

Baltimore,

A compendium

New York, Raven MA,

DiMascio

Related

Shader

RI:

Brown

Press,

Comprehensive

Williams

& Wilkins,

of drugs.

Drug

1974 KF,

A, Killam

Drugs. Manual

& Co, New

SN:

with 12

New

York,

New in

eds: New

A

Psychophar-

York,

psy-

Raven for

the

and Struc-

Press,

1974

Therapeutics:

Psychiatry.

York, Clinical

Guide

Raven

of Psychiatric

WE

Farm York,

The

(eds):

Plenum

Practical

New

York,

Little

in

chlorpromazine.

chronic

J

Am

1973

drugs WF,

on respiraet al: Anti-

psychotic

patients

Psychiatr

132:1204-1206,

1975 Gatz EE: The mechanism of induction hyperpyrexia based on in vitro to in studies. In, Gordon BA (ed): International Hyperthermia.

and

Psychopharmacology

Press,

effects of psychotropic Ther 2:717-741, 1976 Fjarnason DF, Kiely

antibodies

Malignant

Convulsive,

1978 E: Phenothiazines

and

tion. Pharmacol 11 Quismorio FP, nuclear

Ther

1975

C,

9 Eisdorfer

Springfield,

of vivo Ill,

treated

malignant correlative

on

Symposium Thomas,

1972 aspects Bron-

chial

Asthma-Mechanisms and Therapeutics. New York, Little Brown & Co, 1976 14 Burrows GD, Vohra J, Hunt D, et a!: Cardiac effects of different tricycic antidepressant drugs. Br J Psychiatr 129:335-340, 1976 15 Ayd FJ: Lithium-induced nephrotoxicity: a further port. mt Drug Ther Newsletter 13:25-28, 1978 18 El-Yousef KM. Janowsky DS, Davis, HM: Reversal

reof

by physostigmine: a controlled study. Am J Psychiatr 130:141-145, 1973 Burks JS, Walter JE, Rumack BH: Tricycic antidepressant poisoning. JAMA 230:1405-1407, 1974 antiparkinsonian

17

behavior

social

13 Knapp PH, Mathe AA, Vachon L: Psychosomatic of bronchial asthma. In, Reiss EB, Segal M (eds):

medical that

Kaplan

Psychopharmacology

what Since

intervention. patient’s

personnel.

1975

turally

10 Steen and

it is important

significant impact on the patient’s the usefulness of paramedical If the

RM,

Aging.

organiza-

to greatly influence patient will receive. to all

treatment

macology: A Generation of Progress. Press, 1978 6 vanPraag HM: Psychotropic Drugs: Practitioner. New York, Brunner/Mazel,

labora-

determine how extensive the medical and psychosocial needs are and then assess whether he and his office staff alone are willing and able to meet those

peutic

Cain

5 Lipton

of

occupational

by

tempted

attending

psychological

health

primary

LB, Hippius H: Pharmacological, Somatic Treatment in Psychiatry. Grune & Stratton, 1969 4 Greenblatt DJ, Shader RI: Benzodiazephines

8

respiratory

the as

clinical

psychiatric

7 Forrest IS, Carr JC, Usdin

mental health professionals with pulmonary patients, practitioner usually is the

position services the

paramedical the

home

is in the

therefore

to

On made

problems

3 Kalinowsky and Other

the

cardiopulmonary

Association,

therapists, in working The private

professional

first

become

available include

tories

vocational experienced and nurses.

provided, to treatment.

should

resources Resources

tients.

is not

patients. can be

nurse,

AM,

Practice. center for the center

The

2

5:1-16,

in-

the

an ex-

1975

assistance or

by

professional

psychiatric

of Psychiatry

Textbook

If a comprehensive patients is available, are the

treatment carried

or other

1 Freedman

person,

emergencies”

health

for psychosocial out by a psychiatrist,

be

eval-

possible

to whether might best

need.

agency.

mental

a careful as

REFERENCES

is ready

specialized

soon

with COPD a judgment

emergencies.

physician

trained

as

perienced in working basis of this evaluation,

worker

COPD

one

be present,

done

patient

of the

as medical

may

be

psychologist,

population, reduced

for

primary

con-

disease be significantly

psychological

referral

or at-

treatment

physician),

problems should

appropriately

at all.

productive

chological uation

med-

is under

of treatment

as well

“to

specific

psychiatric

and

primary

making

de-

patients

considered

coordinated

psychological,

cludes

be

of

to the pulmonary and mortality can

patient

need

disease

should application

a more

wide

the

addition,

diseases

population can emerge. In general, all aspects

meet

In

some patients, psychosocial intervention should not be

the

optimal

and

available.

ical treatments. psychotherapeutic

With

techniques

flexibility

drug

toxicity

CHEST,

77: 5, MAY, 1980