The effectiveness of a group cognitive-behavioural breathlessness intervention on health status, mood and hospital admissions in elderly patients with chronic obstructive pulmonary disease

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.

Associations of Vitamin D, chronic obstructive pulmonary disease and acute exacerbations of COPD with anxiety and depression: a nested case control study

Background: Lower vitamin D levels have not only been associated with chronic obstructive pulmonary disease (COPD), exacerbations and lower lung functions, but also with anxiety and depression. We examined the associations of severity of anxiety and depression using HAM-A (Hamilton Anxiety Rating Scale) and HAM-D (Hamilton Depression Rating Scale) scores with COPD and vitamin D levels. Methods: Observational nested case control study was conducted in MUDHRA cohort. One hundred COPD subjects and 100 age- gender- matched non-COPD subjects (controls) underwent evaluation of socioeconomic status, respiratory symptoms, spirometry, severity of anxiety and depression, six minute walk test and estimation of serum vitamin D levels. Independent association of low vitamin D levels with severity of anxiety and depression was assessed by logistic regression. Results: COPD group had higher mean±SD anxiety and depression scores (HAM-A 8.0±3.5, HAM-D 8.72±4) compared to control group (HAM-A 4.51±2.2, HAM-D 4.3±2). The COPD group had 53 subjects with mild/moderate anxiety/depression whereas control group had 16 subjects with mild/moderate anxiety/depression. In COPD group, subjects with mild/moderate anxiety/depression had lower vitamin D levels compared to subjects with no/minimal anxiety/depression, while the difference in control group was not significant. In logistic regression, anxiety and depression levels had independent association with vitamin D levels, lung function variables, six-minute walk distance and presence of COPD. In COPD subgroup, anxiety and depression levels had independent association with breathlessness, GOLD FEV1 staging, CAT score, SGRQ-C Symptom score and exacerbation of COPD. Conclusions: Greater proportion of COPD subjects suffer from anxiety and depression as compared to subjects without COPD. Severity of anxiety and depression was greater in COPD subjects. Poorer lung functions, higher respiratory symptoms and lower vitamin D levels are associated with higher levels of anxiety and depression in COPD subjects.  There is an urgent need to recognise anxiety and depression in COPD patients.

The Role of Palliative Care in COPD

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States and is a serious respiratory illness characterized by years of progressively debilitating breathlessness, high prevalence of associated depression and anxiety, frequent hospitalizations, and diminished wellbeing. Despite the potential to confer significant quality of life benefits for patients and their care partners and to improve end-of-life care, specialist palliative care is rarely implemented in COPD and when initiated it often occurs only at the very end of life. Primary palliative care delivered by frontline clinicians is a feasible model, but is not routinely integrated in COPD. In this review, we discuss the following: 1) the role of specialist and primary palliative care for patients with COPD and the case for earlier integration into routine practice; 2) the domains of the National Consensus Project Guidelines for Quality Palliative Care applied to people living with COPD and their care partners; and, 3) triggers for initiating palliative care and practical ways to implement palliative care using case-based examples. In the end, this review solidifies that palliative care is much more than hospice and end-of-life care and demonstrates that early palliative care is appropriate at any point during the COPD trajectory. We emphasize that palliative care should be integrated long before the end of life to provide comprehensive support for patients and their care partners and to better prepare them for the end of life.

What factors influence healthcare professionals to refer children and families to paediatric psychology?

OBJECTIVES

This study aimed to investigate factors influencing referral of children with physical illness to paediatric psychology. Due to high rates of mental health problems within this population, studies have shown that referral to paediatric psychology should be increased. However, few studies have examined factors shaping healthcare professionals' referral behaviour.

METHODS

This study used the theory of planned behaviour to develop a questionnaire which explores factors influencing the referral of children and families to paediatric psychology. Psychometric properties of the questionnaire were examined.

RESULTS

The questionnaire was found to have good reliability and validity. The main constructs of the theory of planned behaviour were useful in predicting intention to refer to paediatric psychology. Specific beliefs about referral were shown to influence intention to refer.

CONCLUSION

Findings suggest that individual attitudes and beliefs can impact healthcare professionals' referral behaviour, indicating that multidisciplinary interventions and inter-professional education relating to the psychological aspects of illness are required.

Cognitive Behavioral Therapy for People with Chronic Obstructive Pulmonary Disease: Rapid Review

Cognitive behavioral therapy (CBT) is increasingly recommended in the management of people living with chronic obstructive pulmonary disease (COPD). This rapid review presents the evidence base for CBT for people with COPD and describes 1) the nature of CBT interventions and comparators in controlled trials (high or low resource intensity); and 2) factors influencing intervention effects on health outcomes (anxiety, depression, breathlessness, quality of life and exercise capacity). Primary studies reporting CBT interventions in adults with COPD were identified with data extracted by a single reviewer (20% of studies checked for data accuracy). Studies were synthesized descriptively with meta-analyses (random effects models) of controlled trials undertaken to report mean standardized effect sizes (95% CI) for health outcomes. Random effects meta-regression models explored whether CBT target, intervention dosage, intensity, facilitator profession, delivery mode, clinically significant anxiety/depression, trial design/quality and sample size predicted effect size. The search identified 33 primary studies published between 1996 and 2019 (controlled trials n=24, single group cohort n=6, case exemplars n=2, phenomenological n=1). Controlled trials frequently compared high-intensity CBT interventions against enhanced/usual care (n=12) or high-intensity CBT interventions against high-intensity comparators (n=11). When all controlled studies were included, small, significant improvements favoring CBT were evident across all health outcomes (SMD ranged from -0.27 to 0.35, p<0.05). When intensity dyads were considered, significant improvements were evident only when high-intensity CBT interventions were compared to enhanced usual care/usual care (SMDs ranged from -0.45 to 0.54, p <0.05). No other variable consistently predicted intervention effect sizes across all health outcomes. Overall, the evidence base supports the use of CBT for a range of health outcomes in people with COPD. Consistent benefits were evident when high-resource-intensive CBT interventions were compared to usual care. Low-resource-intensity CBT warrants further investigation in settings where cost of comprehensive care is prohibitive.

Tailored, psychological intervention for anxiety or depression in people with chronic obstructive pulmonary disease (COPD), TANDEM (Tailored intervention for ANxiety and DEpression Management in COPD): protocol for a randomised controlled trial

BACKGROUND

People with chronic obstructive pulmonary disease (COPD) are at increased risk of depression and anxiety, which greatly reduces their quality of life and is associated with worse outcomes; but these psychological co-morbidities are under-recognised and undertreated in COPD patients. Pulmonary rehabilitation (PR) improves mood for up to 6 months but health practitioners under-refer, and patients commonly fail to attend/complete PR. Research suggests that complex non-pharmacological interventions, including both psychological and exercise components, may reduce anxiety and depression in COPD. We have developed a tailored, cognitive behavioural approach (CBA) intervention for patients with COPD and co-morbid anxiety and/or depression ('TANDEM'), which precedes and optimises the benefits of currently offered PR. We hypothesise that such a psychological intervention, delivered by supervised, trained respiratory healthcare professionals, will improve mood in patients with mild to moderate anxiety and/or depression and encourage uptake and completion of PR.

METHODS

We will conduct a multi-centre, pragmatic, randomised controlled trial of the TANDEM intervention compared to usual care across the Midlands, London, the South East and Bristol, UK. We will train healthcare professionals familiar with COPD to deliver the manualised, tailored, face-to-face, one-to-one intervention weekly for 6-8 weeks. We will recruit 430 participants from primary, community and secondary care with confirmed COPD and moderate to very severe airflow limitation, who are eligible for assessment for PR, and who screen positive for symptoms of mild/moderate depression and/or anxiety using the Hospital Anxiety and Depression scale (HADS). Participants will be randomised 1.25:1 (intervention: usual care). The co-primary outcomes are the HADS anxiety and depression subscale scores at 6 months; participants will be followed up to 12 months. Secondary outcomes include uptake and completion of PR and healthcare resource use. There will be a parallel process evaluation and a health economic evaluation.

DISCUSSION

The TANDEM intervention has the potential to optimise the unrealised synergy between a psychological intervention and PR. The CBA sessions will precede PR and target individuals' cognitions, behaviours and symptoms associated with anxiety and depression to decrease psychological morbidity and increase effective self-management amongst patients with COPD.

TRIAL REGISTRATION

ISRCTN, ID: ISRCTN59537391. Registered on 20 March 2017. Protocol version 6.0, 22 April 2018.

Unmet Needs and Pro-health Behavior in Patients with Chronic Respiratory Diseases

Coordinated healthcare paradigm addressing the biopsychosocial spheres of patients seems advantageous for the management of chronic diseases. The purpose of the study was to determine the influence of unmet needs on pro-health behavior in chronic respiratory diseases and to recognize the factors that help identify the unmet needs. The patients were asked to complete the Camberwell Assessment of Needs Inventory and the Health Behavior Inventory. The study group consisted of 171 adult patients with chronic respiratory diseases. The study participants were recruited from among the patients of 130 general practitioners between July 2011 and March 2016. The findings of this study indicate that any prevention program should focus on increasing the level of satisfied needs in patients with chronic respiratory diseases. For the most effective treatment, fragmented and disease-focused processes should be replaced by integrated health and social care. We conclude that the treatment process that involves interdisciplinary clinical approach, which, aside from the physical treatment, could recognize and address the psychological aspects of unmet needs would be conducive to undertake pro-health behavior by pulmonary patients.

Assessing carer needs in chronic obstructive pulmonary disease

Informal carers play a key role in supporting patients with chronic obstructive pulmonary disease (COPD), particularly when disease is advanced. They also enable delivery of healthcare professional advice. There is a well-established impact of the caring role on carers in both the generic and COPD-specific literature. The needs of carers of patients with COPD are both generic to the caring role and disease specific. Healthcare professionals and health systems supporting patients with COPD need to actively identify and support carers. Carer assessment enables unmet needs to be identified and appropriately addressed. Assessments should consider carers' support needs, their caring capacity and practices, and carers own clinical needs. This narrative review outlines considerations for the assessment process including what should be assessed, who should conduct assessment and what should happen as a result of assessment.

Interventions to Support Integrated Psychological Care and Holistic Health Outcomes in Paediatrics

There are strong calls from many national and international bodies for there to be a 'holistic' and integrated approach to the understanding and management of psychological and physical health needs. Such holistic approaches are characterized by the treatment of the whole person, taking into account mental and social factors, rather than just the symptoms of a disease. Holistic approaches can impact on mental and physical health and are cost-effective. Several psychological interventions have demonstrated efficacy in improving holistic health outcomes, for example Cognitive Behaviour Therapy, Behavioural Therapies and Problem Solving Therapies. They have shown to impact upon a wide range of outcomes, including psychological distress, pain, physical health, medication adherence, and family outcomes. There is increasing recognition that the holistic goals of the child and family should be prioritised, and that interventions and outcomes should reflect these goals. A focus on holistic goals in therapy can be achieved through a combination of personalised goal-based outcomes in addition to symptom-based measures.

Developing and evaluating psychological provision in the acute hospital setting for patients with chronic respiratory disease

Physical health outcomes for patients with long-term conditions can be significantly affected by their psychological wellbeing; those experiencing psychological difficulties are less able to manage symptoms, have a poorer quality of life, and more frequent hospital admissions. National guidance recommends the assessment and treatment of psychological difficulties secondary to respiratory disease, but implementation of this across services is inconsistent. Here, we describe the process and findings of a 9-month study integrating psychological assessment and intervention into an acute respiratory department. The aim of this provision was to provide appropriate interventions for both in-patients and out-patients with identified psychological needs, and to evaluate the impact of these across a range of outcome domains. Psychological assessment and intervention was flexibly implemented as clinically appropriate within the context of the wider multidisciplinary team. Hospital admissions data were collated, and feedback obtained from both patients and staff. Results highlighted that psychological provision was well received by both patients and staff, and was associated with improved patient experiences and a greater focus on holistic care. Of the 73 patients receiving psychology input with at least 1 month of follow-up data, 75% showed a reduction in their admission frequency following intervention. The estimated savings to the wider NHS exceeded the costs of providing psychology input. In light of existing literature, national guidance, and the present findings, we highlight the need for those commissioning and managing respiratory services to consider the various potential benefits of integrating psychological provision for a patient group with high levels of psychological need.

The impact of telephone-delivered cognitive behaviour therapy and befriending on mood disorders in people with chronic obstructive pulmonary disease: A randomized controlled trial

OBJECTIVES

The main objectives of this pragmatic randomized controlled trial were to investigate the impact of cognitive behaviour therapy (CBT) and an active social control (befriending) on depression and anxiety symptoms in people with chronic obstructive pulmonary disease (COPD).

METHODS

Eligible participants were randomly allocated to receive eight weekly telephone interventions of CBT (n = 54) or befriending (n = 56). Repeated-measures ANOVA was used to assess changes in scores and Cohen's d was used to assess effect sizes.

RESULTS

Significant improvement was observed in anxiety symptoms for the befriending group from baseline (T1) to post-intervention assessment (T2) and to 8-week follow-up assessment (T3), with a small to medium effect size (Cohen's d = 0.3). Significant improvement was noted in depression symptoms from T1 to T2 for both groups, but only the CBT group had a significant difference at T3, with a small to medium effect size (Cohen's d = 0.4). For secondary outcomes, there was a significant change in COPD symptoms from T1 to T2 for the befriending group; however, at T3 this change was no longer significant. Finally, there was a significant change in general self-efficacy for both groups between T1 and T2, and T1 and T3.

CONCLUSION

Cognitive behaviour therapy reduced depression symptoms but not anxiety. Befriending reduced depression symptoms in the short term and anxiety symptoms in both the short term and long term. Further research is needed to demonstrate non-inferiority of telephone delivery compared with other formats, and to understand the impact of befriending which has the potential to be a cost-effective support for people with COPD. Statement of contribution What is already known on this subject? Depression and anxiety are common comorbidities in people with chronic obstructive pulmonary disease. Mood disorders are not commonly routinely treated in people with chronic obstructive pulmonary disease. Telephone-administered CBT has been shown to be as effective as face-to-face CBT in reducing depression and anxiety. What does this study add? Telephone-administered CBT can reduce depression symptoms in people with COPD. Telephone-administered befriending can reduce anxiety and depression symptoms in people with COPD. People with COPD who have mood disorders would prefer to have CBT than befriending.

Managing respiratory disease

The diverse and evolving role of a psychologist within a respiratory multidisciplinary team (MDT) is described, providing a working model for service provision. The rationale for appointing a psychologist within a respiratory MDT is presented first, citing relevant policy and research and outlining the wider psychosocial impact of respiratory disease. This is followed by an insight into the psychologist's role by highlighting important areas, including key therapy themes and the challenge of patient engagement. The way in which the psychologist supports the collective aims and aspirations of respiratory colleagues to provide a more holistic package of care is illustrated throughout.

Six key topics informal carers of patients with breathlessness in advanced disease want to learn about and why: MRC phase I study to inform an educational intervention

INTRODUCTION

Breathlessness is a common symptom of advanced disease placing a huge burden on patients, health systems and informal carers (families and friends providing daily help and support). It causes distress and isolation. Carers provide complex personal, practical and emotional support yet often feel ill-prepared to care. They lack knowledge and confidence in their caring role. The need to educate carers and families about breathlessness is established, yet we lack robustly developed carer-targeted educational interventions to meet their needs.

METHODS

We conducted a qualitative interview study with twenty five purposively-sampled patient-carer dyads living with breathlessness in advanced disease (half living with advanced cancer and half with advanced chronic obstructive pulmonary disease (COPD). We sought to identify carers' educational needs (including what they wanted to learn about) and explore differences by diagnostic group in order to inform an educational intervention for carers of patients with breathlessness in advanced disease.

RESULTS

There was a strong desire among carers for an educational intervention on breathlessness. Six key topics emerged as salient for them: 1) understanding breathlessness, 2) managing anxiety, panic and breathlessness, 3) managing infections, 4) keeping active, 5) living positively and 6) knowing what to expect in the future. A cross-cutting theme was relationship management: there were tensions within dyads resulting from mismatched expectations related to most topics. Carers felt that knowledge-gains would not only help them to support the patient better, but also help them to manage their own frustrations, anxieties, and quality of life. Different drivers for education need were identified by diagnostic group, possibly related to differences in caring role duration and resulting impacts.

CONCLUSION

Meeting the educational needs of carers requires robustly developed and evaluated interventions. This study provides the evidence-base for the content of an educational intervention for carers of patients with breathlessness in advanced disease.

Management of chronic obstructive pulmonary disease beyond the lungs

Chronic obstructive pulmonary disease (COPD) is an umbrella term that covers many clinical subtypes with clearly different pulmonary and extra-pulmonary characteristics, but with persistent airflow limitation in common. This insight has led to the development of a more personalised approach in bronchodilator therapy, prevention of exacerbations, and advanced treatments (such as non-invasive ventilation and lung volume reduction techniques). However, systemic manifestations and comorbidities of COPD also contribute to different clinical phenotypes and warrant an individualised approach as part of integrated disease management. Alterations in bodyweight and composition, from cachexia to obesity, demand specific management. Psychological symptoms are highly prevalent, and thorough diagnosis and treatment are necessary. Moreover, prevention of exacerbations requires interventions beyond the lungs, including treatment of gastro-oesophageal reflux disease, reduction of cardiovascular risks, and management of dyspnoea and anxiety. In this Review, we discuss the management of COPD beyond the respiratory system and propose treatment strategies on the basis of the latest research and best practices.

Understanding fear and anxiety in patients at the time of an exacerbation of chronic obstructive pulmonary disease: a qualitative study

OBJECTIVES

To determine the importance of fear and anxiety at the time of an exacerbation of chronic obstructive pulmonary disease. To assess the influence of carers and health professionals on this fear and anxiety.

DESIGN

A qualitative study to elicit the views of patients and their carers during a hospital admission for exacerbations of chronic obstructive pulmonary disease.

SETTING

Interviews were conducted in a District General Hospital.

PARTICIPANTS

Twenty patients were interviewed shortly after admission to hospital with an exacerbation.

MAIN OUTCOME MEASURES

Key themes were identified using cross-sectional thematic analysis of transcripts where commonalities and differences were identified.

RESULTS

Four themes emerged: panic and fear; anxiety management techniques used during an exacerbation; intervention from family members and carers; response to medical services.

CONCLUSION

Panic and fear are important emotions prior to admission. Many patients recognised the link between panic-fear and a worsening of symptoms, and some were able to use self-management techniques to reduce their panic-fear. Some relatives were seen as helping and others exacerbating the symptoms of panic-fear. The emergency services were seen as positive: providing reassurance and a sense of safety. How best to help patients with chronic obstructive pulmonary disease manage panic and fear remains a challenge.

Sustainable psychiatry in the UK

Demands on our mental health services are growing as financial pressures increase. In addition, there are regular changes to service design and commissioning. The current political mantra is 'more and more, of better quality, for less and less, please'. We suggest that mental health services need to actively respond to these constraints and that clinical transformation is needed to move towards a more sustainable system of healthcare. Emphasis on prevention, patient empowerment and leaner, greener services is required alongside more extensive use of technologies. Focusing on these areas will make mental health services more responsive to the challenges we face and serve to future-proof psychiatry in the UK. Services need to be delivered to provide maximum benefit to the health of our patients, but also to our society and the environment.

Overview of the prevalence, impact, and management of depression and anxiety in chronic obstructive pulmonary disease

More than one third of individuals with chronic obstructive pulmonary disease (COPD) experience comorbid symptoms of depression and anxiety. This review aims to provide an overview of the burden of depression and anxiety in those with COPD and to outline the contemporary advances and challenges in the management of depression and anxiety in COPD. Symptoms of depression and anxiety in COPD lead to worse health outcomes, including impaired health-related quality of life and increased mortality risk. Depression and anxiety also increase health care utilization rates and costs. Although the quality of the data varies considerably, the cumulative evidence shows that complex interventions consisting of pulmonary rehabilitation interventions with or without psychological components improve symptoms of depression and anxiety in COPD. Cognitive behavioral therapy is also an effective intervention for managing depression in COPD, but treatment effects are small. Cognitive behavioral therapy could potentially lead to greater benefits in depression and anxiety in people with COPD if embedded in multidisciplinary collaborative care frameworks, but this hypothesis has not yet been empirically assessed. Mindfulness-based treatments are an alternative option for the management of depression and anxiety in people with long-term conditions, but their efficacy is unproven in COPD. Beyond pulmonary rehabilitation, the evidence about optimal approaches for managing depression and anxiety in COPD remains unclear and largely speculative. Future research to evaluate the effectiveness of novel and integrated care approaches for the management of depression and anxiety in COPD is warranted.

Exercise training combined with psychological interventions for people with chronic obstructive pulmonary disease

Previous systematic reviews have confirmed the benefits of both exercise training and psychological interventions in people with chronic obstructive pulmonary disease (COPD). The objective of this systematic review was to examine the effect of interventions which combine exercise training and psychological interventions for a range of health outcomes in people with COPD. Database searches identified randomized controlled trials of people with COPD participating in interventions that combined exercise training with a psychological strategy compared with control (usual care, waiting list) or active comparators (education, exercise, psychological interventions alone). Health outcomes included dyspnoea, anxiety, depression, quality of life or functional exercise capacity. Standardized mean differences (SMD) were calculated for each intervention arm/control comparison. Across the 12 included studies (738 participants), compared with control conditions, SMD consistently favoured interventions which included both exercise + psychological components (SMD range dyspnoea -1.63 to -0.25; anxiety -0.50 to -0.20; depression -0.46 to -0.18; quality of life 0.09 to 1.16; functional exercise capacity 0.22 to 1.23). When compared with active comparators, SMD consistently favoured interventions that included exercise training + psychological component for dyspnoea (SMD range -0.35 to -0.97), anxiety (SMD range -0.13 to -1.00) and exercise capacity (SMD range 0.64 to 0.71) but were inconsistent for depression (-0.11 to 1.27) and quality of life (0.02 to -2.00). The magnitude of effect for most interventions was greater than the minimum required for clinical significance (i.e. > 0.32) in behavioural medicine. While interventions, outcomes and effect sizes differed substantially between studies, combining exercise training with a psychological intervention may provide a means of optimizing rehabilitation in people with COPD.

'The COPD breathlessness manual': a randomised controlled trial to test a cognitive-behavioural manual versus information booklets on health service use, mood and health status, in patients with chronic obstructive pulmonary disease

Background:

Chronic obstructive pulmonary disease (COPD) is a costly long-term condition associated with frequent Accident and Emergency (A&E) and hospital admissions. Psychological difficulties and inadequate self-management can amplify this picture.

Aims:

To compare a cognitive-behavioural manual versus information booklets (IB) on health service use, mood and health status.

Methods:

Two hundred and twenty-two COPD patients were randomly allocated to receive either the COPD breathlessness manual (CM) or IB. They were instructed to work through their programme at home, over 5 weeks. Guidance from a facilitator was provided at an initial home visit plus two telephone call follow-ups.

Results:

After 12 months, total A&E visits had reduced by 42% in the CM group, compared with a 16% rise in the IB group. The odds of people in the IB group attending A&E 12 months post-intervention was 1.9 times higher than for the CM group (CI 1.05–3.53). Reduction in hospital admissions and bed days were greatest in the CM group. At 6 months, there were significantly greater improvements in anxiety (F (2,198)=5.612, P=0.004), depression (F (1.8,176.1)=10.697, P⩽0.001) and dyspnoea (F (2,198)=18.170, P⩽0.001) in the CM group. Estimated savings at 12 months were greatest in the CM group, amounting to £30k or £270 per participant.

Conclusion:

The COPD manual, which addresses physical and mental health, is a straightforward cost-effective intervention that is worth offering to COPD patients within primary or secondary care.

Breathlessness--current and emerging mechanisms, measurement and management: a discussion from an European Association of Palliative Care workshop

BACKGROUND

A pre-conference workshop at the 2012 European Association of Palliative Care meeting discussed the current scientific and clinical aspects of breathlessness.

AIM

To describe a current overview of clinically relevant science in breathlessness.

DESIGN

A collation of workshop presentations and discussions.

DATA SOURCES

Narrative review.

RESULTS

The mismatch between the drive to breathe and the ability to breathe underlies the major theories of breathlessness unifying central processing of peripheral inputs including more recent recognition of the importance of peripheral muscles in mediating efferent inputs, supporting reduction of breathlessness with muscle conditioning. Key questions are whether there is a 'final common pathway' for breathlessness? Are the central nervous system targets for reducing breathlessness identical irrespective of underlying aetiology? Central nervous system functional imaging confirms an ability to differentiate severity (intensity) from affective components (unpleasantness). Breathlessness generates suffering across the community for patients and their caregivers often for long periods. The exertional nature of breathlessness means that reduction rather than elimination of the symptom is the therapeutic goal. No single intervention is likely to relieve chronic refractory breathlessness, but interventions made up of several components may provide incremental relief. Having optimally treated any underlying reversible components, the resultant chronic refractory breathlessness can be treated with pharmacological, psychological and physical therapies to reduce the sensation and its impacts.

CONCLUSION

Ensuring optimal delivery of interventions for breathlessness, whose design is underpinned by improving the understanding in the aetiology and maintenance of breathlessness, is the subject of ongoing controlled clinical trials.

Effectiveness of cognitive behavioural therapy (CBT) interventions for anxiety in patients with chronic obstructive pulmonary disease (COPD) undertaken by respiratory nurses: the COPD CBT CARE study: (ISRCTN55206395)

Background

Anxiety and depression are common co-morbidities in patients with chronic obstructive pulmonary disease (COPD). Serious implications can result from psychological difficulties in COPD including reduced survival, lower quality of life, and reduced physical and social functioning, increased use of health care resources and are associated with unhealthy behaviours such as smoking. Cognitive behavioural therapy (CBT) is a psychological intervention which is recommended for the treatment of many mental health problems including anxiety and depression. Unfortunately access to trained CBT therapists is limited. The aim of this study is to test the hypothesis that CBT delivered by respiratory nurses is effective in the COPD population. In this paper the design of the Newcastle Chronic Obstructive Pulmonary Disease Cognitive Behavioural Therapy Study (Newcastle COPD CBT Care Study) is described.

Methods/Design

This is a prospective open randomised controlled trial comparing CBT with self-help leaflets. The primary outcome measure is the Hospital Anxiety & Depression Scale (HADS) – anxiety subscale. Secondary outcome measures include disease specific quality of life COPD Assessment Tool (CAT), generic quality of life (EQ5D) and HADS-depression subscale. Patients will be followed up at three, six and 12 months following randomisation.

Discussion

This is the first randomised controlled trial to evaluate the use of cognitive behavioural therapy undertaken by respiratory nurses. Recruitment has commenced and should be complete by February 2014.

Trial registration

Current Controlled Trials, ISRCTN55206395

COPD and associated comorbidities: a review of current diagnosis and treatment

Health care utilization and costs associated with chronic obstructive pulmonary disease (COPD) continue to increase, notwithstanding evidence-based management strategies described by major respiratory societies. Cardiovascular diseases, asthma, diabetes and its precursors (obesity and metabolic syndrome), depression, cognitive impairment, and osteoporosis are examples of common comorbidities that can affect or be affected by COPD. Appropriate diagnosis and management (from a pharmacologic and nonpharmacologic perspective) of COPD and its associated comorbidities are important to ensure optimal patient care. An evolving understanding of COPD as a multimorbid disease that affects an aging population, rather than just a lung-specific disease, necessitates an integrated, tailored disease-management approach to improve prognoses and reduce costs.

Caring for the older person with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD), a common disease in elderly patients, is characterized by high symptom burden, health care utilization, mortality, and unmet needs of patients and caregivers. Respiratory failure and dyspnea may be exacerbated by heart failure, pulmonary embolism, and anxiety; by medication effects; and by other conditions, including deconditioning and malnutrition. Randomized controlled trials, which provide the strongest evidence for guideline recommendations, may underestimate the risk of adverse effects of interventions for older patients with COPD. The focus of guidelines on disease-modifying therapies may not address the full spectrum of patient and caregiver needs, particularly the high rates of bothersome symptoms, risk of functional and cognitive decline, and need for end-of-life care planning. Meeting the many needs of older patients with COPD and their families requires that clinicians supplement guideline-recommended care with treatment decision making that takes into account older persons' comorbid conditions, recognizes the trade-offs engendered by the increased risk of adverse events, focuses on symptom relief and function, and prepares patients and their loved ones for further declines in the patient's health and their end-of-life care. A case of COPD in an 81-year-old man hospitalized with severe dyspnea and respiratory failure highlights both the challenges in managing COPD in the elderly and the limitations in applying guidelines to geriatric patients.

Palliative and end-of-life care for patients with idiopathic pulmonary fibrosis: challenges and dilemmas

Idiopathic pulmonary fibrosis (IPF) is a progressive, life-threatening interstitial lung disease of unknown aetiology and with limited proven treatment options. As it is predominantly a disease of older age, a growing elderly population will increase its incidence. IPF has a poor prognosis, with a median survival of 3-5 years after diagnosis and a 5-year survival rate of 10-15%. Patients may suffer gradual decline but acute and unpredictable episodes of respiratory failure may result in death. Further research is needed to ascertain the worth of potential prognostic indicators such as age, respiratory hospitalisations, percentage of predicted forced vital capacity (FVC), and 24-week change in FVC. Integration of palliative care principles into IPF treatment is essential, including advance care planning, relief of physical and psychological burden, and patient and carer education. It is unknown whether pulmonary rehabilitation is of benefit but it may improve fatigue and functional capacity.