Chest ACCP Member Benefits
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Guest Access | Sign In via User Name/Password
First published online on May 15, 2007
Chest, doi:10.1378/chest.07-0134
doi:10.1378/chest.07-0134
(Chest. 2007; 132:148-155)
© 2007 American College of Chest Physicians
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow All Versions of this Article:
chest.07-0134v1
132/1/148    most recent
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via ISI Web of Science (2)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Laurin, C.
Right arrow Articles by Labrecque, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Laurin, C.
Right arrow Articles by Labrecque, M.

Sex Differences in the Prevalence of Psychiatric Disorders and Psychological Distress in Patients With COPD*

Catherine Laurin, PhD; Kim L. Lavoie, PhD; Simon L. Bacon, PhD; Gilles Dupuis, PhD; Guillaume Lacoste, BA; André Cartier, MD and Manon Labrecque, MD, MSc

* From the Research Center (Drs. Laurin, Cartier, and Labrecque, and Mr. Lacoste), Division of Chest Medicine, Hôpital du Sacré-Coeur de Montréal; Department of Psychology (Drs. Lavoie and Dupuis), Université du Québec à Montréal; and Department of Exercise Science (Dr. Bacon), Concordia University, Montréal, QC, Canada.

Correspondence to: Kim L. Lavoie, PhD, Research Center, Division of Chest Medicine, J-3190, 5400 Gouin Ouest, Montréal, QC, H4J 1C5, Canada; e-mail: k-lavoie{at}crhsc.rtss.qc.ca

Abstract

Background: Psychiatric disorders are highly prevalent in patients with COPD. In general, psychiatric disorders are more common in women than in men. The extent to which women with COPD suffer from greater psychiatric and psychological morbidity is not known. The present cross-sectional study evaluated the prevalence of mood and anxiety disorders, levels of psychological distress, and quality of life in 62 women and 54 men with documented, stable COPD.

Methods: All patients (n = 116) underwent a sociodemographic and medical history interview, followed by a structured psychiatric interview and standard spirometry. Patients also completed a battery of questionnaires measuring psychological distress and quality of life.

Results: The overall prevalence of psychiatric disorders was 49%. Significantly more women than men met the diagnostic criteria for anxiety disorders (56% vs 35%), and a trend for greater levels of major depression in women was found (18% vs 7%). Women had significantly higher anxiety sensitivity and depressive symptoms compared to men but did not report more limitations in psychological functioning. Women also reported being less confident in their ability to control respiratory symptoms, and more daily physical limitations compared to men, despite having comparable COPD severity, dyspnea scores, and exacerbation rates.

Conclusions: Results indicate that psychiatric disorders are at least three times higher in COPD patients compared to the general population, and nearly two times higher in women than in men. Women also have greater psychological distress, worse perceived control of symptoms, and greater functional impairment. Greater efforts should be made to identify and treat psychiatric disorders in COPD patients, particularly in women.

Key Words: anxiety • COPD • depression • health-related quality of life • psychiatric disorders • psychological distress • sex

COPD is the fourth-leading cause of death in the United States1 and in Canada,2 affecting 714,000 Canadians (4.3%).3 COPD has been previously shown to impact quality of life in several domains (eg, daily activities, social and familial functioning, and mental health456) and is the only chronic disease in Canada with a mortality rate that is steadily increasing.2

Traditionally, COPD has been considered a disease that primarily affects men, but recently it has become more prevalent among women than among men in North America.78 Moreover, women with COPD appear to have worse health status than men,9 and this trend is expected to continue because the hospitalization and mortality rates due to COPD among women are expected to double over the next 15 years.10

The mental health of COPD patients has received growing attention in the last few decades, with some studies41112 finding psychological factors, like anxiety and depressive symptoms, to be better predictors of COPD-related quality of life than lung function. Depressive symptoms have also been found to predict 1-year mortality in patients discharged from the hospital following an acute exacerbation of COPD (odds ratio, 1.13; 95% confidence interval, 1.02 to 1.26; p = 0.02), whereas age, gender, FEV1, smoking status, pack-years, body mass index (BMI), medical comorbidities, social class, or arterial blood gas levels did not.13

While there has been significant research assessing levels of psychological distress (eg, anxiety and depressive symptoms) in COPD patients,4111415161718192021 with studies22 reporting prevalences from 13 to 50%, few studies have focused on psychiatric disorders; and, in general, these studies have assessed small samples (≤ 50).2324252627 In contrast, one study28 of 204 veterans with COPD undergoing a structured clinical psychiatric interview found depressive and anxiety disorders to be present in 38% and 50% of patients, respectively. However, the fact that all patients were veterans and mostly men (n = 196) limits the generalizability of the data. As such, research on the prevalence of psychiatric disorders in wider range of COPD patients is still lacking.

While depressive and anxiety disorders are more prevalent among women than men in the general population,29 there are currently very few data on the prevalence of psychological distress and psychiatric disorders in women vs men with COPD. Based on self-report measures, some studies15181921 found that women with COPD reported more psychological distress than men. To our knowledge, only one study23 has assessed the relationship between psychiatric disorders and sex, and found a 1:2 male/female ratio for mood disorders in 21 patients (42%) with psychiatric disorders. As such, the extent to which women with COPD have greater psychiatric morbidity and psychological distress is not known.

The main objective of this study was to evaluate the prevalence of psychiatric disorders (ie, mood and anxiety disorders) and how these levels vary by sex in a sample of outpatients with stable COPD. In addition, we assessed sex differences in the levels of psychological distress and health-related quality of life (HRQoL).

Materials and Methods

Subjects
A total of 116 COPD patients (62 women [53%]; mean age ± SD, 66 ± 8 years) attending the respiratory outpatient clinics of Hôpital du Sacré-Coeur de Montréal (an urban university-affiliated hospital, n = 66) and Hôpital de St-Eustache (a suburban community hospital, n = 50) were recruited between April 2003 and December 2005. Potentially eligible patients received a letter giving brief details of the study and indicating that the study coordinator would contact them to discuss participation and confirm eligibility. Eligible and consenting patients were given an appointment to return to the hospital to undergo the study assessment protocol. This study was approved by the Human Ethics Committee of Hôpital du Sacré-Coeur de Montréal, which presides over both hospitals, and written, informed consent was obtained from all participants on the day of their study assessment.

Patients were included in the study if they had documented COPD (emphysema and/or chronic bronchitis) according to American Thoracic Society definitions,1 as confirmed by a chest physician; had a cumulative current or past cigarette smoking of at least 10 pack-years (obtained by multiplying the average number of packs smoked per day by the number of years smoked)30; were < 85 years old; and spoke French. All patients had been hospitalized for an acute exacerbation of COPD within the last 24 months, but their clinical status was stable on the day of their interview (no acute exacerbation in the last 4 weeks). Exclusion criteria were as follows: documented and potentially confounding conditions that conferred greater risk for morbidity than COPD (eg, symptomatic cancer); acute coronary event (eg, myocardial infarction) or invasive surgery within the past 6 months; apparent cognitive deficits; living in long-term health care centers (which treat more severe and disable patients); or physically unable to present to the hospital for the assessment. The participant flowchart is presented in Figure 1 .


Figure 1
View larger version (19K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1.. Figure 1. Flowchart of patient screening, eligibility, and participation.

 
Procedure
Participants underwent a sociodemographic and medical history interview, an assessment of dyspnea severity, standard spirometry according to American Thoracic Society/European Respiratory Society standards,131 a structured psychiatric interview, and completed a battery of health-related and psychological questionnaires. One patient declined to fill out the battery of questionnaires. All interviews were conducted by a trained clinical psychology intern who was supervised by a licensed clinical psychologist (K.L.L.). All psychiatric diagnoses were independently confirmed by a psychologist blind to the patient’s medical status. Spirometry was conducted by trained technicians according to standard procedures. All medical information was confirmed by chart review.

Pulmonary Function Testing and Assessment of Perceived Dyspnea
All patients underwent standard spirometry before and 20 min after inhalation of 200 µg of salbutamol, performed using a dry-seal spirometer (Collins Survey III; Collins; Braintree, MA) or a ventilometer (Ventilometer VM1; Clement Clarke; London, UK) according to American Thoracic Society/European Respiratory Society standards.131 Rescue medication was withheld for at least 4 h before testing. FEV1 and FVC were assessed for each patient, and predicted values for FEV1 and FVC were calculated from reference values.3233 Six patients declined to participate in spirometry testing. Prior to spirometry, patients completed the Medical Research Council dyspnea scale, which consists of five statements about dyspnea severity, with higher scores indicating more severe dyspnea.34

Psychiatric Assessment
Participants underwent a psychiatric interview using the Anxiety Disorders Interview Schedule-IV,35 a valid and reliable structured clinical interview for the assessment of anxiety and mood disorders based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria.36 This interview takes between 15 and 60 min to complete, depending on the presence/absence and number of disorders. It has been translated and validated in French and has demonstrated a good reliability (eg, test-retest reliability = 0.60 to 0.86 for anxiety disorders) with DSM-IV criteria.37

Self-Report Psychological Distress Questionnaires
Patients completed the 23-item psychological distress scale38 to measure general psychological distress; the 16-item anxiety sensitivity index39 to measure fear of anxiety-related symptoms; and the 21-item Beck Depression Inventory-II40 to measure the occurrence and severity of depressive symptomatology. All three instruments have demonstrated good-to-excellent internal consistency (0.81 to 0.92) and reliability (0.71 to 0.93). They also showed good construct validity and factorial validity,384041 and have been validated in French.384243 Higher scores indicate higher psychological distress, anxiety sensitivity, and depressive symptoms.

Perceived General Health, Symptom Control Confidence, and HRQoL
Using question 1 from the Short-Form-36 Health Survey (SF-36),44 participants rated their perception of their general health with higher scores indicating worse perceived health. Question 7 from the Seattle Obstructive Lung Disease Questionnaire 45 was used to measure how often patients felt confident in their ability to deal with their breathing problems, with higher scores indicating greater perceived control over symptoms. Patients also completed the 50-item St. George Respiratory Questionnaire (SGRQ),46 which has been used extensively with COPD patients to assess perceived pulmonary HRQoL.1518 It yields a total score and three subscale scores assessing the impact of COPD on symptoms, activities, and psychosocial functioning (impact subscale) from 1 to 100% (higher scores indicating worse impairment). This questionnaire has been translated and validated in French, and has demonstrated excellent psychometric properties including good criterion validity, internal consistency (0.61 to 0.95), and reliability.47

Statistical Analysis
General linear models were conducted to assess sex differences on baseline variables. Additional general linear model analyses were conducted to examine sex differences in the prevalence of psychiatric disorders and self-reported psychological distress, adjusting for the following covariates (determined a priori): age, recruitment site (urban vs suburban), cigarettes pack-years, COPD duration, and disease severity. Disease severity was calculated using three of the four component of the BODE (BMI, airflow obstruction, dyspnea, and exercise capacity) index,48 the BMI, the degree of airflow obstruction (percentage of predicted FEV1), and dyspnea severity. Severity was scored on a 7-point scale, with a higher score indicating more severe COPD. All tests were two sided, and the level of significance was 0.05. Data analysis was performed using statistical software (v8.2; SAS Institute; Cary, NC).

Results

Sample Characteristics
As detailed in Table 1 , compared to men, women were significantly younger, more likely to live alone, drank less alcohol units per week, and had smoked for fewer pack-years. There were no other significant sociodemographic differences between groups. With the exception of BMI and FEV1/FVC ratio being significantly higher in women than in men, no other COPD-related or medical-related differences were found between the sexes (Table 2 ).


View this table:
[in this window]
[in a new window]

  		Table 1.. Sociodemographic and Sample Characteristics as a Function of Sex*

 

View this table:
[in this window]
[in a new window]

  		Table 2.. COPD Characteristics and Health Services Utilization as a Function of Sex*

 
Prevalence of Psychiatric Disorders
As displayed in Table 3 , the prevalence of psychiatric disorders in the whole sample was 49%, with 24% having two or more disorders, and 14% having both an anxiety and a mood disorder. Anxiety disorders were generally more common (46%) than mood disorders (17%) in this population. As seen in Table 4 , compared to men, women were significantly more likely to meet the diagnostic criteria for one or more psychiatric disorder, to have one or more anxiety disorder, and to have received a diagnosis of panic disorder or a specific phobia. Although there was a nonsignificant trend for women to be more likely to have one or more mood disorders than men, they had significantly more current and/or lifetime major depression.


View this table:
[in this window]
[in a new window]

  		Table 3.. Prevalence of Psychiatric Disorders in the Overall Sample

 

View this table:
[in this window]
[in a new window]

  		Table 4.. Prevalence of Psychiatric Disorders as a Function of Sex, Adjusted for Covariates*

 
Psychological Distress, Symptom Control Confidence, Perceived General Health, and HRQoL
As seen in Table 5 , in comparison to men, women had significantly higher scores on all psychological distress questionnaires, indicating that they exhibited significantly more self-depreciation, anxiety/depression, social disengagement, anxiety sensitivity, and depressive symptoms, independent of covariates. Women reported significantly lower levels of symptom-control confidence and worse HRQoL (total score and activities subscale) compared to men, indicating lower confidence in their ability to control respiratory symptoms, and more functional physical limitations during daily life (Table 6 ). There were no significant differences between sexes on the subscale of the SGRQ that measures psychosocial functioning or on perception of their general health (question 1 from the SF-36).


View this table:
[in this window]
[in a new window]

  		Table 5.. Psychological Distress as a Function of Sex, Adjusted for Covariates*

 

View this table:
[in this window]
[in a new window]

  		Table 6.. Symptom Control Confidence, Perceived Health, and HRQoL as a Function of Sex, Adjusted for Covariates*

 
Discussion

The results of the present cross-sectional study indicate a high rate (49%) of psychiatric disorders among COPD patients compared to published levels in the general population (31%).49 These findings are consistent with the majority of previous studies232425262728 indicating a high prevalence of overall anxiety and depressive disorders among COPD patients (16 to 51%). In contrast to some previous studies232627 that have tended to report higher rates of mood than anxiety disorders among COPD patients, the present study found higher rates of anxiety (46%) than mood (17%) disorders. However, the interviews used to evaluate psychiatric disorders in previous studies assessed a restricted range of disorders (only major depressive episodes and/or generalized anxiety disorder), often neglecting the assessment of a wider range of mood and anxiety disorders (eg, specific phobia, posttraumatic stress disorder).

Independent of age, recruitment site, smoking, and COPD duration and severity, there were significantly higher rates of psychiatric disorders in women (60%) than in men (38%). Specifically, women with COPD had > 1.5 times the rate of anxiety disorders compared to men. For the individual disorders, specific phobia and panic disorder were significantly higher in women compared to men, and there was a trend for greater levels of major depression in women, with women being between two and three times more likely to report these specific disorders. This male/female ratio trend for mood disorders is consistent with the findings reported by Karajgi and colleagues,23 who found the prevalence of mood disorders (n = 9; 18%) to be "twofold greater" in women than in men with COPD. However, these authors23 failed to report the precise number of men and women with mood and anxiety disorders, as well as any statistics for the contrast. As such, it is difficult to interpret the magnitude or significance of the sex differences observed.

Women not only had greater psychiatric morbidity than men in the present study, but they also had more self-reported psychological distress. In general, our results are consistent with the majority of previous studies,15181921 although not all.162025 However, of those studies that did not find a sex difference in psychological distress, issues surrounding small samples sizes,25 the older age of the participants,2025 and the increased airflow limitation2025 may account for the lack of agreement with the current study. Finally, women with COPD reported less confidence in their ability to control their respiratory symptoms and had worse total and activity-related quality of life compared to men.

As this study was cross-sectional, we cannot infer cause and effect. However, one potential explanation for the higher prevalence of psychiatric disorders and psychological symptoms observed in women could be that COPD may impact women’s mental health and well-being more than in men. In the current study, women reported perceiving having less control over their respiratory symptoms compared to men. In addition, women also reported a higher tendency to be socially disengaged, and more self-devalorization than did men. It is well establish that the perception of having no control over one’s symptoms may induce feelings of helplessness and hopelessness that could then lead to the development of depression.50 Further, women in the current study reported more fear about anxiety symptoms (anxiety sensitivity) than men. The construct of anxiety sensitivity is not just another measure of anxiety but actually predicts fearfulness, which is causally related to the development of anxiety disorders.39 Therefore, women’s fear of having unpredictable COPD symptoms may lead them to have more psychiatric disorders, and anxiety disorders in particular, than men.

An alternative explanation for the increased levels of psychiatric disorders in female COPD patients compared to male patients could be a sex difference in the reporting of such disorders. It has been shown that usage of substances like tobacco and alcohol can be used as ways of coping with emotional distress.2451 There is also evidence to suggest that disproportionally more men than women turn to alcohol and other substances as a means of dealing with stress52 rather than verbally expressing their emotions.53 In our sample, men reported significantly greater alcohol and tobacco consumption than women, yet reported less psychiatric morbidity during their interviews. It is therefore possible that men had similar levels of psychological distress as women, but their reported levels of distress were masked or minimized as they potentially used alcohol and tobacco as alternative coping strategies.

As can be seen from above, the mechanisms underlying the relation between psychiatric disorders and COPD are still not clear, especially between the sexes, and further research is needed. As Yohannes and colleagues17 mentioned, depression, anxiety, and respiratory impairment are part of a vicious cycle adding to disability. Longitudinal studies are required to disentangle the complex cause-and-effect relationship.

Study Limitations
The results of the current study must be carefully interpreted in light of some methodologic limitations. Even though our sample size was larger than previous studies2324252627 employing a clinical psychiatric interview, it is still modest with 116 participants. The present study may also be limited by the cross-sectional nature of the design. Causal inferences cannot be drawn on the direction of the relationship between COPD and psychiatric disorders in men and women. Prospective studies are therefore needed to assess the directionality of this relationship.

Despite the above limitations, the present study strengthens previous reports by focusing on sex differences in the prevalence of a wide range of psychiatric disorders among COPD patients. The present study employed a structured psychiatric interview and used established diagnostic criteria (DSM-IV) to make diagnoses. Since many symptoms of COPD and psychological distress may overlap (eg, fatigue, breathlessness), the use of a clinical interview rather than relying on self-report questionnaires is essential. This study also strengthens previous reports by including an equal proportion of men and women.

Conclusions

The results of the present study highlight the high prevalence of psychiatric disorders and psychological morbidity among COPD outpatients, particularly in women. Greater efforts should be made to improve recognition of psychological morbidity in the routine assessment and dissemination of appropriate referral and treatment (ie, pharmacologic and psychotherapeutic interventions). Further studies are needed to assess the long-term impact of psychiatric disorders on COPD morbidity and mortality, especially among women.

Acknowledgements

The authors thank Mr. Philippe Stébenne for his invaluable assistance with data collection and Dr. Marcel Julien for his contributions to earlier versions of the protocol. The authors are also grateful for the assistance of the nurses and inhalotherapist from Hôpital du Sacré-Coeur de Montréal (Lucie Jolicoeur, Lorraine Lachance, Bernadette Tardivel, Suzanne Valois) and Hôpital de St-Eustache (Marie-Noëlle Bélanger).

Footnotes

Abbreviations: BMI = body mass index; DSM-IV = Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition; HRQoL = health-related quality of life; SF-36 = Short-Form-36 Health Survey; SGRQ = St. George Respiratory Questionnaire

This study was supported by La Fondation de l’Hôpital du Sacré-Coeur de Montréal (Gemma Moisan Family Foundation).

None of the authors have declared any potential conflicts of interest.

Received for publication January 15, 2007. Accepted for publication March 21, 2007.

References

  1. . American Thoracic Society. (1995) Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 152(suppl),77-121[Medline]
  2. Statistics Canada. Selected leading cause of death, by sex. Available at: http://epe.lac-bac.gc.ca/100/205/301/statcan/canada_e-book-ef/05–01-21/www.statcan.ca/english/Pgdb/health36.htm_ 1997. Accessed November 10, 2006
  3. Association pulmonaire du Canada.. Maladie pulmonaire obstructive chronique (MPOC): rapport d’évaluation national. 2005 Association Pulmonaire du Canada, Société Canadienne de Thoracologie. Ottawa, ON, Canada:
  4. McSweeny, AJ, Grant, I, Heaton, RK, et al Life quality of patients with chronic obstructive pulmonary disease. Arch Intern Med 1982;142,473-478[Abstract]
  5. Priganato, GP, Wright, EC, Levin, D Quality of life and its predictors in patients with mild hypoxemia and chronic obstructive pulmonary disease. Arch Intern Med 1984;144,1613-1619[Abstract]
  6. Ketelaars, CAJ, Schlösser, MAG, Mostert, R, et al Determinants of health-related quality of life in patients with chronic obstructive pulmonary disease. Thorax 1996;51,39-43[Abstract]
  7. Statistics Canada. Prevalence of physician-diagnosed chronic bronchitis and emphysema adults 35 years of age and over, by sex, Canada, 1994/95, 1996/97, 1998/99, and 2000/2001. Available at: http://www.phac-aspc.gc.ca/ccdpc-cpcmc/crd-mrc/images/facts_e/fig5–1.gif. Accessed November 10, 2006
  8. Mannino, DM COPD: epidemiology, prevalence, morbidity and mortality, and disease heterogeneity. Chest 2002;121,121S-126S[Abstract/Free Full Text]
  9. Antonelli-Incalzi, R, Imperiale, C, Bellia, V, et al Do GOLD stages of COPD severity really correspond to differences in health status? Eur Respir J 2003;22,444-449[Abstract/Free Full Text]
  10. Association Pulmonaire du Canada, Institut Canadien d’information sur la Santé, SantéCanada. et al Les maladies respiratoires au Canada. 2001 Santé Canada. Ottawa, ON, Canada:
  11. Kim, HFS, Kunik, ME, Molinari, VA, et al Functional impairment in COPD patients: the impact of anxiety and depression. Psychosomatics 2000;41,465-471[Abstract/Free Full Text]
  12. Cully, JA, Graham, DP, Stanley, MA, et al Quality of life in patients with chronic obstructive pulmonary disease and comorbid anxiety or depression. Psychosomatics 2006;47,312-319[Abstract/Free Full Text]
  13. Yohannes, AM, Baldwin, RC, Connolly, MJ Predictors of 1-year mortality in patients discharged from hospital following acute exacerbation of chronic obstructive pulmonary disease. Age Ageing 2005;34,491-496[Abstract/Free Full Text]
  14. Engstrom, CP, Person, LO, Larsson, S, et al Functional status and well being in chronic obstructive pulmonary disease with regard to clinical parameters and smoking: a descriptive and comparative study. Thorax 1996;51,825-830[Abstract]
  15. Di Marco, F, Verga, M, Reggente, M, et al Anxiety and depression in COPD patients: the roles of gender and disease severity. Respir Med 2006;100,1767-1774[CrossRef][ISI][Medline]
  16. Wagena, EJ, Arrindell, WA, Wouters, EFM, et al Are patients with COPD psychologically distressed? Eur Respir J 2005;26,242-248[Abstract/Free Full Text]
  17. Yohannes, AM, Baldwin, RC, Connolly, MJ Depression and anxiety in elderly outpatients with chronic obstructive pulmonary disease: prevalence, and validation of the BASDEC screening questionnaire. Int J Geriatr Psychiatry 2000;15,1090-1096[CrossRef][ISI][Medline]
  18. Gudmundsson, G, Gislason, T, Janson, C, et al Depression, anxiety and health status after hospitalisation for COPD: a multicentre study in the Nordic countries. Respir Med 2006;100,87-93[CrossRef][ISI][Medline]
  19. Dowson, C, Laing, R, Barraclough, R, et al The use of the Hospital Anxiety and Depression Scale (HADS) in patients with chronic obstructive pulmonary disease: a pilot study. N Z Med J 2001;114,447-449[ISI][Medline]
  20. Lacasse, Y, Rousseau, L, Maltais, F Prevalence of depressive symptoms and depression in patients with severe oxygen-dependent chronic obstructive pulmonary disease. J Cardiopulm Rehabil 2001;21,80-86[CrossRef][Medline]
  21. Isoaho, R, Laippala, P, Keistinen, T, et al Chronic obstructive pulmonary disease and symptoms related to depression in elderly persons. Psychol Rep 1995;76,287-297[ISI][Medline]
  22. Hynninen, KMJ, Breitve, MH, Wiborg, AB, et al Psychological characteristics of patients with chronic obstructive pulmonary disease: a review. J Psychosom Res 2005;59,429-443[CrossRef][ISI][Medline]
  23. Karajgi, B, Rifkin, A, Doddi, S, et al The prevalence of anxiety disorders in patients with chronic obstructive pulmonary disease. Am J Psychiatry 1990;147,200-201[Abstract/Free Full Text]
  24. Yellowlees, PM, Alpers, JH, Bowden, JJ, et al Psychiatric morbidity in patients with chronic airflow obstruction. Med J Aust 1987;146,305-307[ISI][Medline]
  25. Stage, KB, Middelboe, T, Pisinger, C Depression and chronic obstructive pulmonary disease (COPD): impact on survival. Acta Psych Scand 2005;111,320-323[CrossRef][ISI][Medline]
  26. Orhan Aydin, I, Ulusahin, A Depression, anxiety comorbidity, and disability in tuberculosis and chronic obstructive pulmonary disease patients: applicability of GHQ-12. Gen Hosp Psychiatry 2001;23,77-83[CrossRef][ISI][Medline]
  27. Aghanwa, HS, Erhabor, GE Specific psychiatric morbidity among patients with chronic obstructive pulmonary disease in a Nigerian general hospital. J Psychosom Res 2001;50,179-183[CrossRef][ISI][Medline]
  28. Kunik, ME, Roundy, K, Veazey, C, et al Surprisingly high prevalence of anxiety and depression in chronic breathing disorders. Chest 2005;127,1205-1211[Abstract/Free Full Text]
  29. Kessler, RC, McGonagle, KA, Zhao, S, et al Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;51,8-19[Abstract]
  30. Bernaards, CM, Twisk, JWR, Snel, J, et al Is calculating pack-years retrospectively a valid method to estimate life-time tobacco smoking? A comparison between prospectively calculated pack-years and retrospectively calculated pack-years. Addiction 2001;96,1653-1661[CrossRef][ISI][Medline]
  31. Miller, MR, Hankinson, J, Brusasco, V, et al Standardisation of spirometry. Eur Respir J 2005;26,319-338[Abstract/Free Full Text]
  32. Knudson, R, Lebowitz, C, Holberg, C, et al Changes in the normal maximal expiratory flow-volume curve with growth and aging. Am Rev Respir Dis 1983;127,725-734[ISI][Medline]
  33. Enright, PL, Kronmal, RA, Higgins, M, et al Spirometry reference values for women and men. Am Rev Respir Dis 1993;147,125-133[ISI][Medline]
  34. Bestall, JC, Paul, EA, Garrod, R, et al Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax 1999;54,581-586[Abstract/Free Full Text]
  35. Brown, TA, Di Nardo, PA, Barlow, DH Anxiety disorders interview schedule for DSM-IV: lifetime version (ADIS-IV-L). 1994 Psychological Corporation/Graywind Publications Incorporated. San Antonio, TX:
  36. Diagnostic and statistical manual of mental disorders. 4th ed. 1994 American Psychiatric Association. Washington, DC:
  37. Boivin I, Marchand A. Évaluation structurée pour les troubles anxieux pour le DSM-IV. Thesis presented at Department of Psychology, Université du Québec à Montréal, 1996
  38. Massé, R, Poulin, C, Dassa, C, et al Élaboration et validation d’un outil de mesure de la détresse psychologique dans une population non clinique de Québécois francophones. Can J Public Health 1998;89,183-187[ISI][Medline]
  39. Reiss, S, Peterson, RA, Gursky, DM, et al Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behav Res Ther 1986;24,1-8[CrossRef][ISI][Medline]
  40. Beck, AT, Steer, RA, Brown, GK Manual for Beck depression inventory: second edition (BDI-II). 1996 The Psychological Corporation. San Antonio, TX:
  41. Peterson, RA, Reiss, S The anxiety sensitivity index manual 2nd ed. 1992 International Diagnosis Systems. Worthington, OH:
  42. Bourque, P, Beaudette, D Étude psychométrique du questionnaire de dépression de Beck auprès d’un échantillon d’étudiants universitaires francophones. Rev Can Sci Comport 1982;14,211-218
  43. Stephenson, R, Marchand, A, Lavallée, MC, et al Translation and transcultural validation of the anxiety sensitivity index. 1996 Congrès International de Psychologie. Montreal, QC, Canada:
  44. Ware, JJ, Sherbourne, C The MOS 36-item short-form health survey (SF-36) I: Conceptual framework and item selection. Med Care 1992;30,473-483[ISI][Medline]
  45. Tu, SP, McDonell, MB, Spertus, JA, et al A new self-administered questionnaire to monitor health-related quality of life in patients with COPD: ambulatory Care Quality Improvement Project (ACQUIP) Investigators. Chest 1997;112,614-622[Abstract/Free Full Text]
  46. Jones, P, Quirk, FH, Baveystock, CM, et al A self-complete measure of health status for chronic airflow limitation: the St. George’s Respiratory Questionnaire. Am Rev Respir Dis 1992;145,1321-1327[ISI][Medline]
  47. Bouchet, C, Guillemin, F, Hoang Thi, TH, et al Validation du questionnaire St. Georges pour mesurer la qualité de vie chez les insuffisants respiratoires chroniques. Rev Mal Respir 1996;13,43-46[ISI][Medline]
  48. Celli, BR, Cote, CG, Marin, JM, et al The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med 2004;350,1005-1012[Abstract/Free Full Text]
  49. Kessler, RC, Demier, O, Frank, RG, et al Prevalence and treatment of mental disorders, 1990 to 2003. N Engl J Med 2005;352,2515-2523[Abstract/Free Full Text]
  50. Seligman, M Helplessness: on depression, development, and death. 1975 WH Freeman. San Francisco, CA:
  51. Hughes, JR, Katsukami, DK, Mitchell, JE, et al Prevalence of smoking among psychiatric outpatients. Am J Psychiatry 1986;143,993-997[Abstract/Free Full Text]
  52. Bray, RM, Fairbank, JA, Marsden, MA Stress and substance use among military women and men. Am J Drug Alcohol Abuse 1999;25,239-256[CrossRef][ISI][Medline]
  53. Lazarus, RS, Folkman, S Stress, appraisal and coping. 1984 Springer Publishing. New York, NY:




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow All Versions of this Article:
chest.07-0134v1
132/1/148    most recent
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via ISI Web of Science (2)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Laurin, C.
Right arrow Articles by Labrecque, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Laurin, C.
Right arrow Articles by Labrecque, M.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS