TORONTO--Patients who have chronic lung disease bear two burdens--their physical illness and the anxiety and depression that are often associated with it. While the chances of eliminating their physical illness are slim, much can be done to help alleviate patients' psychologic suffering.

"We've got some fabulous new medications," said Susan Abbey, MD, Head of Medical Psychiatry at the University Health Network in Toronto, Canada. "We've also gone beyond the days of having people lie on the psychiatrist's couch and say, 'Tell me about your mother.' "

Dr. Abbey, who specializes in the treatment of patients with major medical illnesses, discussed the management of anxiety and depression in patients with chronic lung disease at the annual meeting of the American Thoracic Society. She emphasized drug therapy, which she described as first-line treatment for most patients. Many patients also benefit from short-term psychiatric techniques, such as cognitive therapy, which is designed to help them alter maladaptive thought patterns (see box).

LUNG DISEASE AND ANXIETY

Panic is the most common anxiety disorder experienced by patients with chronic lung disease, affecting 10% to 38% of this population. The diagnosis is often difficult to sort out, according to Dr. Abbey. "These patients can have dyspnea from their respiratory disease--or from their panic," she said. Similarly, it may be unclear whether a change in respiratory/cardiovascular status or panic disorder is responsible when these patients develop tachycardia.

Panic episodes usually start suddenly and peak in five to 10 minutes. About 80% of such episodes last 20 to 30 minutes, but some may last up to two hours. They can be quite exhausting, and may leave patients with no energy for the rest of the day.

Patients with chronic lung disease are also at increased risk for post-traumatic stress disorder, which is characterized by flashbacks and other psychologic symptoms related to highly stressful events, such as respiratory arrest and mechanical ventilation. Small numbers of patients with chronic lung disease have obsessive-compulsive disorder or phobic disorders, such as needle phobia.

SSRIs ARE FIRST CHOICE FOR TREATMENT

Pharmacotherapy is the most convenient choice for anxiety disorders. "Often, it's hard to get access to psychotherapists who are trained in cognitive therapy," explained Dr. Abbey. It may therefore be most practical to reserve cognitive therapy for patients who do not improve with medication or who have very complex presentations.

Among the drugs available for anxiety disorders are the selective serotonin reuptake inhibitors (SSRIs), serotonin and noradrenaline reuptake inhibitors (SNRIs), serotonin and dopamine reuptake inhibitors (SDRIs), buspirone, monoamine oxidase (MAO) inhibitors, tricyclic antidepressants, and benzodiazepines.

The first choices are the SSRIs, which alter brainstem serotonin levels such that the heightened carbon dioxide sensitivity of patients with anxiety disorders is reduced. This decreases the perception of dyspnea, a major source of anxiety in patients with chronic lung disease.

"Psychiatry has really been revolutionized by the SSRIs," commented Dr. Abbey. "They're easy to use, they don't have a lot of side effects … and they're relatively well tolerated," she added.

Paroxetine appears to be especially effective for anxiety disorders, particularly panic attacks. As with other SSRIs, once-daily dosing makes it convenient. Anorgasmia is the drug's most troublesome side effect, which occurs in up to 40% of paroxetine users. Recent reports have also linked the drug with weight gain.

Sertraline and citalopram have also shown efficacy against panic attacks, and both have good side-effect profiles. For maximum bioavailability, sertraline must be taken with meals. Citalopram may have an advantage in patients taking multiple medications because it has the least potential for interactions with the cytochrome P450 system.

The SDRI bupropion and the relatively new SNRI venlafaxine also work well against anxiety disorders. Because it is a prosexual agent, Dr. Abbey often adds bupropion to SSRI therapy when the latter induces anorgasmia.

Venlafaxine inhibits serotonin and noradrenaline reuptake at doses above 75 mg. At lower doses, it functions mainly as an SSRI. It may raise systolic blood pressure, though this side effect is uncommon and most often occurs at higher doses of about 225 mg or more.

"Fluvoxamine … is a drug I don't use a lot," said Dr. Abbey. Because it inhibits cytochrome P450 enzymes, fluvoxamine is more often associated with drug interactions. It also has about a 30% rate of gastrointestinal side effects, such as nausea and diarrhea. She added that the anti-anxiety agent buspirone is most useful for generalized anxiety disorder.

A disadvantage of the SSRIs, SNRIs, SDRIs, tricyclic antidepressants, and MAO inhibitors is that they usually do not take effect for at least three weeks. Furthermore, the SSRIs may increase the intensity of panic episodes during the first week to 10 days of treatment.

On the other hand, benzodiazepines take effect in only two to four days. Clonazepam and alprazolam appear to be the most effective benzodiazepines for anxiety disorders. But there are significant drawbacks to the use of benzodiazepines in patients with chronic lung disease: They may interfere with central respiratory drive, and they have high rates of withdrawal symptoms. Thus, when benzodiazepines are given to such patients, Dr. Abbey suggests using "almost homeopathic" doses (ie, half or even a quarter of the usual starting dose).

"Start low and go slow" is the approach Dr. Abbey recommends when initiating treatment for anxiety disorders. Nevertheless, she recommends raising the dose repeatedly--or switching to another agent--to ensure complete elimination of negative sequelae, such as increased disability, hypochondriasis, and suicidality. "You've got to completely stop the anxiety to keep those things from happening," she stressed.

RIDDING PATIENTS OF DEPRESSION

Depression is associated with more functional impairment than are many medical conditions, including rheumatoid arthritis, diabetes, and chronic obstructive pulmonary disease. Among the signs of depression are sleep disturbance, lack of interest in usual activities, feeling guilty or down, low self-esteem, difficulty concentrating, appetite changes, and suicidal thoughts.

The SSRIs are generally the first-line therapies for mild and moderate depression in chronic lung patients. Venlafaxine appears to be most effective for severe depression in these patients, according to Dr. Abbey. As with anxiety disorders, treatment should be initially conservative, but then sufficiently aggressive to produce full symptom remission.

"Once patients are fully recovered, they need to be treated for a minimum of six to 12 months if it's their first episode," said Dr. Abbey. Due to a high risk of recurrent severe depression, lifetime antidepressant therapy may be necessary for those who have had multiple depressive episodes.

Depressed patients with chronic lung disease may benefit from cognitive therapy, as well as two other types of psychotherapy: interpersonal therapy, which focuses on the use of relationships to better cope with physical illness, and problem-solving therapy, in which the therapist helps the patient identify and find solutions to problems that contribute to depression. These therapies typically last 12 to 16 sessions.

--Timothy Begany