COPD Comorbid with Mental Illness: What Psychiatrists Can Do: You Can Do a Great Deal to Ease Patients' Pulmonary Distress as You Manage Their Psychiatric Illness
[ILLUSTRATION OMITTED] Chronic obstructive pulmonary disease (COPD) usually is not diagnosed until clinically apparent and moderately advanced. Patients might not notice chronic dyspnea and smoker's cough, or might consider their symptoms "normal" and not seek medical care. Delayed diagnosis is particularly prevalent in the psychiatric population, in which co existing medical problems tend to remain unrecognized and untreated. (1) Life expectancy of people with serious mental illness (SMI) is 13 to 30 years less than that of the general population a gap that has widened over time. (2) Pulmonary disease is a leading cause of elevated mortality risk in SMI, along with cardiovascular and infectious disease, diabetes, and barriers to care. Having a comorbid mental illness triples the mortality risk of chronic lower respiratory disease (Table 1) (3) This article describes how you can intervene and improve quality of life for your patients with COPD by: asking all patients, especially smokers, if they are experiencing classic symptoms of COPD advocating for and supporting smoking cessation efforts avoiding drug interactions and off target dosing related to COPD and nicotine replacement therapy considering, if feasible, a switch from typical to atypical antipsychotic therapy, which could reduce smoking behavior. What isCOPD? COPD is preventable and treatable. It is characterized by "persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lungs to inhaled noxious particles or gases." (4) Smoking tobacco is the greatest risk factor for developing COPD. (5) An estimated 50% to 80% of people with schizophrenia are smokers, as are 55% of people with bipolar disorder. (6) COPD is a leading cause of morbidity and mortality worldwide, (7,8) and its prevalence is projected to increase as the global population and smoking rates grow. (9) A simplified schema of the pathophysiology of COPD implicates 4 lung areas: parenchyma, pulmonary vasculature, central airways, and peripheral airways. (10) Variation in the areas affected and severity of change contributes to the disease's heterogeneous presentation, which can include pulmonary hypertension, hypersecretion of mucus, ciliary dysfunction, airway hyperinflation, and impaired gas exchange. (11,12) Many of these features lead to systemic effects as well, particularly on cardiac function. When to test a patient for COPD Early diagnosis and treatment can substantially improve quality of life outcomes for patients with COPD. The clinical approach .Figure 1, page 70) begins with recognizing classic symptoms. Consider COPD in any patient with: dyspnea (particularly if becoming worse, persistent, or associated with exercise) chronic cough chronic sputum production history of risk factor exposure (particularly tobacco smoke) family history of COPD. (4) If the history and physical exam suggest COPD (Table 2, page 71) spirometry is the most reliable test to quantify and characterize lung dysfunction. It is not indicated as a screening tool for healthy adults or appropriate when a patient is acutely ill. Forced expiratory volume in the first second of expiration divided by the measured forced vital capacity (FEV1/FVC) Psychopharmacology issues with comorbid COPD Pharmacotherapy for psychiatric disorders can exacerbate comorbid COPD. For example, long term use of phenothiazine related typical antipsychotics for schizophrenia has been linked to an increased incidence of COPD.