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Abstract
Objective To investigate physicians’ perceptions and current practices of identifying and managing depression in patients with chronic obstructive pulmonary disease (COPD).
Design A cross-sectional online survey was employed between March and September 2022.
Settings Saudi Arabia.
Participants 1015 physicians, including general practitioners and family, internal and pulmonary medicine specialists.
Primary outcome measures Physicians’ perceptions, confidence, practices and barriers to recognising and managing depression in patients with COPD.
Results A total of 1015 physicians completed to the online survey. Only 31% of study participants received adequate training for managing depression. While 60% of physicians reported that depression interferes with self-management and worsens COPD symptoms, less than 50% viewed the importance of regular screening for depression. Only 414 (41%) physicians aim to identify depression. Of whom, 29% use depression screening tools, and 38% feel confident in discussing patients’ feelings. Having adequate training to manage depression (OR: 2.89; 95% CI: 2.02 to 3.81; p<0.001) and more years of experience (OR: 1.25; 95% CI: 1.08 to 1.45; p=0.002) were associated with the intention to detect depression in COPD patients. The most common barriers linked to recognising depression are poor training (54%), absence of standard procedures (54%) and limited knowledge about depression (53%).
Conclusion The prevalence of identifying and confidently managing depression in patients with COPD is suboptimal, owing to poor training, the absence of a standardised protocol and inadequate knowledge. Psychiatric training should be supported in addition to adopting a systematic approach to detect depression in clinical practice.
- chronic airways disease
- emphysema
- respiratory medicine (see thoracic medicine)
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The first study to assess the current practice of managing depression in patients with chronic obstructive pulmonary disease in Saudi Arabia.
Different physicians’ specialities were included in the study.
The cross-sectional nature of the study does not allow to study the causal relationships.
Introduction
Chronic obstructive pulmonary disease (COPD) is a complex, multisystem disease that is usually associated with other comorbid conditions, known as comorbidities. Depression is a common comorbidity in patients with COPD, resulting in poor adherence to medical and non-medical therapies,1 2 increased risk of COPD exacerbation3 and greater mortality.4 Because of this, international guidelines, such as the UK National Institute for Health and Care Excellence (NICE) COPD and Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines encourage identifying and managing depression in patients with COPD,5 although there is no evidence to show that depression is currently part of the standard assessment.
The reported prevalence of depression in patients with COPD varies across studies. It ranges from 10% to 42% in patients with stable COPD, and from 10% to 86% in patients with acute COPD exacerbation.6 The incidence of depression following a COPD diagnosis is also greater compared with individuals without COPD.5 7 8 Despite this, depressive symptoms remain undiagnosed in a significant proportion of patients, and hence, undertreated,9 ultimately to the detriment of patients. Therefore, identifying depression as early as possible allows healthcare providers to develop appropriate strategies that meet patients’ needs and guide the choice of pharmacological and non-pharmacological therapies.
Current literature suggests that the diagnosis of depression is missed in up to 50% of patients with physical illnesses,10 leading to under or even untreated depression. In patients with COPD, it has been reported that more than 60% of patients with depression receive no treatments,11 despite more than one-third experiencing depressive symptoms. Multiple factors may contribute to unrecognised and thus unmanaged depression in patients with COPD; such includes poor training, time constrain, patients’ reluctance to discuss their mental health, lack of confidence to address psychological issues in the presence of COPD, and low uptake for treatment even if depression is identified.
Physicians in direct contact with COPD patients play an important role in identifying depression; and consequently, intervene accordingly. However, there is limited information available on the perception of physicians and the current practice of identifying and managing depression in patients with COPD in Saudi Arabia. Therefore, this study aims to (1) investigate the views of physicians on recognising and managing depression in patients with COPD, (2) assess the current practice and confidence of managing depression in COPD and (3) explore the barriers and facilitators linked to physicians’ practice.
Methods
Study design
A cross-sectional questionnaire was conducted through an electronic platform (Survey Monkey) from 1 March 2022 to 30 September 2022.
Questionnaire tool
The questionnaire consisted of five sections with closed-ended questions and free text fields for additional comments. The questionnaire was adopted previously published research which has looked at the management of depression in different populations (eg, COPD and low vision patients).12 13 Modifications to the adopted questionnaires were done based on the current literature related to depression in patients with COPD.6 14 15 An expert panel of healthcare professionals, with experience in COPD management, from different disciplines of respiratory medicine, respiratory epidemiology and family medicine has modified and reformulated the original questionnaires to meet the objectives of this study. After finalising the questionnaire, a pilot study was conducted to ensure the validity of the content. Participants included in the pilot study, 10 physicians working with COPD patients, were excluded from the final analyses. The structure of the questionnaire was as follows:
Section 1 consists of questions regarding participants’ backgrounds, including gender, place of work, years of clinical experience, average time spent with patients, number of patients with COPD seen each month and if physicians ever received training for depression management.
Section 2 consists of seven statements assessing physicians’ views about depression in patients with COPD, using a 5-point Likert scale ranging from 1=strongly disagree to 5=strongly agree.
Section 3 assesses the current practice in relation to working with patients with COPD and depression. It consists of three questions on (1) the intention to identify depression in patients with COPD, (2) the use of screening tools and (3) actions are likely to be taken if depression is suspected in patients with COPD.
Section 4 consists of nine statements about physicians’ confidence in working with patients with COPD, using the 5-point Likert scale ranging from 1=not confident to 5=completely confident.
Section 5 consists of two questions assessing perceived barriers and facilitators to identifying depression in patients with COPD (see online supplemental appendix 1).
Supplemental material
Participant and sample size calculation
The targeted populations were physicians likely to perform a standard assessment for patients with COPD. The targeted populations included general practitioners (GPs, family medicine, internal medicine and pulmonary medicine physicians. Sample size calculation was not required as this was an exploratory study. It is important to mention that the Saudi health council governs and organises the Saudi healthcare system, where regulations are integrated between different organisations to deliver healthcare.16 According to a governmental report published in 2021, the number of GPs is 13 453, pulmonologists and respiratory medicine is 630, family medicine is 8203 and internal medicine is 7465. Therefore, the total population of physicians is around 29 751 physicians.16
Sampling strategy
Professional committees managing respiratory diseases, such as the Saudi Society of Internal Medicine, the Saudi Thoracic Society, the Saudi Society for Respiratory Care and the Saudi Society of Family and Community Medicine, were contacted to distribute the survey. Also, hospital officials in all regions of the country were approached and sent the survey through social networks (Twitter, WhatsApp and Telegram) to reach a greater number of physicians working in Saudi Arabia. In addition, the authors from different institutions in different regions/cities (eg, Jazan, Dammam, Makkah, Jeddah, Riyadh and Al-Ahasa) have also taken roles in the data collection process by following up with hospital officials to ensure that all Saudi geographical regions were covered, and the sample was representative.
Participants were informed of the purpose of the study and the identity of the principal investigator before the beginning of the study. Furthermore, it was made clear that participation in the study was completely voluntary and that participants could withdraw from the study at any time. Participants were also informed that data would be kept confidential and no personal information to be shared or used. Participants were asked if they were willing to take part in the study by answering the following question: ‘Do you agree to take part in the study?’. By answering yes, the participants give their consent to participate. The time required to complete the survey was approximately 5–7 min.
Patient and public involvement statement
None.
Statistical analysis
Data management and analyses were performed using STATA (V.16) statistical software (StataCorp LLC, College Station, TX, USA). The results were presented as number (%) for categorical variables. Demographic variables linked to the intention to identify depression in patients with COPD were assessed using logistic regression models, deriving the OR with 95% CI. Each variable (exposure) and outcome of interest (aim to identify depression) was included in a separate model (single exposure and single outcome). Statistical significance was considered as if the p<0.05.
Results
Overall, 1015 physicians, of whom 69.6% were male, responded to the online survey between March and September 2022. Most of the respondents were from the central region (30.25%). GPs accounted for 29.95% of the respondents, followed by family medicine (24.73%) and pulmonologist/respiratory medicine (23.35%). The majority of participants work at governmental hospitals (83.94%) and have one to four (43.25%) or five to nine (28.08%) years of clinical experience with COPD patients. Only 31.33% had received specific training for managing depression, table 1.
Demographics and professional background for study participants (n=1015)
Physicians’ views on depression in patients with COPD
Of the 1015 physicians, 60% of study participants indicated that depression worsens COPD symptoms and interferes with self-management and that controlling COPD symptoms is the best way to improve depressive symptoms. Further, more than half of the physicians (54%) agreed on the difficulty of convincing COPD patients with comorbid depression to receive treatment. Unexpectedly, only 47% view screening for depression positively, table 2.
Physicians’ views about depression in patients with COPD (n=1015)
Current practice and confidence in managing COPD patients with depression
The current practice of managing depression in COPD patients was assessed by asking whether physicians aim to identify possible depression and whether screening for depression was incorporated as part of patients’ assessment.
Of the 1015 physicians, only 414 (40.79%) indicated that they aim to identify possible depression as a part of COPD patients’ management, table 3. Of whom, a small proportion use screening tools to identify depression, with 45 (11.19%) selecting ‘always’ and 72 (17.91%) choosing ‘often’. When acting in response to suspected depression, the majority of physicians reported that using a formal diagnostic tool to confirm the diagnosis (57.71%) or providing a referral to mental health services such as counselling (52.5%). However, slightly more than one-third indicated that they would provide pharmacological therapy (36.82%) or discuss patients’ feelings (36.57%), table 3.
Current practice in working with COPD patients and depression
Logistic regression analysis was performed to investigate which factors are associated with identifying depression in patients with COPD. Results show that having adequate training on managing depression was associated with identifying depression in COPD patients (OR: 2.89; 95% CI: 2.02 to 3.81; p<0.001). In addition, the more years of experience physicians have, the more likely they will identify depression (OR: 1.25; 95% CI: 1.08 to 1.45; p=0.002). Furthermore, physicians with more than 10 years of experience have more potential to recognise depression compared with those at the beginning of their careers (OR 2.32; 95% CI: 1.39 to 3.88; p=0.001), table 4.
Bivariate logistic regression models of the factors associated with the intention to recognise depression in patients with COPD
The confidence level was assessed among the 414 physicians who have the intention to identify depression as a part of the assessment. Only 38% of physicians indicated that they are confident in discussing patients’ feelings during visits. In addition, almost half of the participants feel completely or fairly confident in recognising signs of depression, educating their patients about their depression, and referring them to appropriate services, table 5.
Confidence level in managing COPD patients with depression (n=414)
Barriers to identifying and managing depression in COPD patients
The most commonly reported barriers among all physicians were poor training about identifying and managing depression in COPD patients (54%), followed by the absence of standard procedures for managing depression in COPD patients (54%) and limited knowledge about depression as a comorbidity in patients with COPD (53%), figure 1.
The most common barriers to identifying and managing depression in COPD patients (n=1015). COPD, chronic obstructive pulmonary disease.
Factors that facilitate to identify and manage depression in COPD patients
The most commonly reported factors among all physicians were the presence of standard procedures for managing depression in COPD patients (58%), followed by appropriate training about identifying and managing depression in COPD patients (58%) and patents’ acceptance to treatments (eg, psychological and pharmacological therapies) (54%), figure 2
The most common facilitators to identifying and managing depression in COPD patients (n=1015). COPD, chronic obstructive pulmonary disease.
Discussion
To the best of our knowledge, this is the first study to assess physicians’ perceptions, confidence, current practice and barriers and facilitators for managing depression in patients with COPD in Saudi Arabia. Our main findings showed that majority of the physicians agreed that controlling COPD symptoms is important in alleviating depressive symptoms, and that depression interferes with self-management and worsens COPD symptoms. Despite this, less than half aimed to identify possible depression and the confidence level in managing depression in patients with COPD was low. The most common barriers to managing depression in patients with COPD were poor training and the absence of standard guidelines.
Recognising and managing depression starts with active screening. Although almost two-thirds of the participants in this study agree on the negative impacts associated with depression in patients with COPD, less than half view the importance of routine screening of depression. This may lead to a missed opportunity to identify possible depression and early intervention. In line with this, it has recently been reported that depression remains undiagnosed; and thus, untreated in a significant proportion of COPD patients.9 11 With the considerable impacts of depression in patients with COPD, such as impaired quality of life,17 poor adherence to medical treatment,1 2 increased risks of COPD exacerbation,3 hospital readmission18 and mortality,4 it is therefore imperative to emphasise on the role of routine depression screening in patients with COPD in Saudi Arabia.
International guidelines encourage recognising depression in patients with COPD,5 as it allows healthcare providers to develop appropriate treatment strategies and guide the choice of therapies (pharmacological and non-pharmacological); all of which aim to improve the clinical outcomes. Disappointingly, only 41% of the study participants aim to identify comorbid depression during patients’ visits. Even among those who seek to recognise depression, a small proportion (29%) frequently use validated depression screening tools. A previous study conducted in the UK including 857 GPs reported that 72% aim to identify depression in people with COPD, compared with only 41% of our participants. This might be explained by the lack of training of managing, as the majority of our participants reported not receiving adequate training. Indeed, training seems to be a major predictor for identifying and managing depression and our results showed that those show have adequate training were two times more likely to recognise depression, in concordant with current literature. This puts a lot of emphasis on the healthcare system to provide adequate training in order to address the issue. Another key element which should be incorporated within the training programme is communication skills (eg, initiating the conversation and responding to emotion) which might work hand in hand with screening.
The impact of depression can be reduced if it is timely detected and managed. One way to approach this is by active screening. Indeed, there are a number of validated screening tools which are easy efficient and easy tools. The NICE guidelines recommend using the Patient Depression Questionnaire (PHQ-2) which asks the patient two screening questions as follows ‘during the last month, have you often been bothered by feeling down, depressed or hopeless?’and ‘during the last month, have you often been bothered by having little interest or pleasure in doing things?’.19 The answer to these questions will provide an overview whether further assessment is required. Such screening tools (two quick questions) can be easily incorporated within the respiratory assessment; and therefore, help in recognising depression and intervening accordingly.
The findings that only one-third of the study participants have received proper training for managing depression is alarming and suggest that physicians need to be trained on how to identify depression in patients with COPD. Moreover, our findings may also emphasise why a significant proportion of patients with COPD and depression remain undiagnosed and do not receive appropriate treatment. Maurer et al reported multistage barriers to recognising and managing depression in patients with COPD; one of which is a lack of training.20 A previous study also showed that diagnostic skills for depression among Saudi primary care physicians are poor.21 It is worth noting, however, assessing comorbid conditions such as depression in COPD is not part of standard practice, and current international COPD guidelines do not offer specific management strategies for such a comorbidity. It is recommended that depression should be managed according to usual care, as if the patient does not have COPD. In the absence of standard procedures for managing depression in patients with COPD, depression may be missed as COPD symptoms (eg, shortness of breath, coughing and chest tightness) are likely to be the central focus during patients’ visits. Therefore, there needs to be a systematic approach to assessing depressive symptoms in this population.
The lack of confidence in assessing the psychological status of patients with COPD has been documented.20 In line with this, less than 50% of participants in this study indicated that they feel confident in managing depression in patients with COPD. Reasons such as lack of training (which translates into a lack of skills and knowledge) and poor utilisation of screening tools may all contribute to the lack of confidence. Although the national guidelines issued by the Saudi ministry of health emphasise screening for depression in patients with chronic illnesses, there is indeed an underuse of screening tools in clinical practices.22 A previous study conducted in the UK reported that not all GPs have the confidence to discuss an issue regarding depression with their patients, as they are inadequately trained in psychiatric care, and there is a fear that patients may lack confidence about their care.13 Within the Saudi context, a previous study of 380 physicians from different specialities reported that physicians would prefer to work with physical illness during patients’ visits compared with those with psychological issues and showed less confidence compared with psychiatric physicians.22 This emphasises the importance of appropriate training for physicians to boost their confidence in discussing, detecting and managing depression in this population.
Several barriers to the detection of depression in patients with COPD have been suggested, including poor training, the absence of standardised assessment and limited knowledge. Such barriers may explain why depression remains undetected in many patients with COPD. Although there are no-specific tools that have been validated to assess depressive symptom in patients with COPD, a number of screening tools are currently used in clinical practice. Thus, clinicians should understand these tools’ strengths and limitations and how to use them properly. Psychiatric training is also necessary to tackle mental illness in patients with COPD. Moreover, the stigma associated with psychological disorders may lead patients not to disclose their feelings to their physicians; thus, depression remains unrecognised. Patients should be educated about the risk of depression and encouraged to discuss their symptoms with their physicians. Similarly, physicians should not be preserved to ask about patients’ feelings and moods. System issues such as time constraints and heavy workloads may prevent physicians from performing a comprehensive medical assessment. These barriers should be facilitated in order to improve patients’ outcomes.
Strengths and limitations
This study has several strengths. It is the first study conducted in the field highlighting important points about the current practice of identifying and managing depression in patients with COPD. Second, physicians were included from different disciplines (who are known to encounter patients with COPD frequently) and from across the country, thus, offering high external validity. However, there are some limitations to be discussed. The cross-sectional nature of the study does not allow assessment for any causality. Another limitation is that the convenience sampling strategy may have imposed a selection bias. However, participants were recruited from all geographical regions in the country. In addition, the survey method does not entail the same experiences, applications and real-world occurrences as routine practices are not easily explored, recorded and analysed. It is worth mentioning, however, that the collected data aimed to provide an overall picture of the perceptions and current practices in Saudi Arabia.
Conclusion
Depression is highly prevalent in patients with COPD with serious consequences, and should be identified and managed as early as possible. However, the rate of physicians with adequate training and aim to identify depression, or use of screening tools is significantly alarming. There needs to be aggressive training in psychiatric care to allow the timely identification of depressive symptoms. Screening should also be considered as a valuable tool during patients’ assessments.
Ethics statements
Patient consent for publication
Ethics approval
Ethical approval was obtained from an independent research committee at King Faisal University (ID: KFU-REC-2022-FEB-EA000447).
Acknowledgments
The author acknowledges the Deanship of Scientific Research, Vice Presidency for Graduate Studies and Scientific Research at King Faisal University, Al-Ahsa, for providing financial support under the Promising Researcher Track “Grant No. 3316”.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @DrAbdulelah1989
Contributors Conceptualisation; RAS, AMA, YSA and AMA: data curation; AMA, JSA, SMA, AAA, BOB, SKK and HSA: formal analysis; RAS, AMA and SSA: investigation; RAS, MA and FFA: methodology; RAS and AAA: project administration; RAS, AAA, MAA, AMA, JSA, SMA and AAA: resources; RAS: supervision; RAS and HSA: validation; RAS, FFA, SSA, MA, MAA, YSA, AAA and AMA: writing of the original draft; all authors contributed to the writing, review and editing.
Funding This work was supported by the Deanship of Scientific Research, Vice Presidency for Graduate Studies and Scientific Research, King Faisal University, Saudi Arabia (Grant No. 3316).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.