, Volume 192, Issue 2, pp 243–249 | Cite as

Association of Depression with Disease Severity in Patients with Chronic Obstructive Pulmonary Disease

  • Ki Uk Kim
  • Hye-Kyung Park
  • Hee Young Jung
  • Jong-Joon Ahn
  • Eunsoo Moon
  • Yun Seong Kim
  • Min Ki Lee
  • Haejung Lee



Patients with chronic obstructive pulmonary disease (COPD), which is predicted to be the third most common cause of death worldwide by 2020, often suffer from depression, one of the most common and modifiable comorbidities of COPD. This study assessed the prevalence of depression in patients with COPD and the association of depression with disease severity.


This was a multicenter, prospective cross-sectional study of 245 patients with stable COPD. Disease severity was assessed using two scales: the global initiative for chronic obstructive lung disease (GOLD) stage and BODE index. Depression was measured using the Centers for Epidemiologic Studies Depression (CES-D) scales. Data were analyzed using descriptive statistics, Spearman correlation, and multivariate logistic regression.


Depression defined as a CES-D score of 24 and higher was observed in 17.6 % of patients with COPD. The prevalence of depression increased with disease severity based on the BODE quartile (r = 0.16; P = 0.014). By contrast, no difference was observed in the prevalence of depression among the severity groups using the GOLD staging system (r = − 0.01; P = 0.898). Elementary school graduates were more likely to experience depression than graduates of high school and above [odds ratio (OR) = 3.67; 95 % confidence interval (CI) 1.37–9.85] and patients in BODE quartile II were more likely to experience depression than those with BODE quartile I (OR = 2.5; 95 % CI  1.04–6.06).


Depression was associated with disease severity according to the BODE quartile in patients with COPD. BODE quartile II was a significant predictor of depression. Screening patients with a high risk of depression and proactive intervention for those patients are needed.


Airflow Depression Dyspnea Exercise Obstruction 



This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (2009-0088833) and Pusan National University Research Grant, 2013.

Conflict of interest



  1. 1.
    Bousquet J, Anto JM, Sterk PJ, Adcock IM, Chung KF, Roca J, Agusti A, Brightling C, Cambon-Thomsen A, Cesario A et al (2011) Systems medicine and integrated care to combat chronic noncommunicable diseases. Genome Med 3(7):43PubMedCentralCrossRefPubMedGoogle Scholar
  2. 2.
    Mannino DM, Buist AS (2007) Global burden of COPD: risk factors, prevalence, and future trends. Lancet 370(9589):765–773CrossRefPubMedGoogle Scholar
  3. 3.
    Buist AS, McBurnie MA, Vollmer WM, Gillespie S, Burney P, Mannino DM, Menezes AM, Sullivan SD, Lee TA, Weiss KB et al (2007) International variation in the prevalence of COPD (the BOLD Study): a population-based prevalence study. Lancet 370(9589):741–750CrossRefPubMedGoogle Scholar
  4. 4.
    Ng TP, Niti M, Tan WC, Cao Z, Ong KC, Eng P (2007) Depressive symptoms and chronic obstructive pulmonary disease: effect on mortality, hospital readmission, symptom burden, functional status, and quality of life. Arch Intern Med 167(1):60–67CrossRefPubMedGoogle Scholar
  5. 5.
    van Manen JG, Bindels PJ, Dekker FW, IJzermans CJ, van der Zee JS, Schadé E (2002) Risk of depression in patients with chronic obstructive pulmonary disease and its determinants. Thorax 57(5):412–416PubMedCentralCrossRefPubMedGoogle Scholar
  6. 6.
    Gudmundsson G, Gislason T, Janson C, Lindberg E, Hallin R, Ulrik CS, Brøndum E, Nieminen MM, Aine T, Bakke P (2005) Risk factors for rehospitalisation in COPD: role of health status, anxiety and depression. Eur Respir J 26(3):414–419CrossRefPubMedGoogle Scholar
  7. 7.
    Ries AL (2006) Impact of chronic obstructive pulmonary disease on quality of life: the role of dyspnea. Am J Med 119(10 Suppl 1):12–20CrossRefPubMedGoogle Scholar
  8. 8.
    Kawamura T, Shioiri T, Takahashi K, Ozdemir V, Someya T (2007) Survival rate and causes of mortality in the elderly with depression: a 15-year prospective study of a Japanese community sample, the Matsunoyama-Niigata suicide prevention project. J Investig Med 55(3):106–114CrossRefPubMedGoogle Scholar
  9. 9.
    Mykletun A, Bjerkeset O, Dewey M, Prince M, Overland S, Stewart R (2007) Anxiety, depression, and cause-specific mortality: the HUNT study. Psychosom Med 69(4):323–331CrossRefPubMedGoogle Scholar
  10. 10.
    Xu W, Collet JP, Shapiro S, Lin Y, Yang T, Platt RW, Wang C, Bourbeau J (2008) Independent effect of depression and anxiety on chronic obstructive pulmonary disease exacerbations and hospitalizations. Am J Respir Crit Care Med 178(9):913–920CrossRefPubMedGoogle Scholar
  11. 11.
    Wagena EJ, Kant I, van Amelsvoort LG, Wouters EF, van Schayck CP, Swaen GM (2004) Risk of depression and anxiety in employees with chronic bronchitis: the modifying effect of cigarette smoking. Psychosom Med 66(5):729–734CrossRefPubMedGoogle Scholar
  12. 12.
    Yohannes AM, Baldwin RC, Connolly MJ (2000) Depression and anxiety in elderly outpatients with chronic obstructive pulmonary disease: prevalence, and validation of the BASDEC screening questionnaire. Int J Geriatr Psychiatry 15(12):1090–1096CrossRefPubMedGoogle Scholar
  13. 13.
    Solano JP, Gomes B, Higginson IJ (2006) A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manag 31(1):58–69CrossRefGoogle Scholar
  14. 14.
    Gallo JJ, Bogner HR, Morales KH, Post EP, Lin JY, Bruce ML (2007) The effect of a primary care practice-based depression intervention on mortality in older adults: a randomized trial. Ann Intern Med 146(10):689–698PubMedCentralCrossRefPubMedGoogle Scholar
  15. 15.
    Cully JA, Graham DP, Stanley MA, Ferguson CJ, Sharafkhaneh A, Souchek J, Kunik ME (2006) Quality of life in patients with chronic obstructive pulmonary disease and comorbid anxiety or depression. Psychosomatics 47(4):312–319CrossRefPubMedGoogle Scholar
  16. 16.
    Jordan N, Lee TA, Valenstein M, Weiss KB (2007) Effect of care setting on evidence-based depression treatment for veterans with COPD and comorbid depression. J Gen Intern Med 22(10):1447–1452PubMedCentralCrossRefPubMedGoogle Scholar
  17. 17.
    Mahler DA, Weinberg DH, Wells CK, Feinstein AR (1984) The measurement of dyspnea. Contents, interobserver agreement, and physiologic correlates of two new clinical indexes. Chest 85(6):751–758CrossRefPubMedGoogle Scholar
  18. 18.
    Burge PS, Calverley PM, Jones PW, Spencer S, Anderson JA, Maslen TK (2000) Randomised, double blind, placebo controlled study of fluticasone propionate in patients with moderate to severe chronic obstructive pulmonary disease: the ISOLDE trial. BMJ 320(7245):1297–1303PubMedCentralCrossRefPubMedGoogle Scholar
  19. 19.
    Alsaeedi A, Sin DD, McAlister FA (2002) The effects of inhaled corticosteroids in chronic obstructive pulmonary disease: a systematic review of randomized placebo-controlled trials. Am J Med 113(1):59–65CrossRefPubMedGoogle Scholar
  20. 20.
    Pinto-Plata VM, Cote C, Cabral H, Taylor J, Celli BR (2004) The 6-min walk distance: change over time and value as a predictor of survival in severe COPD. Eur Respir J 23(1):28–33CrossRefPubMedGoogle Scholar
  21. 21.
    Agusti A, Thomas A. Neff Lecture (2006) Chronic obstructive pulmonary disease: a systemic disease. Proc Am Thorac Soc 3(6):478–481Google Scholar
  22. 22.
    Celli BR, Cote CG, Marin JM, Casanova C, Montes de Oca M, Mendez RA, Pinto Plata V, Cabral HJ (2004) The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med 350(10):1005–1012CrossRefPubMedGoogle Scholar
  23. 23.
    Ong KC, Earnest A, Lu SJ (2005) A multidimensional grading system (BODE index) as predictor of hospitalization for COPD. Chest 128(6):3810–3816CrossRefPubMedGoogle Scholar
  24. 24.
    Medinas Amorós M, Mas-Tous C, Renom-Sotorra F, Rubí-Ponseti M, Centeno-Flores MJ, Gorriz-Dolz MT (2000) Health-related quality of life is associated with COPD severity: a comparison between the GOLD staging and the BODE index. Chron Respir Dis 6(2):75–80CrossRefGoogle Scholar
  25. 25.
    The Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2008.
  26. 26.
    Bestall JC, Paul EA, Garrod R, Garnham R, Jones PW, Wedzicha JA (1999) Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax 54(7):581–586PubMedCentralCrossRefPubMedGoogle Scholar
  27. 27.
    Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A, Crapo R, Enright P, van der Grinten CP, Gustafsson P et al (2005) Standardisation of spirometry. Eur Respir J 26(2):319–338CrossRefPubMedGoogle Scholar
  28. 28.
    Haringsma R, Engels GI, Beekman AT, Spinhoven P (2004) The criterion validity of the Center for Epidemiological Studies Depression Scale (CES-D) in a sample of self-referred elders with depressive symptomatology. Int J Geriatr Psychiatry 19(6):558–563CrossRefPubMedGoogle Scholar
  29. 29.
    Hanania NA, Müllerova H, Locantore NW, Vestbo J, Watkins ML, Wouters EF, Rennard SI, Sharafkhaneh A (2011) Determinants of depression in the ECLIPSE chronic obstructive pulmonary disease cohort. Am J Respir Crit Care Med 183(5):604–611Google Scholar
  30. 30.
    Shafer AB (2006) Meta-analysis of the factor structures of four depression questionnaires Beck, CES-D, Hamilton, and Zung. J Clin Psychol 62(1):123–146CrossRefPubMedGoogle Scholar
  31. 31.
    Chiu S, Webber MP, Zeig-Owens R, Gustave J, Lee R, Kelly KJ, Rizzotto L, Prezant DJ (2010) Validation of the Center for Epidemiologic Studies Depression Scale in screening for major depressive disorder among retired firefighters exposed to the World Trade Center disaster. J Affect Disord 121(3):212–219CrossRefPubMedGoogle Scholar
  32. 32.
    Shin S, Kim M, Yun K, Kim J, Lee M, Moon S, Lee M, Lee H, Yoo K (1991) The Center for Epidemiologic Studies-Depression Scale: its use in Korea. J Korean Neuropsychiatr Assoc 30(4):752–767Google Scholar
  33. 33.
    Funk GC, Kirchheiner K, Burghuber OC, Hartl S (2009) BODE index versus GOLD classification for explaining anxious and depressive symptoms in patients with COPD: a cross-sectional study. Respir Res 10:1PubMedCentralCrossRefPubMedGoogle Scholar
  34. 34.
    An L, Lin YX, Yang T, Zhang H, Jiao X, Zhang S, Chang XH, Wang ZM, Wang C (2010) Predictive validity of BODE index for anxious and depressive symptoms in patients with chronic obstructive pulmonary disease. Chin Med J (Engl) 123(14):1845–1851Google Scholar
  35. 35.
    Al-shair K, Dockry R, Mallia-Milanes B, Kolsum U, Singh D, Vestbo J (2009) Depression and its relationship with poor exercise capacity, BODE index and muscle wasting in COPD. Respir Med 103(10):1572–1579CrossRefPubMedGoogle Scholar
  36. 36.
    Lamers F, Jonkers CC, Bosma H, Penninx BW, Knottnerus JA, van Eijk JT (2008) Summed score of the Patient Health Questionnaire-9 was a reliable and valid method for depression screening in chronically ill elderly patients. J Clin Epidemiol 61(7):679–687CrossRefPubMedGoogle Scholar
  37. 37.
    Julian LJ, Gregorich SE, Earnest G, Eisner MD, Chen H, Blanc PD, Yelin EH, Katz PP (2009) Screening for depression in chronic obstructive pulmonary disease. COPD 6(6):452–458PubMedCentralCrossRefPubMedGoogle Scholar
  38. 38.
    Puhan MA, Frey M, Büchi S, Schünemann HJ (2008) The minimal important difference of the hospital anxiety and depression scale in patients with chronic obstructive pulmonary disease. Health Qual Life Outcomes 6:46PubMedCentralCrossRefPubMedGoogle Scholar
  39. 39.
    Andrade L, Caraveo-Anduaga JJ, Berglund P, Bijl RV, De Graaf R, Vollebergh W, Dragomirecka E, Kohn R, Keller M, Kessler RC et al (2003) The epidemiology of major depressive episodes: results from the International Consortium of Psychiatric Epidemiology (ICPE) Surveys. Int J Methods Psychiatr Res 12(1):3–21CrossRefPubMedGoogle Scholar
  40. 40.
    Chavannes NH, Huibers MJ, Schermer TR, Hendriks A, van Weel C, Wouters EF, van Schayck CP (2005) Associations of depressive symptoms with gender, body mass index and dyspnea in primary care COPD patients. Fam Pract 22(6):604–607CrossRefPubMedGoogle Scholar
  41. 41.
    von Leupoldt A, Taube K, Lehmann K, Fritzsche A, Magnussen H (2011) The impact of anxiety and depression on outcomes of pulmonary rehabilitation in patients with COPD. Chest 140(3):730–736CrossRefGoogle Scholar
  42. 42.
    Kim HF, Kunik ME, Molinari VA, Hillman SL, Lalani S, Orengo CA, Petersen NJ, Nahas Z, Goodnight-White S (2000) Functional impairment in COPD patients: the impact of anxiety and depression. Psychosomatics 41(6):465–471CrossRefPubMedGoogle Scholar
  43. 43.
    Almagro P, Calbo E, Ochoa de Echagüen A, Barreiro B, Quintana S, Heredia JL, Garau J (2002) Mortality after hospitalization for COPD. Chest 121(5):1441–1448CrossRefPubMedGoogle Scholar
  44. 44.
    Griffiths TL, Burr ML, Campbell IA, Lewis-Jenkins V, Mullins J, Shiels K, Turner-Lawlor PJ, Payne N, Newcombe RG, Ionescu AA et al (2000) Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet 355(9201):362–368CrossRefPubMedGoogle Scholar
  45. 45.
    Eaton T, Garrett JE, Young P, Fergusson W, Kolbe J, Rudkin S, Whyte K (2002) Ambulatory oxygen improves quality of life of COPD patients: a randomised controlled study. Eur Respir J 20(2):306–312CrossRefPubMedGoogle Scholar
  46. 46.
    Lorig KR, Sobel DS, Ritter PL, Laurent D, Hobbs M (2001) Effect of a self-management program on patients with chronic disease. Eff Clin Pract 4(6):256–262PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Ki Uk Kim
    • 1
    • 2
  • Hye-Kyung Park
    • 1
    • 2
  • Hee Young Jung
    • 3
  • Jong-Joon Ahn
    • 4
  • Eunsoo Moon
    • 5
  • Yun Seong Kim
    • 1
    • 2
  • Min Ki Lee
    • 1
    • 2
  • Haejung Lee
    • 3
  1. 1.Department of Internal MedicinePusan National University School of MedicineBusanRepublic of Korea
  2. 2.Medical Research InstitutePusan National University HospitalBusanRepublic of Korea
  3. 3.Department of NursingPusan National University College of NursingYangsan-siRepublic of Korea
  4. 4.Department of Internal MedicineUniversity of Ulsan College of MedicineUlsanRepublic of Korea
  5. 5.Department of PsychiatryPusan National University HospitalBusanRepublic of Korea

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