Breathlessness and psychiatric morbidity in chronic bronchitis and emphysema: a study of psychotherapeutic management

A tailored psychological intervention for anxiety and depression management in people with chronic obstructive pulmonary disease: TANDEM RCT and process evaluation

Background

People with chronic obstructive pulmonary disease have high levels of anxiety and depression, which is associated with increased morbidity and poor uptake of effective treatments, such as pulmonary rehabilitation. Cognitive-behavioural therapy improves mental health of people with long-term conditions and could potentially increase uptake of pulmonary rehabilitation, enabling synergies that could enhance the mental health of people with chronic obstructive pulmonary disease.

Aim

Our aim was to develop and evaluate the clinical effectiveness and cost effectiveness of a tailored cognitive-behavioural approach intervention, which links into, and optimises the benefits of, routine pulmonary rehabilitation.

Design

We carried out a pragmatic multicentre randomised controlled trial using a 1.25 : 1 ratio (intervention : control) with a parallel process evaluation, including assessment of fidelity.

Setting

Twelve NHS trusts and five Clinical Commissioning Groups in England were recruited into the study. The intervention was delivered in participant's own home or at a local NHS facility, and by telephone.

Participants

Between July 2017 and March 2020 we recruited adults with moderate/very severe chronic obstructive pulmonary disease and mild/moderate anxiety and/or depression, meeting eligibility criteria for assessment for pulmonary rehabilitation. Carers of participants were invited to participate.

Intervention

The cognitive-behavioural approach intervention (i.e. six to eight 40- to 60-minute sessions plus telephone support throughout pulmonary rehabilitation) was delivered by 31 trained respiratory healthcare professionals to participants prior to commencing pulmonary rehabilitation. Usual care included routine pulmonary rehabilitation referral.

Main outcome measures

Co-primary outcomes were Hospital Anxiety and Depression Scale - anxiety and Hospital Anxiety and Depression Scale - depression at 6 months post randomisation. Secondary outcomes at 6 and 12 months included health-related quality of life, smoking status, uptake of pulmonary rehabilitation and healthcare use.

Results

We analysed results from 423 randomised participants (intervention, n = 242; control, n = 181). Forty-three carers participated. Follow-up at 6 and 12 months was 93% and 82%, respectively. Despite good fidelity for intervention delivery, mean between-group differences in Hospital Anxiety and Depression Scale at 6 months ruled out clinically important effects (Hospital Anxiety and Depression Scale - anxiety mean difference -0.60, 95% confidence interval -1.40 to 0.21; Hospital Anxiety and Depression Scale - depression mean difference -0.66, 95% confidence interval -1.39 to 0.07), with similar results at 12 months. There were no between-group differences in any of the secondary outcomes. Sensitivity analyses did not alter these conclusions. More adverse events were reported for intervention participants than for control participants, but none related to the trial. The intervention did not generate quality-of-life improvements to justify the additional cost (adjusted mean difference £770.24, 95% confidence interval -£27.91 to £1568.39) to the NHS. The intervention was well received and many participants described positive affects on their quality of life. Facilitators highlighted the complexity of participants' lives and considered the intervention to be of potential valuable; however, the intervention would be difficult to integrate within routine clinical services. Our well-powered trial delivered a theoretically designed intervention with good fidelity. The respiratory-experienced facilitators were trained to deliver a low-intensity cognitive-behavioural approach intervention, but high-intensity cognitive-behavioural therapy might have been more effective. Our broad inclusion criteria specified objectively assessed anxiety and/or depression, but participants were likely to favour talking therapies. Randomisation was concealed and blinding of outcome assessment was breached in only 15 participants.

Conclusions

The tailored cognitive-behavioural approach intervention delivered with fidelity by trained respiratory healthcare professionals to people with chronic obstructive pulmonary disease was neither clinically effective nor cost-effective. Alternative approaches that are integrated with routine long-term condition care are needed to address the unmet, complex clinical and psychosocial needs of this group of patients.

Trial registration

This trial is registered as ISRCTN59537391.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/146/02) and is published in full in Health Technology Assessment; Vol. 28, No. 1. See the NIHR Funding and Awards website for further award information.

Psychosocial Intervention in Chronic Obstructive Pulmonary Disease: Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Many patients with chronic obstructive pulmonary disease (COPD) experience persistent interrelated psychological and physical symptoms despite optimal treatment. Several studies of psychosocial intervention in COPD have been published in recent years. The present study aimed to conduct a quantitative summary of the efficacy of such interventions on psychological and physical outcomes.

METHODS

Two independent raters screened PubMed, PsycINFO, Embase, Web of Science, Cochrane Library, and CINAHL for eligible studies. In all, 35 independent, randomized controlled trials with a total of 3,120 patients with COPD were included, assessed for their methodological quality, and subjected to meta-analytic evaluation.

RESULTS

Meta-analyses revealed small, statistically significant effects of psychosocial intervention on combined psychological (Hedges's g = 0.28; 95%CI: 0.16-0.41) and physical outcomes (g = 0.21; 95%CI: 0.07-0.35) with no indications of publication bias. Supplementary Bayesian meta-analyses provided strong evidence for a non-zero overall effect on psychological outcomes (Bayes factor (BF) = 305) and moderate support for physical outcomes (BF = 6.1). Exploring sources of heterogeneity with meta-regression indicated that older age of patients and longer duration of interventions were associated with smaller effects on psychological outcomes.

CONCLUSIONS

The results support psychosocial intervention as an additional, useful tool in multidisciplinary respiratory care with the potential to improve both psychological and physical outcomes. Future studies are recommended to monitor adverse effects, apply blinding of active control conditions, and determine sample sizes with a priori power calculations.

REGISTRATION

Registered with Prospero (www.crd.york.ac.uk/prospero/) prior to initiation of the literature search (Reg. ID: CRD42020170083).

Psychological therapies for the treatment of depression in chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) has been recognised as a global health concern, and one of the leading causes of morbidity and mortality worldwide. Projections of the World Health Organization (WHO) indicate that prevalence rates of COPD continue to increase, and by 2030, it will become the world's third leading cause of death. Depression is a major comorbidity amongst patients with COPD, with an estimate prevalence of up to 80% in severe stages of COPD. Prevalence studies show that patients who have COPD are four times as likely to develop depression compared to those without COPD. Regrettably, they rarely receive appropriate treatment for COPD-related depression. Available findings from trials indicate that untreated depression is associated with worse compliance with medical treatment, poor quality of life, increased mortality rates, increased hospital admissions and readmissions, prolonged length of hospital stay, and subsequently, increased costs to the healthcare system. Given the burden and high prevalence of untreated depression, it is important to evaluate and update existing experimental evidence using rigorous methodology, and to identify effective psychological therapies for patients with COPD-related depression.

OBJECTIVES

To assess the effectiveness of psychological therapies for the treatment of depression in patients with chronic obstructive pulmonary disease.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2018, Issue 11), and Ovid MEDLINE, Embase and PsycINFO from June 2016 to 26 November 2018. Previously these databases were searched via the Cochrane Airways and Common Mental Disorders Groups' Specialised Trials Registers (all years to June 2016). We searched ClinicalTrials.gov, the ISRCTN registry, and the World Health Organization International Clinical Trials Registry Platform (ICTRP) to 26 November 2018 to identify unpublished or ongoing trials. Additionally, the grey literature databases and the reference lists of studies initially identified for full-text screening were also searched.

SELECTION CRITERIA

Eligible for inclusion were randomised controlled trials that compared the use of psychological therapies with either no intervention, education, or combined with a co-intervention and compared with the same co-intervention in a population of patients with COPD whose depressive symptoms were measured before or at baseline assessment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the titles and abstracts identified by the search to determine which studies satisfied the inclusion criteria. We assessed two primary outcomes: depressive symptoms and adverse events; and the following secondary outcomes: quality of life, dyspnoea, forced expiratory volume in one second (FEV₁), exercise tolerance, hospital length of stay or readmission rate, and cost-effectiveness. Potentially eligible full-text articles were also independently assessed by two review authors. A PRISMA flow diagram was prepared to demonstrate the decision process in detail. We used the Cochrane 'Risk of bias' evaluation tool to examine the risk of bias, and assessed the quality of evidence using the GRADE framework. All outcomes were continuous, therefore, we calculated the pooled standardised mean difference (SMD) or mean difference (MD) with a corresponding 95% confidence interval (CI). We used a random-effects model to calculate treatment effects.

MAIN RESULTS

The findings are based on 13 randomised controlled trials (RCTs), with a total of 1500 participants. In some of the included studies, the investigators did not recruit participants with clinically confirmed depression but applied screening criteria after randomisation. Hence, across the studies, baseline scores for depressive symptoms varied from no symptoms to severe depression. The severity of COPD across the studies was moderate to severe.Primary outcomesThere was a small effect showing the effectiveness of psychological therapies in improving depressive symptoms when compared to no intervention (SMD 0.19, 95% CI 0.05 to 0.33; P = 0.009; 6 studies, 764 participants), or to education (SMD 0.23, 95% CI 0.06 to 0.41; P = 0.010; 3 studies, 507 participants).Two studies compared psychological therapies plus a co-intervention versus the co-intervention alone (i.e. pulmonary rehabilitation (PR)). The results suggest that a psychological therapy combined with a PR programme can reduce depressive symptoms more than a PR programme alone (SMD 0.37, 95% CI -0.00 to 0.74; P = 0.05; 2 studies, 112 participants).We rated the quality of evidence as very low. Owing to the nature of psychological therapies, blinding of participants, personnel, and outcome assessment was a concern.None of the included studies measured adverse events.Secondary outcomesQuality of life was measured in four studies in the comparison with no intervention, and in three studies in the comparison with education. We found inconclusive results for improving quality of life. However, when we pooled data from two studies using the same measure, the result suggested that psychological therapy improved quality of life better than no intervention. One study measured hospital admission rates and cost-effectiveness and showed significant reductions in the intervention group compared to the education group. We rated the quality of evidence as very low for the secondary outcomes.

AUTHORS' CONCLUSIONS

The findings from this review indicate that psychological therapies (using a CBT-based approach) may be effective for treating COPD-related depression, but the evidence is limited. Depressive symptoms improved more in the intervention groups compared to: 1) no intervention (attention placebo or standard care), 2) educational interventions, and 3) a co-intervention (pulmonary rehabilitation). However, the effect sizes were small and quality of the evidence very low due to clinical heterogeneity and risk of bias. This means that more experimental studies with larger numbers of participants are needed, to confirm the potential beneficial effects of therapies with a CBT approach for COPD-related depression.New trials should also address the gap in knowledge related to limited data on adverse effects, and the secondary outcomes of quality of life, dyspnoea, forced expiratory volume in one second (FEV₁), exercise tolerance, hospital length of stay and frequency of readmissions, and cost-effectiveness. Also, new research studies need to adhere to robust methodology to produce higher quality evidence.

Five-Year follow up of Patients Treated with Inpatient Psychotherapy at the Cassel Hospital for Nervous Diseases

Twenty-eight patients who were admitted consecutively to a single-adult unit of the Cassel Hospital in 1977/8 were followed up 5 years after discharge. Those who were found to have improved at the end of treatment remained well 5 years later. These could be distinguished by their combination of neurotic psychopathology, considerable depression, superior intelligence, and lack of a chronic outpatient history. Patients who had improved 5 years after discharge did not show these characteristics, but had all spent at least 9 weeks on the waiting list and had the capacity to form close and helpful relationships. Patients who were judged to have improved were less dependent on the Health Service and their economic productivity was improved, often as a consequence of returning to education or training. Those who did not improve clinically continued to be admitted to hospital and tended to become less economically productive.

Psychodynamic psychotherapy: developing the evidence base

Psychodynamic psychotherapy has been criticised as being based on outdated principles of psychoanalysis and lacking an adequate evidence base to convincingly demonstrate its efficacy. This article summarises the recent evidence from high-quality outcome studies to show that psychodynamic psychotherapy is as effective in the treatment of a range of mental disorders as other psychological treatment modalities such as cognitive-behavioural therapy, as well as reviewing process-outcome research aiming to elucidate mechanisms of therapeutic change. A paradigm for psychodynamic psychotherapy research based on attachment theory is introduced, which may inform the development of psychodynamic therapeutic modalities tailored for specific conditions.

LEARNING OBJECTIVES

Efficacy of psychosocial interventions on psychological and physical health outcomes in chronic obstructive pulmonary disease: a systematic review and meta-analysis

BACKGROUND

Psychosocial intervention has been suggested as a potentially effective supplement to medical treatment in chronic obstructive pulmonary disease (COPD), but no reviews so far have quantified the existing research in terms of both psychological and physical health outcomes. We therefore conducted a systematic review and meta-analysis of controlled trials evaluating the effects of psychosocial interventions on psychological and physical health outcomes in COPD.

METHODS

Two independent raters screened 1,491 references for eligibility. Twenty independent studies investigating a total of 1,361 patients were included, assessed for their methodological quality, and subjected to meta-analytic evaluation.

RESULTS

After adjusting for potential publication bias, a statistically significant overall effect was found for psychological (Hedges' g = 0.38, 95% confidence interval, CI = 0.19-0.58; p < 0.001) outcomes. When analyzing individual intervention types, cognitive behavioral therapy appeared to be effective (g = 0.39, CI = 0.15-0.62; p = 0.001) for improving psychological outcomes. In contrast, for physical outcomes, only mind-body interventions (e.g. mindfulness-based therapy, yoga, and relaxation) revealed a statistically significant effect (g = 0.40; CI = 0.01-0.79; p = 0.042).

CONCLUSIONS

Taken together, the results lend support to psychosocial intervention as a tool in the management of COPD. However, due to indications of possible publication bias towards positive findings, the results should be interpreted with some caution, and more high quality research is needed.

WITHDRAWN: Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases

This review is now out of date although it is correct as of the date of publication [Issue 2, 2008]. The authors are developing a new protocol which will replace this review. Publication of the protocol is expected in 2014, and serves to update the existing review and incorporate the latest evidence into a new Cochrane Review. The latest version of this review (available in 'Other versions' tab on The Cochrane Library) may still be useful to readers until the new review is published.

In 2016, the replacement review titled 'Non‐pharmacological interventions for breathlessness in advanced stages of malignant and non‐malignant diseases' was deregistered and split into four separate reviews of individual interventions: Respiratory interventions for breathlessness in adults with advanced diseases; Physical interventions for breathlessness in adults with advanced diseases; Cognitive‐emotional interventions for breathlessness in adults with advanced diseases; Multi‐dimensional interventions for breathlessness in adults with advanced diseases.

At September 2020, these replacement titles were deregistered (Multi‐dimensional interventions) or the protocols withdrawn (Cognitive‐emotional interventions; Multi‐dimensional interventions; Respiratory interventions) as they did not meet Cochrane standards or expectations.

The editorial group responsible for this previously published document have withdrawn it from publication.

The effect of complex interventions on depression and anxiety in chronic obstructive pulmonary disease: systematic review and meta-analysis

Background

Depression and anxiety are very common in people with chronic obstructive pulmonary disease (COPD) and are associated with excess morbidity and mortality. Patients prefer non-drug treatments and clinical guidelines promote non-pharmacological interventions as first line therapy for depression and anxiety in people with long term conditions. However the comparative effectiveness of psychological and lifestyle interventions among COPD patients is not known. We assessed whether complex psychological and/or lifestyle interventions are effective in reducing symptoms of anxiety and depression in patients with COPD. We then determined what types of psychological and lifestyle interventions are most effective.

Methods and Findings

Systematic review of randomised controlled trials of psychological and/or lifestyle interventions for adults with COPD that measured symptoms of depression and/or anxiety. CENTRAL, Medline, Embase, PsychINFO, CINAHL, ISI Web of Science and Scopus were searched up to April 2012. Meta-analyses using random effects models were undertaken to estimate the average effect of interventions on depression and anxiety. Thirty independent comparisons from 29 randomised controlled trials (n = 2063) were included in the meta-analysis. Overall, psychological and/or lifestyle interventions were associated with small reductions in symptoms of depression (standardised mean difference −0.28, 95% confidence interval −0.41 to −0.14) and anxiety (standardised mean difference −0.23, 95% confidence interval −0.38 to −0.09). Multi-component exercise training was the only intervention subgroup associated with significant treatment effects for depression (standardised mean difference −0.47, 95% confidence interval −0.66 to −0.28), and for anxiety (standardised mean difference −0.45, 95% confidence interval −0.71 to −0.18).

Conclusions

Complex psychological and/or lifestyle interventions that include an exercise component significantly improve symptoms of depression and anxiety in people with COPD. Furthermore, multi-component exercise training effectively reduces symptoms of anxiety and depression in all people with COPD regardless of severity of depression or anxiety, highlighting the importance of promoting physical activity in this population.

The efficacy of psychologically based interventions to improve anxiety, depression and quality of life in COPD: a systematic review and meta-analysis

OBJECTIVE

To systematically evaluate the efficacy of psychologically based interventions for addressing psychological outcomes in patients with chronic obstructive pulmonary disease (COPD).

METHODS

Electronic databases, key journals and reference lists of included studies were scrutinised for inclusion; in addition authors were contacted for potential unpublished research. Nine studies were identified for inclusion. Data was extracted by two reviewers independently using a standardised extraction sheet and a series of meta-analyses completed for measures of anxiety, depression and quality of life.

RESULTS

Eight studies evaluated a cognitive behavioural- or psychotherapeutically based intervention and one study evaluated taped progressive muscle relaxation. The studies revealed some evidence for the interventions' impact on anxiety, but, taken together interventions had limited effectiveness. The meta-analyses that were conducted revealed a small effect for anxiety only.

CONCLUSION

The results are discussed considering the limitations of the research and previous work in this area. A systematic evaluation of psychological interventions on psychological co-morbidity in patients with COPD is recommended.

PRACTICE IMPLICATIONS

There is some evidence that psychological interventions impact anxiety and this should be explored further and more interventions should target quality of life.

Improving outcomes for COPD patients with mild-to-moderate anxiety and depression: A systematic review of cognitive behavioural therapy

PURPOSE

Anxiety and depression are highly prevalent in patients with chronic obstructive pulmonary disease (COPD) and are associated with lower levels of self-efficacy, impaired health status, poorer treatment outcomes and reduced survival following emergency admission. Cognitive behavioural therapy (CBT) may be effective for treating anxiety and depression in COPD patients but evidence for this is uncertain.

METHODS

A systematic review of controlled trials that evaluated the effectiveness of CBT for treating mild-to-moderate anxiety or depression in adults with clinically stable COPD. Ovid electronic bibliographic databases were searched from inception to May 2006; all content held by the Cochrane Library Issue 3, 2006 was also searched.

RESULTS

One small randomized controlled trial (RCT) of moderate quality showed that CBT, when given with exercise training and education, was associated with large and significant treatment effects for both anxiety (-1.39 (95% CIs -2.19, -0.59)) and depression (-0.86 (95% CIs -1.61, -0.11)). Additionally, a larger RCT of higher quality demonstrated that CBT, when given with exercise and education, was associated with large and significant treatment effects for depression (-0.76 (95% CIs -1.34, -0.17)), but not for anxiety. No other included study reported significant reductions in either anxiety or depression in COPD patients given CBT.

CONCLUSION

There is only limited evidence that CBT, when used with exercise and education, can contribute to significant reductions in anxiety and depression in COPD patients. There is scope for a well-powered RCT to evaluate the effectiveness and acceptability of CBT among this patient population.

Illness perceptions and COPD: an emerging field for COPD patient management

OBJECTIVE

Patients with chronic obstructive pulmonary disease have perceptions of their illness and its management that determine their coping behaviors (e.g., adherence, self-management) and, consequently, their outcomes. This article reviews the empirical literature on illness perceptions in patients with COPD to provide clinicians with information regarding the potential utility of incorporating illness perceptions into clinical COPD care.

METHOD

A literature search in PubMed identified 16 studies examining associations between illness perceptions and outcomes in patients with COPD.

RESULTS

Seven of the 16 papers were from US authors, followed by 3 each from the UK and The Netherlands, and one study each from Australia, Canada, and New Zealand. The first study was published in 1983, and the numbers of patients per study ranged fom 10 to 266. The illness perceptions were those delineated by two theoretical models (cognitive behavioral theory and the Common Sense Model), and they were assessed with open interviews and validated questionnaires. Outcomes were disability, quality of life, and psychological characteristics. The studies revealed clinically meaningful associations between illness perceptions and outcomes.

CONCLUSION

Our review supports the incorporation of illness perceptions into clinical care for patients with COPD. The assessment of illness perceptions should be routine, similar to routine assessments of pulmonary function. Discussing and changing illness perceptions will improve COPD patients' quality of life and reduce their levels of disability. COPD-specific assessments ("diagnosis") of illness perceptions and COPD-specific intervention methods ("therapy") that help change inadequate and maladaptive illness perceptions are research priorities.

Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases

BACKGROUND

Breathlessness is a common and distressing symptom in the advanced stages of malignant and non-malignant diseases. Appropriate management requires both pharmacological and non-pharmacological interventions.

OBJECTIVES

The primary objective was to determine the effectiveness of non-pharmacological and non-invasive interventions to relieve breathlessness in participants suffering from the five most common conditions causing breathlessness in advanced disease.

SEARCH STRATEGY

We searched the following databases: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, British Nursing Index, PsycINFO, Science Citation Index Expanded, AMED, The Cochrane Pain, Palliative and Supportive Care Trials Register, The Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effectiveness in June 2007. We also searched various websites and reference lists of relevant articles and textbooks.

SELECTION CRITERIA

We included randomised controlled and controlled clinical trials assessing the effects of non-pharmacological and non-invasive interventions to relieve breathlessness in participants described as suffering from breathlessness due to advanced stages of cancer, chronic obstructive pulmonary disease (COPD), interstitial lung disease, chronic heart failure or motor neurone disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed relevant studies for inclusion. Data extraction and quality assessment was performed by three review authors and checked by two other review authors. Meta-analysis was not attempted due to heterogeneity of studies.

MAIN RESULTS

Forty-seven studies were included (2532 participants) and categorised as follows: single component interventions with subcategories of walking aids (n = 7), distractive auditory stimuli (music) (n = 6), chest wall vibration (CWV, n = 5), acupuncture/acupressure (n = 5), relaxation (n = 4), neuro-electrical muscle stimulation (NMES, n = 3) and fan (n = 2). Multi-component interventions were categorised in to counselling and support (n = 5), breathing training (n = 3), counselling and support with breathing-relaxation training (n = 2), case management (n = 2) and psychotherapy (n = 2). There was a high strength of evidence that NMES and CWV could relieve breathlessness and moderate strength for the use of walking aids and breathing training. There is a low strength of evidence that acupuncture/acupressure is helpful. There is not enough data to judge the evidence for distractive auditory stimuli (music), relaxation, fan, counselling and support, counselling and support with breathing-relaxation training, case management and psychotherapy. Most studies have been conducted in COPD patients, only a few studies included participants with other conditions.

AUTHORS' CONCLUSIONS

Breathing training, walking aids, NMES and CWV appear to be effective non-pharmacological interventions for relieving breathlessness in advanced stages of disease.

Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines

BACKGROUND

Pulmonary rehabilitation has become a standard of care for patients with chronic lung diseases. This document provides a systematic, evidence-based review of the pulmonary rehabilitation literature that updates the 1997 guidelines published by the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation.

METHODS

The guideline panel reviewed evidence tables, which were prepared by the ACCP Clinical Research Analyst, that were based on a systematic review of published literature from 1996 to 2004. This guideline updates the previous recommendations and also examines new areas of research relevant to pulmonary rehabilitation. Recommendations were developed by consensus and rated according to the ACCP guideline grading system.

RESULTS

The new evidence strengthens the previous recommendations supporting the benefits of lower and upper extremity exercise training and improvements in dyspnea and health-related quality-of-life outcomes of pulmonary rehabilitation. Additional evidence supports improvements in health-care utilization and psychosocial outcomes. There are few additional data about survival. Some new evidence indicates that longer term rehabilitation, maintenance strategies following rehabilitation, and the incorporation of education and strength training in pulmonary rehabilitation are beneficial. Current evidence does not support the routine use of inspiratory muscle training, anabolic drugs, or nutritional supplementation in pulmonary rehabilitation. Evidence does support the use of supplemental oxygen therapy for patients with severe hypoxemia at rest or with exercise. Noninvasive ventilation may be helpful for selected patients with advanced COPD. Finally, pulmonary rehabilitation appears to benefit patients with chronic lung diseases other than COPD.

CONCLUSIONS

There is substantial new evidence that pulmonary rehabilitation is beneficial for patients with COPD and other chronic lung diseases. Several areas of research provide opportunities for future research that can advance the field and make rehabilitative treatment available to many more eligible patients in need.

Short-term psychodynamic psychotherapies for common mental disorders

BACKGROUND

Over the past 40 years, short-term psychodynamic psychotherapies (STPP) for a broad range of psychological and somatic disorders have been developed and studied. Four published meta-analyses of STPP, using different methods and samples, have found conflicting results.

OBJECTIVES

This review evaluated the efficacy of STPP relative to minimal treatment and non-treatment controls for adults with common mental disorders.

SEARCH STRATEGY

We searched CCDANCTR-Studies and CCDANCTR-References on 25/4/2005, CENTRAL, MEDLINE, CINAHL, EMBASE, PsycINFO, DARE and Biological Abstracts were also searched. We contacted triallists and checked references from papers retrieved.

SELECTION CRITERIA

All randomised controlled trials (RCT) of adults with common mental disorders, in which a brief psychodynamic therapy lasting less than 40 hours in total, and provided in individual format, were included.

DATA COLLECTION AND ANALYSIS

Three reviewers working in pairs evaluated studies. Studies were selected only if pairs of reviewers agreed they met inclusion criteria. A third reviewer was consulted if two reviewers could not reach consensus. Data were collected and entered into Review Manager. Study quality was assessed and scored by pairs of raters. Publication bias was assessed using a funnel plot. Sensitivity analyses were also conducted.

MAIN RESULTS

23 studies of 1431 randomised patients with common mental disorders were included. These studies evaluated STPP for general, somatic, anxiety, and depressive symptom reduction, as well as social adjustment. Outcomes for most categories of disorder suggested significantly greater improvement in the treatment versus the control groups, which were generally maintained in medium and long term follow-up. However, only a small number of studies contributed data for each category of disorder, there was significant heterogeneity between studies, and results were not always maintained in sensitivity analyses.

AUTHORS' CONCLUSIONS

STPP shows promise, with modest to moderate, often sustained gains for a variety of patients. However, given the limited data and heterogeneity between studies, these findings should be interpreted with caution. Furthermore, variability in treatment delivery and treatment quality may limit the reliability of estimates of effect for STPP. Larger studies of higher quality and with specific diagnoses are warranted.

Managing respiratory symptoms at the end of life

Early and clear discussion and articulation of preferences about interventions with increasing burdens and diminishing benefits is helpful in identifying the goals of care and planning management for patients who have unremitting terminal illnesses. The development of respiratory symptoms such as dyspnea, cough, and hiccups is common and can often be anticipated. Aggressive evaluation and treatment should be pursued and offered to palliate symptoms at the end of life.

The most effective psychologically-based treatments to reduce anxiety and panic in patients with chronic obstructive pulmonary disease (COPD): a systematic review

Chronic obstructive pulmonary disease (COPD) is irreversible and causes a progressive reduction in physical functioning. There is evidence that emotional distress contributes to loss of function and that improvements may be obtained via psychologically based interventions to alleviate anxiety and panic. This systematic review examined the most effective interventions to date. A literature search revealed 25 studies; these were assessed using standardised criteria for inclusion and quality. Six randomised, controlled trials fulfilled the criteria, but the variety of methods, interventions and measures prevented the use of a meta-analysis. Two studies were unpublished doctoral theses, four were published studies. All of the studies had one or more deficiencies; failure to measure or report lung function, large variation in attrition, lack of blinding in assessment of treatment outcome, lack of use of standardised anxiety measures. Description of the intervention was not always sufficient to allow replication. There were no trials of interventions aimed at reducing panic. No study was adequately designed to provide an assessment of psychological intervention aimed at anxiety in COPD. Secondary outcomes included impacts on breathlessness, disability and quality of life. It can be concluded that currently there is insufficient research of quality on which to base recommendations for effective interventions for anxiety and panic in COPD. Future research should tie the design of evaluation to interventions based on theories of the relationship between dyspnoea and anxiety.

Managing dyspnea and cough

Dyspnea, like pain, is a subjective experience that incorporates physical elements and affective components. Management of breathlessness in patients with cancer requires expertise that includes an understanding and assessment of the multidimensional components of the symptom, knowledge of the pathophysiologic mechanisms and clinical syndromes that are common in cancer, and familiarity with the indications and limitations of the available therapeutic approaches. Relief of breathlessness should be the goal of treatment at all stages of cancer. Good control of dyspnea will improve the patient's quality of life.

Complementary and alternative medicine in the management of pain, dyspnea, and nausea and vomiting near the end of life. A systematic review

To review the evidence for efficacy of complementary and alternative medicine (CAM) modalities in treating pain, dyspnea, and nausea and vomiting in patients near the end of life, original articles were evaluated following a search through MEDLINE, CancerLIT, AIDSLINE, PsycLIT, CINAHL, and Social Work Abstracts databases. Search terms included alternative medicine, palliative care, pain, dyspnea, and nausea. Two independent reviewers extracted data, including study design, subjects, sample size, age, response rate, CAM modality, and outcomes. The efficacy of a CAM modality was evaluated in 21 studies of symptomatic adult patients with incurable conditions. Of these, only 12 were directly accessed via literature searching. Eleven were randomized controlled trials, two were non-randomized controlled trials, and eight were case series. Acupuncture, transcutaneous electrical nerve stimulation, supportive group therapy, self-hypnosis, and massage therapy may provide pain relief in cancer pain or in dying patients. Relaxation/imagery can improve oral mucositis pain. Patients with severe chronic obstructive pulmonary disease may benefit from the use of acupuncture, acupressure, and muscle relaxation with breathing retraining to relieve dyspnea. Because of publication bias, trials on CAM modalities may not be found on routine literature searches. Despite the paucity of controlled trials, there are data to support the use of some CAM modalities in terminally ill patients. This review generated evidence-based recommendations and identified areas for future research.

The effects of psychological therapies under clinically representative conditions: a meta-analysis

Recently, concern has arisen that meta-analyses overestimate the effects of psychological therapies and that those therapies may not work under clinically representative conditions. This meta-analysis of 90 studies found that therapies are effective over a range of clinical representativeness. The projected effects of an ideal study of clinically representative therapy are similar to effect sizes in past meta-analyses. Effects increase with larger dose and when outcome measures are specific to treatment. Some clinically representative studies used self-selected treatment clients who were more distressed than available controls, and these quasi-experiments underestimated therapy effects. This study illustrates the joint use of fixed and random effects models, use of pretest effect sizes to study selection bias in quasi-experiments, and use of regression analysis to project results to an ideal study in the spirit of response surface modeling.

Pulmonary rehabilitation

There has been a resurgence of interest in pulmonary rehabilitation mainly because the prevalence of COPD has increased, scientific studies document consistent benefits (increased exercise endurance and reduced dyspnea), and thoracic surgeons recognize that preoperative and postoperative conditioning enhances the results of lung volume reduction surgery and lung transplantation. Although education and psychosocial/behavioral interventions are important components of a multidimensional program, exercise training of the upper and lower extremities is essential to achieve the described improvements. Current programs vary considerably in the frequency, intensity, and duration of exercise reconditioning. Two "key" questions relating to pulmonary rehabilitation are as follows. What is an appropriate training intensity? How should patients monitor the training intensity? Maintenance exercise programs and the development of home- or community-based programs will be important future developments.

Meta-analysis of the effects of psychoeducational care in adults with chronic obstructive pulmonary disease

Meta-analysis, a quantitative research review, was conducted on 65 studies of the effect of education, exercise and/or psychosocial support (hereafter called psychoeducational care) in adults with chronic obstructive pulmonary disease (COPD). Studies ranged in publication date from 1954 to 1994. Only 34% of studies had subjects that were randomly assigned to treatment condition, and only 15% of studies had a placebo-type control group. Analyses by type of treatment showed that pulmonary rehabilitation (large muscle exercise and education plus a variety of psychosocial or behavioral interventions) had statistically significant beneficial effects on psychological well-being (d+ = 0.58, n = 13), endurance (d+ = 0.77, n = 13), functional status (d+ = 0.63, n = 8), VO2 (d+ = 0.56, n = 5), dyspnea (d+ = 0.71, n = 10), and adherence (d+ = 1.76, n = 2). A statistically significant beneficial effect of pulmonary rehabilitation was not found on Forced Expiratory Volume at 1 s. Across 7 outcomes examined, treatments including education-alone had significant beneficial effect on the accuracy of performing inhaler skills (d+ = 1.27, n = 7). Based on a very small sample of studies, a non-significant but small or medium sized effect of education-alone was evident on health care utilization (d+ = 0.26, n = 3) and on adherence to treatment regimen (d+ = 0.50, n = 2). Such results are inconclusive, suggesting that further research may be indicated. Relaxation-alone had statistically significant beneficial effects on both dyspnea (d+ = 0.91, n = 3) and psychological well-being (d+ = 0.39, n = 6). The research base has methodological weaknesses that should be rectified in future research. Nonetheless, based on the best evidence available to date, identified types of psychoeducational care have been shown to improve the functioning and well-being of adults with COPD.

Emotional disorder in chronic illness: psychotherapeutic interventions

BACKGROUND

Emotional disorder associated with physical illness falls into two main groups: psychological reaction to physical illness and somatic presentation of psychological disorder Psychological treatments are becoming more widespread in the general hospital setting, but there are few systematic evaluations.

METHOD

A manual and computer (MEDLINE) literature search was performed. Studies which provided insight into clinical practice were selected for discussion, and randomised controlled trials of at least 6 weeks duration and inclusion of 30 or more subjects were selected for review.

RESULTS

Fourteen empirical studies were found: six involving patients with chronic organic disorder and eight involving patients with somatisation.

CONCLUSIONS

There is little empirical evidence that psychotherapeutic interventions are of benefit when applied indiscriminately to patients with organic disease. Further work is required to delineate subgroups of patients who may be responsive. There is mounting evidence that psychotherapy is beneficial in patients with somatisation disorders. Patients with very chronic symptoms may require intensive treatment approaches.

The St George's Respiratory Questionnaire

The St George's Respiratory Questionnaire is a standardized self-completed questionnaire for measuring impaired health and perceived well-being ('quality of life') in airways disease. It has been designed to allow comparative measurements of health between patient populations and quantify changes in health following therapy. The background and rationale for its development are discussed together with an analysis of its performance.

Dyspnea: a case for nursing diagnosis status

Dyspnea, the unpleasant subjective sensation of difficult breathing, is one of the most common symptoms experienced by patients with pulmonary and cardiac disorders. This article reviews the research concerning dyspnea and proposes it for consideration as a nursing diagnosis. The etiologies are categorized according to the neurosensory, neurochemical, cognitive, and affective mechanisms. The defining characteristics include the subjective words describing dyspnea, such as shortness of breath, suffocation, and tightness. The most supported objective sign of dyspnea in the literature is an increased use of accessory muscles of respiration. Nursing interventions for dyspnea relief are geared toward reducing the afferent activity from receptors in the respiratory muscles and dealing with the affective component of dyspnea. These interventions include pacing activities, breathing techniques, and inducing the relaxation response. Because most research for interventions to reduce dyspnea have focused on patients with obstructive lung disorders who have chronic dyspnea, recommendations for further research include using acutely ill patients and those with a variety of medical conditions.

Assessing the consequences of chronic respiratory disease: a critical review

This paper offers an overview of problems involved in assessing respiratory disablement. Health status and quality of life research have become of increasing importance but critical gaps remain, especially in relation to the multidimensional consequences of chronic obstructive airways disease (COAD). It is argued that much existing psychosocial research has been long on the 'psycho' and short on the wider social consequences and dimensions of respiratory disablement. Many general measures of quality of life and disability are not well suited to assessment of these problems. There is a need to supplement general instruments with more disease-specific measures--many for breathlessness, the most disabling symptom of COAD, have been crude and insensitive. There is also a need to augment predominantly quantitative techniques with qualitative data derived from patients' and carers' perspectives. Wider implications of disability assessment at the welfare policy level are discussed, and the paper concludes by suggesting future research areas on respiratory disablement.

'Breathtaking': the consequences of chronic respiratory disorder

Chronic obstructive airways disease (COAD) is a major, though neglected, medical and social problem in the United Kingdom today. Dyspnoea is one of the most distressing and disabling symptoms of COAD, which is itself the largest single cause of absence from work in the United Kingdom. This paper reports on 92 patients suffering from COAD, who were interviewed in order to assess impairment, disability and handicap, and a smaller subsample of 24 of these patients who were followed-up using open-ended, semi-structured, tape-recorded interviews in order to cover in more detail some of the issues raised in the first quantitative stage of the study. Low correlations were found between lung function and disability (-0.38 p less than 0.001), accounting for only 14% of the variance, and high correlations between measures of dyspnoea and disability (-0.90 p less than 0.001). Major areas of disability and handicap included: household management, ambulation, sleep and rest, recreation and pastimes, and work. Financial problems and difficulties, housing problems and problems of social isolation were also frequently reported. The paper then attempts to explore the relationship between impairment, disability and handicap, drawing on both the quantitative and qualitative data collected in order to illustrate the variable nature of this relationship. The paper concludes by suggesting both the need for a more integrated approach to the care and rehabilitation of COAD patients and their families, and for a complementary social perspective and approach to COAD and its treatment.

Bilateral carotid body resection for the relief of dyspnea in severe chronic obstructive pulmonary disease. Physiologic and clinical observations in three patients

For many patients with advanced chronic airflow limitation (COPD) the treatment of dyspnea remains inadequate despite medications, rehabilitation programs, and supplemental oxygen. Bilateral carotid body resection (BCBR) is a controversial operation which has been reported anecdotally to relieve dyspnea in such patients, but its risks and long-term effects are not known. We studied pulmonary function and the ventilatory response to exercise of three severely dyspneic COPD patients who had chosen independently and without our knowledge to undergo this operation. All three patients reported improvement in dyspnea following BCBR despite the absence of improvement in their severe airflow limitation (mean FEV1 = 0.71 L before and 0.67 L after BCBR). The three patients died 6, 18 and 36 months after the removal of their carotid bodies, still convinced of the efficacy of their surgery. Their reported relief of dyspnea was associated with substantial decreases in minute ventilation and deterioration in arterial blood gases. Arterial blood gases worsened both at rest (PO2 fell from 57 to 45 mm Hg; PCO2 rose from 45 to 57 mm Hg) and during identical steady state exercise (at peak exercise, PO2 fell from 46 to 37 mm Hg and PCO2 rose from 50 to 61 mm Hg) postoperatively. Total minute ventilation decreased postoperatively both at rest (-3.4 L/min, -25 percent) and with exercise (-9.4 L/min, -39 percent) primarily because of decreases in respiratory rate (from 21 to 16 breaths/min at rest and from 25 to 18 breaths/min with exercise), and this was associated with decreases in both oxygen uptake (-26 percent) and carbon dioxide production (-22 percent) for the same external exercise workload. Whether the reported improvement in dyspnea was due to decrease in ventilation resulting from decrease in respiratory drive, a surgical placebo effect or some other unestablished effect of removal of the carotid bodies deserves further study.

Impairment, disability and handicap in chronic respiratory illness

Chronic obstructive airways disease (COAD) is a major, though neglected, medical and social problem in the United Kingdom today. Dyspnoea is one of the most distressing and disabling symptoms of COAD, which is itself the largest single cause of absence from work in the United Kingdom. 92 patients suffering from COAD were interviewed in order to assess impairment, disability and handicap. Measures included spirometric tests of lung function; the Fletcher breathlessness grading scale, the oxygen cost diagram and a visual analogue scale of dyspnoea; the Functional Limitations Profile (FLP); and the shortened 12 item General Health Questionnaire (GHQ-12), supplemented by the 7-item GHQ sub-scales of anxiety and severe depression. Low correlations were found between lung function and disability (-0.38, P less than 0.001), accounting for only 14% of the variance, and high correlations were found to exist between measures of dyspnoea and disability (-0.90, P less than 0.001). Major areas of disability and handicap included; household management, ambulation, sleep and rest, recreation and pastimes and work. Financial problems and difficulties, housing problems and problems of social isolation were also frequently reported. The paper goes on to discuss both the need for a more integrated approach to the care and rehabilitation of COAD patients and their families and for a complementary social perspective and approach to COAD and its treatment.

Chronic respiratory illness and disability: a critical review of the psychosocial literature

The paper attempts to offer a critical review of the current psychosocial literature on chronic obstructive airways disease (COAD: emphysema, chronic obstructive bronchitis and chronic asthma) from a (medical) sociological perspective. Following a brief exposition of the clinical nature of COAD and its epidemiology the paper reviews some of the main psychosocial literature in the field. It then focuses on some of the problems concerning issues of methodology and measurement within the existing research, particularly the inadequacy of many of the 'quality of life' instruments and disability measures used; the lack of research which combines both quantitative and qualitative data; and the predominant concern with the psychological aspects of the condition to the detriment of the social dimensions involved. Using the International Classification of Impairments, Disabilities and Handicaps (ICIDH) as its conceptual scaffold, the paper then goes on to argue that a sociological perspective is both a necessary and essential complement to existing research in this area in order to achieve a fuller understanding of chronic respiratory illness/disability and its sequelae. Finally, the paper attempts to offer some possible reasons why chronic respiratory and disability has received relatively little attention from within the social sciences and concludes with some reflections and suggestions on possible future developments in research into chronic respiratory illness and disability from within the social sciences.

A study to evaluate the intervention of a nurse visiting patients with disabling chest disease in the community

This paper describes the work of two nurses visiting patients with chronic respiratory disease at home. The outcome measures suggested that there were fewer deaths in the nurses' group but failed to show any changes in quality of life. The nurses chose the nursing model devised by Roper et al. as a framework for their intervention. Initial assessment by the nurses showed the patients had a number of problems which could be grouped into physical health, knowledge, psychosocial and social. The nurses' monthly visits were used to assist the patients to plan strategies for resolving their problems. Advice was directed at helping patients promote and control their own health and measurable goals were set. Most of the patients achieved the goals set, valued the visits and said they wished them to continue. Psychosocial problems proved most difficult to solve. Patients' knowledge was demonstrated to have increased. A nursing audit found the patients had received 'excellent' quality of care. The nursing method used in this study would be appropriate for such work as it focuses attention on the individual patient and his problems. Application of this approach will require education and support for nurses.

Assessing the benefits of psychotherapy: the economic approach

Recent debate about the place of psychotherapy in the National Health Service, while emphasising the importance of economic evaluation, has concentrated almost exclusively on issues of clinical outcome. This paper argues that the debate has focussed on too narrow a definition of psychotherapy and too limited a view of the possible effects of psychotherapy, both good and bad. It reviews evidence concerning the demand and need for psychotherapy services in a number of clinical settings, and discusses the economic implications of the provision of such services. Economic studies of psychotherapy are reviewed and a conclusion drawn that it might be possible to justify the provision of psychotherapy services on economic grounds, but that considerably more research needs to be done in this area. The directions such future research might take are outlined.

"Invalidity" due to chronic bronchitis and emphysema: how real is it?

Hospital discharges and deaths attributed to chronic bronchitis and emphysema have fallen in recent years while the number of those receiving invalidity benefit for these conditions has remained constant. One hundred and fifty seven such persons were invited to take part in this study, in which the diagnosis, degree of respiratory impairment, and other factors contributing to disability were reviewed. The scope for rehabilitation was considered. One hundred subjects agreed to take part; 96 were men and 70 were over 60 years. In only 67 was the main diagnosis chronic bronchitis and emphysema. There was a bimodal distribution of functional impairment, most being severely disabled, but in 20 the FEV1 was within the normal range. Among these asthma was more common and psychological factors were important. Economic factors contributed to "invalidity," especially among those with a normal FEV1. For 32 of the 57 who had declined to take part some information was available from hospital records. The findings in this group were similar. There was little scope for rehabilitation in the group as a whole as motivation was poor. Less than half had ever seen a chest physician. Specialist assessment before invalidity benefit is claimed is probably desirable.

Psychosocial factors and the management of physical illness: a contribution to the cost-containment of medical care

Cost-containment of medical care has become of increasing importance to both medical administrators and politicians. Recently, studies have examined the impact of psychological and psychiatric treatments on medical care utilisation and hospitalisation rates and the cost-effectiveness of such treatments. These studies have demonstrated that interventions based on a consideration of psychosocial factors in physical illness are effective in reducing the morbidity, and mortality, of a wide range of illnesses and that they lead to reduced medical care utilisation and a lower rate of hospital treatment. It has also been demonstrated that holistic management based on the 'biopsychosocial' model of illness is cost-effective and that there is an overall reduction of expenditure after allowing for the cost of the psychological or psychiatric treatment. It is concluded that further development of consultation-liaison psychiatry should be encouraged to promote awareness of the influence of psychosocial factors on physical illness and their early management as both clinically important and cost-effective.