Pulmonary rehabilitation
For many patients with COPD who have anxiety and/or depressive symptoms, referral for nonpharmacologic therapies such as psychotherapy, cognitive-behavioral therapy (CBT), and pulmonary rehabilitation (PR) is “one of the best things you can do,” Dr. Iyer said.
“If patients haven’t done pulmonary rehabilitation, get them in. And if they have done it before, get them back into it again,” he emphasized. “Accredited programs give a holistic approach to improving your strength, your breathlessness, your mindset and understanding of your breathlessness, and your own levels of security.”
Studies addressing the impact of PR and CBT on anxiety have been mostly small and observational but have yielded encouraging findings. A 2017 review reported that PR and CBT were effective in the treatment of anxiety and dyspnea, in the short term, in the majority of 47 studies (JAMA. 2017;18[12]:1096.e1-1096.e17). And a 2019 systematic review and meta-analysis focused on PR reported that, across 11 studies comprising 734 patients, PR conferred significant benefits for anxiety and depression compared with usual care (CHEST. 2019;156[1]:80-91).
Dr. Yohannes, Dr. Hanania, and colleagues recently reported on 734 patients with clinically stable COPD who completed a community-based 8-week PR program of 2 hours a week: 1 hour of exercise and 1 hour of education, the latter of which covered anxiety, panic management, and relaxation.
Patients who had severe dyspnea and comorbid anxiety and depression prior to PR – one-third of the group compared with 20% having anxiety alone and 5% having depression alone – had the most significant improvements in dyspnea scores and anxiety and depression scores (Respir Med. Apr 9. doi: 10.1016/j.rmed.2022.106850.)
The problem is, pulmonary rehabilitation is under-reimbursed and not widely accessible. It’s logistically challenging for patients to attend therapy 2-3 times a week. And according to a recently published study by Dr. Yohannes, Dr. Hanania, and colleagues, patients with more anxiety and dyspnea may be at higher risk of dropping out (Respir Med. 2022 Jan 20. doi: 10.1016/j.rmed.2022.10674). Moreover, Dr. Iyer said, there is a shortage of programs that are accredited.
Telehealth may help on some of these fronts. The efficacy of real-time video PR for COPD is being investigated in a randomized NIH trial (now in the recruitment phase) led by pulmonologist Surya P. Bhatt, MD, also at the University of Alabama at Birmingham.
Researchers also need to investigate issues of sustainability – to learn what “works best in the long run,” Dr. Iyer said.
Dr. Yohannes and Dr. Hanania are encouraged by a recent finding that patients with COPD who completed 8 weeks of PR maintained improvements in anxiety and quality-of-life scores at 2 years. (Improvements in dyspnea and other outcomes did not persist.) (CHEST. 2021;159[3]:967-74). Prospective studies contrasting maintenance programs with no maintenance following PR, are needed, they wrote.
Understanding psychological interventions
Dr. Hoth and Dr. Garvin advise their pulmonologist colleagues to feel as confident as possible in describing for patients what CBT and other psychological therapies entail.
“A person [with COPD] who is experiencing something on the continuum of anxiety might be really turning inward and [assessing] unwanted internal experiences” and accompanying thoughts, sensations, emotional impacts and behaviors, Dr. Garvin said.
Among the goals, she said, are to “make shifts around those internal experiences that might invoke some more tolerance or that might shift their relationship with the experiences, or even with the diagnosis itself and all the uncertainties it carries.”
Psychological therapies can involve social support, or “breath and grounding work,” she said. “There are lots of different approaches from different providers.”
Dr. Yohannes advocates incorporating principles of CBT into PR. “In the absence of one-on-one or group [stand-alone] CBT … the principles are worth incorporating as part of the education piece [of PR],” he said. “CBT helps patients to refocus their attention. … and gives them self-confidence to engage in exercise and to function a bit more in their daily activities.”
None of those interviewed for this story reported having any relevant conflicts of interest.