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

https://doi.org/10.1016/j.pec.2010.04.010Get rights and content

Abstract

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reference lists of included studies were scrutinised for inclusion; in addition authors were contacted for potential unpublished research.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.

Introduction

Chronic obstructive pulmonary disease (COPD) is a preventable respiratory condition characterised by progressive and irreversible airflow obstruction. Tobacco use has traditionally been cited as the primary risk factor for COPD [1] but a recent review of COPD in non-smokers has revealed exposure to biomass fuels may be a more significant risk factor [2]. In the UK, COPD prevalence is reported at rates between 2% and 4% with general practices reporting prevalence at levels from 0% to 7.4% [3]. More recently prevalence has been reported as high as 10.2% in Spain [4]. COPD is reported to cost the NHS £800 million per annum with a further loss of 24 million working days and 30,000 deaths per annum [5]. The disease is currently rated as the fourth leading cause of death worldwide, and is projected by the World Health Organisation (WHO) to increase to the third most likely cause of death by 2020 due to the continuation of, and increased exposure to, risk factors and the increasing age of the population [6].

In addition to disabling physical symptoms, such as breathlessness, chronic cough and sputum production, a large proportion of patients also experience psychological distress [7]. Anxiety and depression are common; a systematic review and meta-analysis reported the prevalence of clinically significant anxiety and depression as approximately 36% and 40%, respectively [8]. There is also evidence that quality of life is significantly reduced in patients with COPD [9]. These psychological outcomes appear to be linked with the physical manifestations of the disease; for example breathlessness can precipitate anxiety, and vice versa [10].

Despite the wealth of literature highlighting the problems of anxiety, depression and quality of life in COPD, medical management has focused on the physical characteristics of the disease [11]. This focus is reflected in the current treatment guidelines [1], despite evidence that patients exhibiting symptoms of psychological distress are at increased risk of relapse, re-admission and use disproportionately high levels of resources [12]. There is also evidence that COPD may be inadequately managed [13]. Less than 30% of treatment providers have been reported to follow treatment guidelines for the management of anxiety and depression in COPD [14]. Pulmonary rehabilitation is commonly accepted as effective for patients with COPD [15], [16], [17], but anxiety and depression can lead to a reduction in engagement with it [18], [19]. Further, it has been recommended that the priority in COPD treatment should be optimising quality of life as the disease process is irreversible [20]; patients with COPD have a reduced quality of life exceeding that expected by disease severity or co-morbid medical illness [21]. Interventions targeting psychological distress can be expected to result in improvements in quality of life [22].

The efficacy of psychologically based interventions to reduce anxiety and panic in patients with COPD has been reviewed [23]. Rose et al. [23] concluded that the evidence, including randomised control trials, was insufficient and not of quality to enable recommendations to be made. However, recent evaluations of cognitive behavioural and psychotherapeutic interventions have added to the evidence base in this area [24], [25]. Another recent review that focused on cognitive behavioural therapy for anxiety and depression in COPD also concluded that further research is needed to determine the efficacy of interventions for this patient group. However, this review only included four studies and did not assess quality of life [26].

The current review systematically examines the evidence concerning the efficacy of psychologically based interventions to improve anxiety, depression and quality of life in patients with COPD. It aims to ascertain the range of psychologically based interventions available for addressing anxiety, depression and quality of life in patients with COPD outside of comprehensive pulmonary rehabilitation interventions. Secondly it aims to assess the effectiveness of interventions in improving psychological outcomes for COPD patients suffering from psychological co-morbidity.

Section snippets

Search protocol and inclusion/exclusion of studies

Comprehensive searches of the following health and psychology databases were conducted to identify research studies for inclusion up to September 2009: Blackwell Synergy, Index to Theses, PsycARTICLES, PsycINFO, Web of Science, Cochrane Library and Medline. The contents lists for the preceding five years of key journals were reviewed online: Thorax, Chest, European Respiratory Journal, Journal of Patient Education & Counseling, American Journal of Respiratory Critical Care Medicine and COPD:

Participants

All nine studies utilised a clinical population of patients with a confirmed diagnosis of COPD on spirometry. Four studies included patients with moderate to severe COPD [40], [41], [42], [43] and one study included patients with mild to severe COPD [44]. The remaining four studies confirmed diagnosis with spirometry, but did not report disease severity [38], [45], [46]. The mean age of participants ranged from 66 years [44] to 71 years [38]. Five studies were conducted in the USA [38], [39],

Discussion

The literature evaluating the efficacy of psychological interventions to improve anxiety, depression and/or quality of life for patients with COPD is relatively sparse but growing. This systematic review identified nine studies for inclusion which compares favourably with Rose et al.’s review (n = 6) [23]. The study population predominantly comprised patients with moderate–severe disease and with existing morbidity of mild–moderate anxiety and/or depression. Six interventions were based on

Practice implications

The benefit of psychological interventions in the management of patients with COPD remains largely unclear with mixed results being reported from studies of varying methodological quality. There was some evidence that psychological interventions impact anxiety in patients with COPD. However, whether this improves engagement with pulmonary rehabilitation has yet to be examined. High quality research is needed in this area to establish the efficacy of psychologically based interventions and how

References (52)

  • Healthcare Commission

    Clearing the air: a national study of chronic obstructive pulmonary disease

    (2006)
  • M. Miravitlles et al.

    Prevalence of COPD in Spain: impact of undiagnosed COPD on quality of life and daily life activities

    Thorax

    (2009)
  • Chief Medical Officer. Annual Report of the Chief Medical Officer 2004 on the state of public health. Department of...
  • GOLD. Executive Summary: Global Strategy for the diagnosis, management and prevention of COPD. Online:...
  • E.J. Wagena et al.

    Are patients with COPD psychologically distressed?

    Eur Respir J

    (2005)
  • A. Yohannes et al.

    Depression and anxiety in elderly patients with chronic obstructive pulmonary disease

    Age Ageing

    (2006)
  • H.S. Wu et al.

    Effectiveness of acupressure in improving dyspnoea in chronic obstructive pulmonary disease

    J Adv Nurs

    (2004)
  • J.E. Jacobs et al.

    Management of patients with asthma and COPD: monitoring quality of life and the relationship to subsequent GP interventions

    Fam Pract

    (2001)
  • F. Karadag et al.

    Psychological distress in chronic obstructive pulmonary disease patients

    Stress Health

    (2008)
  • L. van Ede et al.

    Prevalence of depression in patients with chronic obstructive pulmonary disease: a systematic review

    Thorax

    (1999)
  • I. Peytremann-Bridevaux et al.

    Effectiveness of chronic obstructive pulmonary disease-management programs: systematic review and meta-analysis

    Am J Med

    (2008)
  • A. Burgess et al.

    Chronic obstructive pulmonary disease: assessing and treating psychological issues in patients with COPD

    Geriatrics

    (2005)
  • Y. Lacasse et al.

    Pulmonary rehabilitation for chronic obstructive pulmonary disease (review)

    Cochrane Database Syst Rev

    (2006)
  • G.F. Salman et al.

    Rehabilitation for patients with chronic obstructive pulmonary disease: meta-analysis of randomized controlled trials

    J Gen Internal Med

    (2003)
  • A.M.M. Schoo

    A literature review of rehabilitative intervention for chronic obstructive pulmonary disease patients

    Aust Health Rev

    (1997)
  • P. Coventry et al.

    Comprehensive pulmonary rehabilitation for anxiety and depression in adults with chronic obstructive pulmonary disease: a systematic review and meta-analysis

    J Psychosom Res

    (2007)
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