Description of the PR programs
Most programs ran as stand-alone services belonging to a larger health organization. All clinics had a multidisciplinary team attending to the patients at various stages throughout the program. However, the physiotherapist and allied health staff were mainly responsible for onsite running of the program. Although the overall rehabilitation program resulted from multidisciplinary contributions, the physiotherapist usually worked alone in providing the exercise component. The numbers of patients attending each program varied from five to 15 (average n = 8), depending on client compliance and attendance since initial assessment to enter the program. Most (n = 12) PR programs were run on an ongoing (continuous) basis, whereas six clinics ran intermittent programs (one to four programs per year). Program sessions varied from once weekly for 8–12 weeks to twice weekly for 6–10 weeks.
On average, patients attended twelve program sessions based on a twice-weekly, 6-week program cycle.
Components of the programs
All programs (100%, n = 22) included an exercise component and an education component, and most, but not all, clinics included psychosocial or psychological support to varying degrees.
shows the amount of psychological and psychosocial support offered in the clinics. Over one-third of clinics (36%) did not offer any psychological support to patients. The remainder, 23% (n = 5) offered formal psychological support from specialist staff, and the majority (63%) offered informal psychological support.
Types of psychological support offered in a sample of pulmonary rehabilitation clinics (categories are not mutually exclusive)
Ten clinics referred their patients to patient support groups, and eight clinics had no links to any patient support groups. Although there was a general preference by coordinators to establish support groups, factors such as varied literacy levels of patients, diverse ethnicities, and poor patient compliance acted as barriers hindering this type of support being available.
Use of depression and anxiety guidelines/screening tools/referral pathways
When clinic coordinators were asked about guidelines for management of mood in their patients, 32% (seven of 22) were not aware of COPD-X guidelines on assessment, treatment, or management of mood disorders. The majority of coordinators, however, were aware of these guidelines and found them to be either useful or very useful in terms of applicability to the rehabilitation program. Twenty-three percent of coordinators found the guidelines to be very useful in forming the framework/structure of the rehabilitation program and how the rehabilitation program operates broadly. One coordinator, in particular, stated that the recent update of these guidelines prompted a revision of the clinic’s pulmonary rehabilitation program, and another stated that these guidelines were used in annual reviews. A third coordinator stated that the Hospital Admission Risk Program and COPD-X guidelines ensured uniformity and similarity in approach. In addition to these guidelines, one rehabilitation clinic also referred to US Pulmonary Best Practice guidelines, although none referred to the UK guidelines.
Despite a substantial proportion of clinics not providing formal psychological support for their patients, most used screening tools or broader psychosocial tools to measure quality of life, which to some extent contained emotional or psychological indicators of well-being. All except four clinics used some specific mood disorder tool, a broader tool, or informal methods to screen for depression and anxiety amongst their patients. Tools used included the Chronic Respiratory Disease Questionnaire, Quality of Life Questionnaire, RAND-36 Health-related Quality of Life Survey, Short Form-36 Health Survey, GUYATT Quality of Life Tool, St George’s Respiratory Questionnaire and Depression Anxiety Stress Scales, and the HADS. Overall, depression and anxiety screening tools were considered useful at all clinics participating in this study, with requests for recommendation of suitable screening tools, but many clinics did not use tools that were specifically measuring depression and anxiety. Some of the issues raised in relation to screening tools included that the HADS was not particularly useful, due to it being nonspecific to respiratory diseases.
When questioned about what paths were used to refer patients with depressive symptoms if they were recognized, most clinics used either formal or informal referral paths and processes to manage patients with depressive symptoms.
These referral paths included referral to community health services (eg, counselor, social worker, dietician, client’s general practitioner, etc) or to the counselor or psychologist within the organization, and providing information regarding services such as beyondblue (a community organization specialising in anxiety and depression). In instances where the client had a mental health care plan, this was taken into account in responding to a perceived need to refer, and this referral was likely to be to the primary care physician. Often, clinics used a care assessment tool that identifies referral pathways for risk factors when the client is initially assessed to enter a rehabilitation program. In some clinics, all health professionals in the multidisciplinary rehabilitation team, including the client’s referring doctor, were involved in the referral process to a psychologist. Referrals to psychological care and support were made through the social worker or welfare or other health network structures. Usually, the respiratory physician or the counselor was involved in referring, with contribution, although to a lesser extent, from the client’s primary care physician.
Three clinics followed informal referral mechanisms when psychological concerns in patients were identified. This was due to inadequate program (organizational) structure and lack of means (ie, lack of training to identify and deal with patients exhibiting mood disorders, lack of referral processes to implement, lack of assessment/screening tools) to manage patients with depressive symptoms. Two of these clinics were able to identify patients with depressive symptoms through this study, which enabled the patients to be referred on for further support.
However, again, 32% (n = 7) of clinics did not have a process for managing depression. Reasons for not using any referral pathways included lack of an onsite psychologist and no responsibility for cases where the patient already had a doctor managing their mental health.
In summary, although the majority of clinics surveyed had some awareness of local guidelines to manage anxiety and depression associated with COPD, approximately one-third of clinics lacked formal mechanisms for detecting mood disorders, adequate staffing to manage symptoms, or adequate referral pathways.
Patient sample results
In this context we attempted to determine the prevalence of anxiety and depression symptoms in patients from the sample of PR clinics. We received questionnaires from 105 patients, and all questionnaires were completed fully. We found that of the sample of 105 patients surveyed in these 22 clinics, 43% were male and 57% were female. The mean age was 70.9 years (standard deviation [SD] 8.3 years, range 52–90 years). Approximately one-third (31%) lived alone. The mean Duke Social Support Index score was 8.0 (SD 1.6). When patients were asked to self-rate their COPD symptoms, 20.2% rated them as mild, 67.7% rated them as moderate, and 12.1% rated them as severe. Therefore, the majority of these patients were experiencing moderate to severe COPD symptoms. Most patients (71.6%) were previous smokers. In this sample, the mean depression score from the HADS was 5.0 (SD 3.0, range 0–13) and the mean anxiety score was 5.5 (SD 3.4, range 0–18). Therefore, the mean depression and anxiety scores were within the normal range. However, the range of scores indicated that a number of patients were experiencing concerning symptoms of depression and/or anxiety. When we analyzed scores that were suggestive of case-level depression, we found that, overall, 20.4% of patients reported depression and 27.2% of patients reported suggestive or case-level anxiety. However, these patients were not clustered within clinics that had no formal psychological supports.
Correlating social network scores with depression and anxiety, there was a negative, but nonsignificant, correlation, ie, people with lower social network scores tended to have higher depression scores, although the relationship was not significant. In addition, there was no evidence of a link between depression or anxiety symptom scores and compliance with programs. We found only three patients of the 105 surveyed who did not complete the program of PR (one client with high depression/anxiety, two without). Therefore, there were insufficient numbers to calculate any statistical relationship between completion of PR and the HADS subscale scores.