Griffith Matthew F, Chen Hung-Yuan P, Bekelman David B, Feemster Laura C, Spece Laura J, Donovan Lucas M, Au David H, Carey Evan P
Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado.
Department of Medicine, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado.
Ann Am Thorac Soc. 2021 Mar;18(3):442-451. doi: 10.1513/AnnalsATS.201912-877OC.
Patients with chronic obstructive pulmonary disease (COPD) and anxiety or depression experience more symptoms and exacerbations than patients without these comorbidities. Failure to provide beneficial COPD therapies to appropriate patients (underuse) and provision of potentially harmful therapies to patients without an appropriate indication (overuse) could contribute to respiratory symptoms and exacerbations. Anxiety and depression are known to affect the provision of health services for other comorbid conditions; therefore, underuse or overuse of therapies may explain the increased risk of severe symptoms among these patients. To determine whether diagnosed anxiety and depression, as well as significant anxiety and depression symptoms, are associated with underuse and overuse of appropriate COPD therapies. We analyzed data from a multicenter prospective cohort study of 2,376 participants (smokers and control subjects) enrolled between 2010 and 2015. We identified two subgroups of participants, one at risk for inhaled corticosteroid (ICS) overuse and one at risk for long-acting bronchodilator (LABD) underuse based on the 2011 Global Initiative for Chronic Obstructive Lung Disease statement. Our primary outcomes were self-reported overuse and underuse. Our primary exposures of interest were self-reported anxiety and depression and significant anxiety and depression symptoms. We adopted a propensity-score method with inverse probability of treatment weighting adjusting for differences in prevalence of confounders and performed inverse probability of treatment weighting logistic regression to evaluate all associations between the exposures and outcomes. Among the 1,783 study participants with COPD confirmed by spirometry, 667 (37.4%) did not have an indication for ICS use, whereas 985 (55.2%) had an indication for LABD use. Twenty-five percent ( = 167) of patients reported ICS use, and 72% ( = 709) denied LABD use in each subgroup, respectively. Neither self-reported anxiety and depression nor significant anxiety and depression symptoms were associated with overuse or underuse. At least 50% of patients in both subgroups with significant symptoms of anxiety or depression did not report a preexisting mental health diagnosis. Underuse of LABDs and overuse of ICSs are common but are not associated with comorbid anxiety or depression diagnosis or symptoms. Approximately one-third of individuals with COPD experience anxiety or depression, and most are undiagnosed. There are significant opportunities to improve disease-specific and patient-centered treatment for individuals with COPD.
与没有这些合并症的患者相比，患有慢性阻塞性肺疾病（COPD）且伴有焦虑或抑郁的患者会经历更多症状且病情更易加重。未向合适的患者提供有益的COPD治疗（治疗不足）以及向无适当指征的患者提供可能有害的治疗（治疗过度）可能会导致呼吸道症状及病情加重。已知焦虑和抑郁会影响针对其他合并症的医疗服务提供；因此，治疗不足或过度可能解释了这些患者出现严重症状风险增加的原因。为了确定已诊断的焦虑和抑郁以及明显的焦虑和抑郁症状是否与COPD适当治疗的使用不足和过度使用相关。我们分析了一项多中心前瞻性队列研究的数据，该研究纳入了2010年至2015年间的2376名参与者（吸烟者和对照者）。根据2011年慢性阻塞性肺疾病全球倡议声明，我们确定了两个参与者亚组，一个有吸入性糖皮质激素（ICS）使用过度风险，另一个有长效支气管扩张剂（LABD）使用不足风险。我们的主要结局是自我报告的使用过度和使用不足。我们感兴趣的主要暴露因素是自我报告的焦虑和抑郁以及明显的焦虑和抑郁症状。我们采用倾向评分法，通过治疗权重的逆概率来调整混杂因素患病率的差异，并进行治疗权重逆概率逻辑回归以评估暴露因素与结局之间的所有关联。在通过肺活量测定确诊为COPD的1783名研究参与者中，667名（37.4%）没有使用ICS的指征，而985名（55.2%）有使用LABD的指征。在每个亚组中，分别有25%（=167） 的患者报告使用了ICS，72%（=709） 的患者否认使用了LABD。自我报告的焦虑和抑郁以及明显的焦虑和抑郁症状均与使用过度或使用不足无关。在两个亚组中，至少50%有明显焦虑或抑郁症状的患者未报告既往有心理健康诊断。LABD使用不足和ICS使用过度很常见，但与合并焦虑或抑郁诊断或症状无关。约三分之一 的COPD患者伴有焦虑或抑郁，且大多数未被诊断出来。对于COPD患者，有很大机会改善针对疾病特异性和以患者为中心的治疗。
