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The University of Texas Medical Branch, Galveston, TX
Correspondence to: Mukaila A. Raji, MD, MSc (Pharm), Assistant Professor and Director, Geriatric Outpatient Clinics, Sealy Center on Aging, Department of Internal Medicine, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0460; e-mail: muraji{at}utmb.edu
To the Editor:
In their excellent article (January 2005),1 Dr. Stapleton and colleagues described the association of high depressive symptoms on the Center for Epidemiologic Studies-Depression (CES-D) scale with a lower preference for cardiopulmonary resuscitation (CPR) in patients with COPD. Approximately 36% of their study subjects reported a history of clinical depression as a current coexisting illness. It is not clear why the authors did not examine the association between end-of-life preferences and the presence of self-reported depression given that clinical depression was already diagnosed; the presence of high depressive symptoms measured by the CES-D indicates possible depression. I thus wonder if the authors would have had similar results if self-reported clinical depression was used as a predictor of treatment preferences for CPR and mechanical ventilation. Reanalyzing their data using self-reported depression may also help in explaining the discrepancy in their finding of a lower preference for CPR and a similar preference for mechanical ventilation by subjects with CES-D scores 
16 when compared to those with scores CES-D < 16.
In their discussion, the authors rightly suggest that patients responding to antidepressant medications might change their end-of-life preferences as their moods improved. In view of this suggestion, it would also be important if the authors could reanalyze their data examining whether the preference rates for CPR among the depressed COPD patients might change with adjustment for antidepressant medication use in the multivariate analyses. Adjustment for antidepressant medication use might lend further support to the need for end-of-life preferences reassessment after an adequate trial of antidepressants. In addition to improving mood, antidepressant medications may have additional benefits for other common COPD comorbidities: reduction of tobacco craving, palliation of subjective dyspnea, improvement of appetite with weight loss reversal, and lowering of anxiety symptoms.234 The nihilistic attitude fostered by depressive symptoms and other common psychological comorbidities in COPD patients may dissipate with antidepressant use, possibly leading to a more informed decision regarding end-of-life-care preferences. Given the high prevalence of depression in the COPD population,5 screening for (and early treatment of) depression in these patients should be part of routine care, as treatment might improve their overall quality and quantity of life. A large, controlled trial of the impact of antidepressants on overall well-being and survival of COPD patients with depression is long overdue.
References
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