Prescribe SSRIs and SNRIs Cautiously for Older Patients With COPD

Author:
Nicholas T. Vozoris, MD
Department of Medicine, University of Toronto, and St. Michael’s Hospital, Toronto, Ontario, Canada

Editor’s note: Because depression is a common comorbidity among patients with COPD, antidepressants are widely prescribed to help these patients. But the findings of newly published research Nicholas T. Vozoris, MD, suggest that prescribers should take an even more cautious approach when initiating an SSRI or an SNRI in patients with COPD, particularly older patients.

I see a lot of patients with chronic obstructive pulmonary disorder (COPD), and many of them are on psychoactive medications such as serotonergic antidepressants. Depression and anxiety are common comorbidities in COPD, explaining why serotonergic antidepressants might be frequently prescribed in this group. So, are these drugs potentially not helpful from a respiratory perspective in individuals with COPD who have preexisting lung problems? And there are several theoretical mechanisms through which serotonergic antidepressants might do respiratory harm in COPD patients. So the purpose of our study was to formally look into this question, “What is the potential respiratory impact of serotonergic antidepressants amongst individuals with COPD?”

Study Design

For this study we used population-level data from the province of Ontario in Canada. It was collected by the Ministry of Health, so we have data on all Ontarians who’ve been diagnosed with COPD, and there were over 130,000 people included in the study. We took those who newly got a serotonergic antidepressant, and the comparison group were individuals who didn’t get such a drug. They would have gotten another new drug, but not a serotonergic antidepressant. We matched the 2 groups—the new serotonergic antidepressant drug users vs those that didn’t—on a long list of other variables so that the 2 groups in the study were balanced in terms of risk factors that could influence outcomes. We looked at markers of respiratory morbidity and mortality, and we set a 90-day window following drug receipt.

Study Findings

After balancing the new antidepressant drug users vs those that didn’t, we found that the new users had significantly increased risk compared to the control group for coming to hospital for COPD or pneumonia, coming to the emergency department for COPD or pneumonia, COPD- or pneumonia-related death, and all-cause death. And we even found this similar pattern of findings when we even looked at individuals with COPD who were not having respiratory exacerbations, which would be a healthier subgroup of the total COPD population. We found this similar pattern of increased morbidity and mortality markers in the healthiest subgroup of patients, which just adds further credibility and robustness to the overall findings.

The Take-Home Message

First off, it is important to point out that the findings are not meant to alarm patients and physicians. And the message is not for patients who are getting serotonergic antidepressants to immediately come of off them, or for physicians to never prescribe them under any circumstance. There will be circumstances where these drugs are needed—for example, if someone has a serious case of depression or anxiety disorder. But what my coauthors and I would like for physicians and patients to take away is to just have this knowledge about the potential for respiratory harms in this population, to have it in the prescribing decision-making and discussion, and for both the physician and the patient to be vigilant if they start a serotonergic antidepressant, to be vigilant about looking for possible negative respiratory events happening early on when they receive the drug.

These drugs are also sometimes used off-label for reasons other than to manage depression and anxiety (eg, to treat chronic pain or to use as sleeping aids for insomnia), and the message about possible harms becomes even more relevant when a physician and patient are considering these drugs for off-label use.

Another practical message is that there are nondrug strategies for depression and anxiety symptoms in COPD, and such nondrug strategies include psychotherapy and also pulmonary rehabilitation. Given our study findings, patients and physicians might consider going to those nondrug treatment strategies first, and to optimize use of them, before going to serotonergic antidepressants.

Nicholas T. Vozoris, MD, is an assistant professor and a clinician investigator in the Department of Medicine at the University of Toronto. He is also a staff respirologist at St. Michael’s Hospital in Toronto.