Efficacy of Different Treatment Models in COPD
Managing depression and anxiety in primary and specialty medical settings starts with an accurate diagnosis. Many COPD patients have transitory mood symptoms during respiratory exacerbations that improve spontaneously as their physical status improves. There is no evidence that these timelimited minor depressive symptoms require specific treatment. By contrast, major depression is likely to require antidepressant medication or other specific mood-focused therapy79
to improve functioning and reduce the risk of chronic depression with its long-term adverse effects on overall disability.
Evidence for antidepressant therapy in COPD is limited, with only one small, randomized, placebo-controlled trial53
of treatment in patients with major depression having been published. This study found high efficacy for nortriptyline, a tricyclic antidepressant, in improving short-term outcomes for depression, anxiety, panic attacks, cognitive function, and overall disability. A second small randomized placebo-controlled trial80
using citalopram (a selective serotonin reuptake inhibitor [SSRI] antidepressant) in lung transplant patients with self-rated depressive symptoms, rather than major depression, found no overall benefit, with small improvements seen only in the less severely affected patients.
Anxiety and panic attacks are often associated with acute respiratory exacerbations but may also be associated with the pharmacologic effects of β2
-agonists or high-dose corticosteroid therapy. If such attacks are frequent and meet specific diagnostic criteria, a panic disorder may be diagnosed (). In stable patients with severe COPD and marginal physiologic reserve, small amounts of exercise can precipitate panic attacks due to severe dyspnea sometimes accompanied by hypoxemia. This mechanism should be distinguished from panic disorders. Frequent panic attacks in COPD patients who are receiving medications as prescribed are most often related to a concurrent depressive syndrome, and treatment should be directed to both depressive and anxiety components.52
DSM-IV Criteria for Panic Disorder
As seen in other patients with depression, Yohannes and colleagues81
reported that people with COPD are reluctant to take yet another medication, and data supporting the efficacy of medication-only treatment are extremely limited.52
Psychological approaches to care have not been adequately developed or studied in clinically depressed COPD patients. Brief CBT will help decrease the sensation of dyspnea as well as symptoms of anxiety and depression. CBT is based on the assumption that individuals with emotional distress tend to interpret their life experiences in a distorted way. These distortions become “habitual errors in thinking,” for example, magnification, in which a minor insult is blown out of proportion. Over a period of time, these habitual errors in thinking become second nature, reflex, or automatic thoughts. CBT is a direct, reality-based therapy that involves educating the patient to identify this faulty thinking and correcting the thoughts to fit more closely with reality. Core concepts of CBT can be integrated into primary care interactions and can be useful adjuncts or alternatives to pharmacotherapy for depression and anxiety. In cases of severe major depression, CBT may be used to supplement the effects of antidepressant therapy.82
In one pilot study9
of CBT, a single intensive 2-h session of CBT resulted in some improvement in depressive and anxiety symptoms relative to an education-only intervention. In another study83
that compared CBT with COPD education in patients with anxiety and depressive symptoms, both treatments had a significant effect in improving quality of life and decreasing anxiety and depression (p < 0.005) over 8 weeks. These improvements were maintained during follow-up.83
The Collaborative-Care Model in COPD
The Institute of Medicine “Chasm Report” has shown that most Americans with chronic illnesses such as COPD, asthma, diabetes, or major depression are not receiving recommended care.48
Only one half of patients with major depression receive an accurate diagnosis in primary care and, of those with a diagnosis of major depression, only one third to one half receive appropriate pharmacotherapy or psychotherapy.84
In recent years, a model of care termed the collaborative-care model
has been found to be associated with marked improvements in the quality of depression care in primary care and significant improvement in depression outcomes.74
Gilbody et al85
reported in a systematic review of 37 randomized trials of collaborative care vs usual primary care that a collaborative-care model was associated with a twofold increase in adherence to antidepressant medication over a 6-month period as well as significant improvement in depressive symptoms for 2 to 5 years.
Effective collaborative care is a multimodal intervention that has at least two core components: (1) use of allied health professionals (such as nurses) or mental health professionals to support primary care providers by helping improve patient education about depression; these individuals also provide follow-up, track outcomes with a depression tool such as the PHQ-9,86
as well as track adherence to antidepressant medication; they facilitate return visits to the primary care physician for patients with persistent symptoms; and (2) consultation by a psychiatrist who provides case-load supervision to depression care managers and clinical advice and decision support to primary care physicians focusing on patients with persistent symptoms.74
In recent years, collaborative-care models have been tested in patients with comorbid major depression and significant medical illness burden. For instance, the Pathways Study74
examined the effectiveness of integrating a depression-care manager into primary care to enhance treatment of depression in patients with diabetes and major depression. The same intervention that was successful in patients with diabetes and comorbid depression was also tested in the Improving Mood–Promoting Access to Collaborative Treatment for Late Life Depression study87
that randomized 1,801 elderly patients with major depression in eight health-care systems to a depression case manager vs usual primary care. These patients had a mean of three comorbid major medical illnesses, and > 400 patients had COPD or asthma. This study87
showed that the nurse collaborative-care intervention was associated with significant improvements in quality of depression care, depressive outcomes, and physical functioning compared to usual care over a 2-year period. The enhancements found in quality of care and depression and functional outcomes associated with collaborative care were equally robust compared to usual primary care in the subgroup with COPD or asthma.
PR: an Example of a Collaborative-Care Model
PR is operationally defined as an intervention that is evidence based, multidisciplinary, and comprehensive.88
It provides an example of one type of collaborative-care model, addressing the physical disease as well as the psychological factors associated with it. It is intended for patients with chronic respiratory diseases who are symptomatic and are having decreased daily life activities, and it is designed to reduce symptoms, optimize functional status, increase participation, reduce health-care costs, and address systemic manifestations of the disease.88
Key outcomes such as exercise capacity and health-related quality of life may be accurately measured with valid, interpretable instruments.
The core components of PR comprise supervised exercise training, education, and psychological support.89
The latter presents an ideal opportunity for a collaborative-care approach between those skilled in mental health and the multidisciplinary pulmonary team. Semistructured interviews and standardized questionnaires can address quality of life, adjustment to the disease, self-efficacy, motivation, and adherence to treatment strategies.89
The high prevalence of symptoms consistent with anxiety or depression among those enrolling in PR means that such symptoms are often identified by COPD disease-specific quality of life instruments, such as the Chronic Respiratory Disease Questionnaire90
or the St. George Respiratory Questionnaire.91
The issue of separating these symptoms from a major mood or anxiety disorder requiring prompt specialist care is an important one. Case-finding questionnaires for use in primary care have been reviewed.92
Depression among patients in PR is often evident in typical symptoms such as hopelessness and pessimism, as well as in less obvious symptoms such as difficulties with concentration and increased social withdrawal.7
Symptoms of anxiety may be reflected in a variety of ways, including agitation as well as physiologic signs of arousal such as tachycardia, sweating, and dyspnea.93
Symptoms of anxiety may contribute to the patient’s reluctance to engage in exercise as well as to difficulty concentrating. Dyspnea is a symptom of both COPD and anxiety; thus, it is particularly important to address in the rehabilitation setting. Because both depression and anxiety may be manifested in physical symptoms during the course of a rehabilitation program, collaborative care is essential among all involved health-care professionals. Regular communication will ensure that patient problems are identified, evaluated, and treated.
Managing depression within the framework of PR begins with the optimization of pharmacologic therapies, both respiratory and antidepressant. The improvement in airflow associated with effective bronchodilators will improve dyspnea and exercise tolerance.94
Subsequent participation in supervised whole-body exercise training has been shown in several randomized controlled trials95–98
to improve symptoms of anxiety and depression as a consequence of training-related gains in functional capacity. Participation in a comprehensive education program will promote cognitive restructuring by dispelling common myths about COPD, such as “I am going to suffocate when I get short of breath,” and incorporate strategies of chronic disease self-management. Patients with chronic conditions can take responsibility for the day-to-day management of their condition, with the result of improving their confidence, control, and autonomy.99
By providing patients with a structured, enjoyable activity, PR appears to help patients engage in behavior that may reduce depressive symptoms. In addition, from a behavioral perspective, the exercise and respiratory therapy components of PR may be instrumental in helping to desensitize patients who are excessively sensitive to dyspnea. In the rehabilitation setting, patients learn that they can have increases in activity levels and in dyspnea without perceiving that increase in dyspnea as a medical crisis.
Exercise-based PR programs have been among the most consistently helpful interventions for minor mood symptoms in COPD.98,100–102
Griffiths and colleagues97
reported reduced symptoms of anxiety and depression following a 6-week PR program, with symptoms of depression remaining significantly reduced at 12-month follow-up. Emery and colleagues96
found reductions in symptoms of anxiety and depression following a 10-week PR intervention. However, in an observational 12-month follow-up study of the same cohort, Emery et al100
noted that participants who discontinued exercise had increases in depressive symptoms. Other observational studies71,90,91
have found similar reductions in symptoms of depression, anxiety, and emotional distress associated with PR. A study by de Godoy and de Godoy103
reported reductions in depression and anxiety only among patients who participated in education and stress management in addition to exercise training during a 12-week intervention. They found that exercise training alone did not appear to have a beneficial effect on symptoms of depression and anxiety. However, the only study104
of PR to address its effect on diagnosed major depression reported remission of depression in 39% of 63 inpatient program participants and clinically significant response in 51%. History of treatment for depression was associated with limited change in depressive symptoms, whereas social support and satisfaction with treatment were predictors of improvement. All disability domains were lower at discharge compared to baseline (p < 0.0001). Subjects with pronounced disability at baseline had the greatest improvement if their depression improved by discharge. The authors104
concluded that acute inpatient rehabilitation is followed by improvement of depressive symptoms and disability in older patients with COPD and major depression. However, while there is strong evidence that suggests PR improves exercise capacity and quality of life, the evidence for its impact on clinical anxiety and depression is less defined.
Biological mechanisms associated with exercise activity may affect depression and anxiety among patients undergoing PR. Possible mechanisms include changes in central monoamine function, enhanced hypothalamic-pituitary-adrenal axis regulation, increased release of endogenous opioids, and reduced systemic inflammation. In all likelihood, biological and behavioral mechanisms operate together to produce reductions of symptoms in the rehabilitation setting in patients with mild mood disorders.
The variable response among individuals to exercise training and the more limited response particularly in those with a history of depression treatment104
suggest a subgroup of COPD patients require specific psychological interventions beyond that offered as part of PR. Within a collaborative-care model, this approach will include access to a clinical case manager responsible for coordinating and monitoring their response to treatment, access to a psychiatrist, and access to specific mental health treatments.87
Managing depression within a collaborative-care model has been demonstrated to be effective in an older primary care population.87