The most effective psychologically-based treatments to reduce anxiety and panic in patients with chronic obstructive pulmonary disease (COPD): a systematic review

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Abstract

Chronic obstructive pulmonary disease (COPD) is irreversible and causes a progressive reduction in physical functioning. There is evidence that emotional distress contributes to loss of function and that improvements may be obtained via psychologically based interventions to alleviate anxiety and panic. This systematic review examined the most effective interventions to date. A literature search revealed 25 studies; these were assessed using standardised criteria for inclusion and quality. Six randomised, controlled trials fulfilled the criteria, but the variety of methods, interventions and measures prevented the use of a meta-analysis. Two studies were unpublished doctoral theses, four were published studies. All of the studies had one or more deficiencies; failure to measure or report lung function, large variation in attrition, lack of blinding in assessment of treatment outcome, lack of use of standardised anxiety measures. Description of the intervention was not always sufficient to allow replication. There were no trials of interventions aimed at reducing panic. No study was adequately designed to provide an assessment of psychological intervention aimed at anxiety in COPD. Secondary outcomes included impacts on breathlessness, disability and quality of life. It can be concluded that currently there is insufficient research of quality on which to base recommendations for effective interventions for anxiety and panic in COPD. Future research should tie the design of evaluation to interventions based on theories of the relationship between dyspnoea and anxiety.

Introduction

People with chronic obstructive pulmonary disease (COPD) experience a progressive reduction in functioning due to symptoms, such as fatigue and breathlessness (dyspnoea). The effects of COPD are largely irreversible and although pulmonary rehabilitation programmes have produced improvements in physical functioning [1], the effects are often short-lived [2]. There is evidence that emotional distress contributes to dyspnoea [3], which may cause loss of breathing control [4] and lead to panic. Psychological interventions have been shown to have beneficial effects on physical and psychological functioning and symptom reduction [2].

For studies of the psychological aspects of COPD the following three features need to be considered: First, as measurement of lung function is essential in the diagnosis of COPD, it is necessary to standardise methods of measurement. Second, to address the factors that contribute to loss in physical function it is necessary to develop and test models of causality. Third, so that interventions designed to alleviate anxiety and panic can be effectively evaluated, the usefulness of standardised outcome measures must be examined.

Section snippets

Medical assessment of COPD

The term COPD embraces those conditions characterised by irreversible airflow obstruction and includes both emphysema and obstructive bronchitis. Emphysema results from destruction of the alveolar walls, while obstructive bronchitis results from destruction of the normal small airways.

Lung function measures: measurement of forced expiratory volume in 1 s (FEV1) is the best measure of airflow obstruction; it predicts mortality [5] and is the measurement of choice for following the progress of

Drug treatment of breathlessness associated with anxiety

Dyspnoea is a symptom of many diseases and a variety of empirical treatments for this symptom have been described. Treatments, such as anti-histamines and opiates are contra-indicated in COPD and are thus not used, except for the occasional use of morphine agonally. Dihydrocodeine, a mild opiate, in one study improved 6-min walk distances in COPD to a modest degree [11], but is not used routinely for this in clinical practice. Alcohol can relieve breathlessness in asthma, partly because of its

Theoretical background for psychological interventions in COPD

Patients with COPD suffer greater than normal levels of anxiety [12] and panic disorder (PD) is more common in COPD (range 8–67% [14], [15]) than the estimate of 1.5–3.5% for the general population [16]. PD comprises persistent attacks of intense anxiety with cognitive components of dread or impending death, accompanied by fear of them. Because dyspnoea is a central symptom of both panic and respiratory disease, respiratory symptomatology may contribute to the development and exacerbation of

The measurement of anxiety and panic

Panic: Moore and Zebb [24] used their panic attack questionnaire, modified from an existing version [25], in a COPD population. Thirty-two percent reported panic symptoms and more breathlessness and fatigue during everyday activities unrelated to panic. It was concluded that fear of future panic attacks and behaviour intended to reduce their impact, characterise people with PD [23].

Pollack et al. [15] formulated and used a questionnaire followed by a structured clinical interview (SCID) and

Systematic review methodology

This review was conducted to assess the evidence that psychological intervention has any part to play in the management of COPD and, if so, which is the most effective method of reducing anxiety or panic in these patients. It was performed in line with recommendations from NHS CRD and the Cochrane collaboration.

Results

The searches yielded 25 studies that claimed to examine the effects of a psychological intervention on COPD patients; 19 were excluded because they failed to meet the inclusion criteria. Six studies were identified where an intervention including a psychological component had been performed and assessed (Table 2). Two studies were post-graduate theses [38], [45] and four were published studies [46], [49].

Discussion and conclusions

Most of the studies in the review used an inadequate sample size to detect significant changes in the measures they employed (Table 3). The treatment groups in both relaxation-only studies had higher baseline anxiety scores than the control groups, which makes interpretation of the results difficult. In the studies where anxiety scores were similar between the groups, changes were not significant. The most effective relaxation study [48] was also the only study in which female patients

Acknowledgements

Clinical advice provided by: Clare Taylor, Principal Lecturer in Occupational Therapy, Coventry University, UK; Nicky Knowles, Senior Lecturer in Physiotherapy, Coventry University, UK; and Rachael Booker, Nurse, National Respiratory Training Centre, Warwick, UK.

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