1. The Impact of Disability on Depression Among Individuals With COPD Patricia P. Katz, PhD ; Laura J. Julian, PhD ; Theodore A. Omachi, MD, MBA ; Steven E. Gregorich, PhD ; Mark D. Eisner, MD, MPH, FCCP ; Edward H. Yelin, PhD ; and Paul D. Blanc, MD, MSPH, FCCP CHEST 2010; 137(4):838– 845 R1 Chihyeok Oh, M.D.

2. Introduction Depression –common in chronic diseases In COPD patients –high prevalence of depression –greater levels of disability  but, little known about this subject. (progression of disability or what co-morbidities or disease-related factors) TheImpactofDisabilityonDepressionAmongIndividualsWithCOPD TheImpactofDisabilityonDepressionAmongIndividualsWithCOPDTheImpactofDisabilityonDepressionAmongIndividualsWithCOPD

3. The aim of this article –relationship between increases in disability and depressive symptoms among individuals with COPD –prevalence of high levels of depressive symptoms and disability increases in a population-based cohort of individuals with COPD

4. Materials and Methods - Sample A population-based, longitudinal cohort study –US adults with various airways diseases, aged 55 to 75 years at recruitment Airway disease cohort –chronic bronchitis, emphysema, COPD, or asthma Group –COPD/emphysema with or without concomitant chronic bronchitis (COPD) –chronic bronchitis with or without concomitant reports of asthma (CB) Annual follow – up telephone interview –T1 : 2006 / T2 : 2007 / T3 : 2008 TheImpactofDisabilityonDepressionAmongIndividualsWithCOPD TheImpactofDisabilityonDepressionAmongIndividualsWithCOPDTheImpactofDisabilityonDepressionAmongIndividualsWithCOPD

5. Materials and Methods - Variables Disability –Using VLA(valued Life activities) scale difficulty in functioning in 28 activity domains, ranging from self-care to household chores to social and recreational activities –% unable : the proportion of activities individuals are unable to perform –% affected : the proportion of activities affected –mean difficulty score : 0-3 : 0=no difficulty, 1=a little difficulty, 2=a lot of difficulty, 3=unable to perform Depression –Geriatric Depression Scale Short Form(S-GDS) Total scores range from 0 to 15 “depressed” = individuals with S-GDS scores of ≥4 TheImpactofDisabilityonDepressionAmongIndividualsWithCOPD TheImpactofDisabilityonDepressionAmongIndividualsWithCOPDTheImpactofDisabilityonDepressionAmongIndividualsWithCOPD

6. Age, sex, race, education, and smoking history –collected in the telephone interview –smoking history : classified as current, former, or never –High BP, heart disease, DM, arthritis, ca., stroke, kidney disease categorized as having 0,1,or2 of these co-morbid conditions COPD Severity Scores –respiratory symptoms –systemic corticosteroid use –other COPD medication use –previous hospitalization or intubation for resp. disease –home oxygen use Materials and Methods – Other Measures TheImpactofDisabilityonDepressionAmongIndividualsWithCOPD TheImpactofDisabilityonDepressionAmongIndividualsWithCOPDTheImpactofDisabilityonDepressionAmongIndividualsWithCOPD

7. Results – Subject characteristics Majority of the sample –≥66 years and older, women, and past or current smokers COPD group –more older, more current or former smokers, higher disease severity scores The depressive –less than high school education, current smokers, more comorbid conditions, higher COPD Severity Scores TheImpactofDisabilityonDepressionAmongIndividualsWithCOPD TheImpactofDisabilityonDepressionAmongIndividualsWithCOPDTheImpactofDisabilityonDepressionAmongIndividualsWithCOPD

8. Prevalence of Depression - More common in COPD - After adjustment : no difference in prevalence of depression Results – Prevalence of Depression TheImpactofDisabilityonDepressionAmongIndividualsWithCOPD TheImpactofDisabilityonDepressionAmongIndividualsWithCOPDTheImpactofDisabilityonDepressionAmongIndividualsWithCOPD

9. Substantial disability : evident at T1 Greater disability : evident among depressed individuals Results – T1 Disability and Depression TheImpactofDisabilityonDepressionAmongIndividualsWithCOPD TheImpactofDisabilityonDepressionAmongIndividualsWithCOPDTheImpactofDisabilityonDepressionAmongIndividualsWithCOPD

10. 8% ~ 19% : T1 to T2 disability increase Unadjusted odds : higher in COPD compared with CB But, after adjustment : differences not significant Results – T1 to T2 Increases in Disability TheImpactofDisabilityonDepressionAmongIndividualsWithCOPD TheImpactofDisabilityonDepressionAmongIndividualsWithCOPDTheImpactofDisabilityonDepressionAmongIndividualsWithCOPD

11. Individuals who experienced a T1 to T2 disability : increase were more likely to be depressed at T3 Unadjusted & after adjustment : elevation of the odds significantly Results – T1 to T2 Increases in Disability and T3 Depression TheImpactofDisabilityonDepressionAmongIndividualsWithCOPD TheImpactofDisabilityonDepressionAmongIndividualsWithCOPDTheImpactofDisabilityonDepressionAmongIndividualsWithCOPD The relationship between T1 to T2 disability increases and T3 depression but excluded individuals whose depression scores were ≥4 at T1 or T2 ⇒ The time ordering of changes in disability and onset of depression % unable and mean difficulty : significant predictors of the onset of new depression % affected : no significant association

12. Discussion Depression –Common in COPD, CB individuals Previous study –Prevalence of depression 7~60% COPD patient –Broad range wide variability –number of subjects –characteristics of subjects –method of estimating depression TheImpactofDisabilityonDepressionAmongIndividualsWithCOPD TheImpactofDisabilityonDepressionAmongIndividualsWithCOPDTheImpactofDisabilityonDepressionAmongIndividualsWithCOPD

13. In this article… –Crude depression rate COPD > CB alone –After adjustment (socio-demographic characteristics, co-morbidities, and disease severity) : not significantly different  Socio-demographic and health-related characteristics : the critical factors associated with depression Disability & Disability increase : common in COPD (previous study & current study)

14. Disability increase  Onset of depressive symptoms - ↑depressive symptom risk ⇒ ×2 T1 to T2 disability increase : predict new T3 depression -among not depressed at T1 or T2 With a disability increase > no increase –A risk of new depression ⇒ ↑ ×3 (defined using mean VLA difficulty) –A risk of new depression ⇒ ↑ ×17 (defined by the proportion of unable to perform VLA)

15. Depression –Poor self-care, medication adherence –Continued smoking –Increased disease exacerbation  Accelerate declines in health, as well as with increases in health- care use and mortality The American College of Chest Physicians Panel on Anxiety and Depression –Early predictors of depression in COPD ?? ※ This article  recognizing increasing disability  psychological intervention  prevent the onset of psychological distress and depressive disorder

16. Discussion - Limitation Classification of depression : based on a depressive symptoms questionnaire. The criteria of disability increase : not represent the critical values. The airways cohort : be unrepresentative of individuals. TheImpactofDisabilityonDepressionAmongIndividualsWithCOPD TheImpactofDisabilityonDepressionAmongIndividualsWithCOPDTheImpactofDisabilityonDepressionAmongIndividualsWithCOPD

17. Discussion - In summary, Significant portions of our cohort –At least mild depression over 3 years 8~19% of our cohort –disability increase over 2 years Disability increase  strongly predictive of later depressive symptoms (even among individuals who were not depressed initially) Increases in VLA disability  and important role in the onset of depressive symptoms in individuals with COPD. TheImpactofDisabilityonDepressionAmongIndividualsWithCOPD TheImpactofDisabilityonDepressionAmongIndividualsWithCOPDTheImpactofDisabilityonDepressionAmongIndividualsWithCOPD

18. Should identify factors –The development and progression of VLA disability –Factors that may protect against or ameliorate such disability Important, because these may represent potential targets for intervention Discussion - Future research… TheImpactofDisabilityonDepressionAmongIndividualsWithCOPD TheImpactofDisabilityonDepressionAmongIndividualsWithCOPDTheImpactofDisabilityonDepressionAmongIndividualsWithCOPD