Perceived Stress Worsens Outcomes in People With COPD

New research has found that perceived stress was associated with worse outcomes in people with chronic obstructive pulmonary disease (COPD).1

The Comparing Urban and Rural Effects of Poverty on COPD (CURE COPD) was a longitudinal observational study of former smokers with COPD from low-income urban areas that examined the impact of obesity, adverse dietary patterns, and indoor air pollution on adverse respiratory outcomes.

Study participants completed Perceived Stress Scale (PSS) evaluations, St George's Respiratory Questionnaire [SGRQ]), respiratory health status (COPD Assessment Test [CAT] and Clinical COPD Questionnaire [CCQ]), and respiratory symptoms (modified Medical Research Council [mMRC] scale and Ease of Cough and Sputum Clearance [ECSC] questionnaire) at study visits.

“There is increased evidence that psychosocial factors, including perceived stress, are associated with worsened respiratory symptoms for people with COPD. Platelet activation, which may contribute to inflammation, and oxidative stress, which may lead to cell and tissue damage, are also impacted by increased perceived stress,” lead investigator Obiageli Lynda Offor, MD, MPH, a Pulmonary and Critical Care Fellow at Johns Hopkins Medicine in Baltimore, said in a statement.2 “While our study examined a small group of patients, our results demonstrate the need for further research on how perceived stress impacts respiratory health and the importance of addressing psychosocial factors to help improve people’s quality of life.”

The study included 116 participants, 17 (14.7%) of which withdrew before all baseline data was collected, for a total of 99 participants completing a baseline visit between 2016 and 2021. Participants had a mean age of 66.4 years, 56% were female, 57% were Black, and most had moderate COPD.1

At baseline, participants had a mean PSS score of 12.9 (standard deviation [SD], 6.4), with 52 (52.5%) participants in the lowest tertile (0–13), 45 (45.5%) in the middle tertile, and 2 (2.0%) in the highest tertile of PSS scores. Investigators found that mean PSS was similar at each follow-up visit (14.1 [SD, 8.6] at 3 months and 12.8 [SD, 8.1] at 6 months). Most participants had PSS scores consistently in the same category throughout the study but, 38.4% moved between categories at least once.1

“In COPD, increasing exertional dyspnea, lack of energy, and limitations in daily activities result in deteriorating quality of life and impact mental health symptoms. Several studies have shown a higher prevalence of symptoms of anxiety and depression among individuals with COPD, which are associated with adverse clinical outcomes. There is limited literature on the biological mechanisms and pathways by which psychosocial factors, such as perceived stress, may impact COPD outcomes and potentially be therapeutically targeted,” Offor and colleagues wrote.1

Offor and colleagues found that a 4-point increase in PSS score was associated with a higher CAT score (mean difference [β], 0.91; 95% CI, 0.40-1.43), SGRQ (β, 2.17; 95% CI, 1.21-3.13), CCQ (β, 0.11; 95% CI, 0.05-0.17), and ECSC (β, 0.36; 95% CI, 0.11-0.61) but not mMRC (β, 0.03; 95%CI, -0.05 to 0.10) or odds of at least 1 exacerbation during the 12-month study period.1

Notably, moderate PSS and high PSS were associated with progressively worse respiratory symptoms when. compared with low PSS, with the association between high versus low PSS and CAT, SGRQ, and CCQ all surpassing the minimum clinically important difference (MCID). High stress was also associated with a 4.15 higher odds of at least one moderate/severe COPD exacerbation than low stress (95% C ,1.28-13.47) over the 12 months. Moderate stress was not associated with odds of experiencing an exacerbation. Investigators also conducted stratified analyses which revealed that PSS was only associated with respiratory outcomes among those with severe COPD (GOLD≥3).1

“In conclusion, perceived stress was associated with worse respiratory morbidity, particularly among individuals with severe COPD, and with higher levels of systemic platelet activation and lipid peroxidation among individuals with mild-moderate COPD. This study suggests that individuals with milder COPD may exhibit a relationship between psychosocial stress and adverse biological mechanisms that are potential therapeutic targets,” Offor and colleagues concluded.1

REFERENCES

1. Offor O, Eakin MN, Woo H, et al. Perceived Stress is Associated With Health Outcomes, Platelet Activation, and Oxidative Stress in COPD. Chronic Obstr Pulm Dis. 2025; 12(2): 98-108. doi: 10.15326/jcopdf.2024.0561

2. Feeling stressed may lead to worsened respiratory symptoms, decreased quality of life. News release. COPD Foundation. April 29, 2025. https://www.eurekalert.org/news-releases/1081508