New hope for COPD patients with anxiety: study
The link between anxiety and chronic obstructive pulmonary disease (COPD) has long been a treatment challenge.
Now a well-designed trial has found cognitive behavioural therapy (CBT) reduces anxiety and keeps COPD patients out of hospital.
UK researchers randomised 279 patients with COPD of varying levels of severity and concomitant anxiety to either CBT plus self-help leaflets or self-help leaflets alone.
The intervention was delivered one-to-one by respiratory nurses who had completed at least three days of training in CBT, and included components such as breathing control, relaxation, distraction to avoid triggers for panic and positive self-talk. Patients received up to six 30-minute CBT sessions, depending on their need.
In both the treatment and control groups, patients experienced improvements in anxiety at three months (as assessed by the Hospital Anxiety and Depression Anxiety Subscale). However, the change in the CBT group was superior by a clinically important difference (mean difference 1.52, 95% CI 0.49-2.54, p=0.003).
CBT was associated with fewer emergency department attendances and hospital admissions and more Quality Adjusted Life Years. It was also found to be more cost-effective than self-help leaflets alone, with the advantages sustained at 12 months.
Writing in the European Respiratory Society’s journal ERJ Open Research, the authors concluded CBT should be incorporated into routine clinical care pathways for patients with COPD.
“Training respiratory staff can lead to better recognition and treatment of breathlessness and anxiety symptoms, in patients who otherwise may not have engaged with mental health services,” they wrote.
“Begging for an intervention”
Professor Christine Jenkins, head of the Respiratory Group at the George Institute for Global Health, welcomed the study, saying it was “a well-designed trial showing good outcomes in an area begging for an intervention”.
“We are generally not good at managing anxiety in COPD, even though we know there is a strong feedback loop between anxiety and respiratory symptoms,” she said. “When a patient becomes anxious their breathing rate goes up and they can experience dynamic hyperinflation. Beta-agonists also ramp up anxiety.”
Professor Jenkins said she had seen many COPD patients for whom anxiety had played a major role in their presentation.
“I can recall patients who have been extremely breathless, but who within an hour of getting into the ED and being in the reassuring presence of health professionals, have completely calmed down such that they are very stable,” she said.
Previous studies of pharmacotherapy or cognitive behavioural therapy to treat anxiety in COPD patients had been small or inconclusive, Professor Jenkins said.
“It’s really nice to see this adequately powered randomised controlled trial showing you can train nurses to deliver CBT and it leads to patients gaining better control over their breathing so they have fewer hospital visits,” she said.
“Using CBT in this way is entirely feasible in Australia, whether it were to be delivered by respiratory nurses or clinical psychologists involved in pulmonary rehab programs.”
Removing barriers to CBT
The researchers screened 1518 COPD outpatients and found 59% had a HADS-Anxiety Subscale of eight or more, making them eligible for the study.
However, around one quarter of eligible patients (26%) declined to take part. The authors said while this was not unusual in a clinical trial setting, it was unknown whether a similar refusal rate would occur outside of trial conditions.
“Screening for comorbid anxiety symptoms in the clinic and having a nurse skilled in both respiratory and CBT management may remove stigma or other barriers to CBT, improve engagement and allow more holistic care,” they wrote.
The study found no correlation between baseline anxiety score and severity of lung function. Patients with major psychiatric problems or receiving current psychological treatment were excluded from the trial.