General points

• The evidence available for the use of antidepressants drug therapy to treat comorbid depression in patients with COPD is inconclusive [53, 54]. In the absence of clear evidence of benefits, it is important for clinicians to monitor COPD patients using a validated depression rating scale regularly and following any patient who has been prescribed antidepressants to determine response to therapy and the emergence of the prescription of antidepressants for any adverse events.

• When prescribing antidepressants, the principle of ‘start low and go slow’ should be followed provided there is an attempt to but try not reach a therapeutic dose in patients with adequate tolerance.

• Prior to commencing antidepressant drug treatment, COPD patients should be informed of potential side effects. It is important to emphasise that most of side effects are transient and to ensure that clinician backup is easily available make yourself available in case side effects develop.

Specific medication points

• Depressed COPD patients who are poorly tolerating or failing to respond antidepressants should be referred to a psychiatrist for detailed assessment.

• In older people, it has been reported over the third of the patients [49] on SSRIs and tramadol or oxycodone exhibit drug interactions. Thus, older patients who are treated with combined drugs require close monitoring and adjust the therapeutic doses accordingly in relation to patients’ symptoms in order to reduce potential side effects. Opioids in lower doses (<30 mg oral morphine equivalent per day) are not associated with increased hospital admission or deaths in patients receiving long-term oxygen therapy for COPD.

• Benzodiazepines and opioids in higher doses might increase mortality in patients with chronic respiratory diseases.

• Lower-dose opioids might be safe for reducing symptoms of dyspnoea in patients with respiratory disease.

  Safety data from clinical practice for benzodiazepines and opioids in patients with severe COPD are lacking.