People with COPD often experience anxiety and depression related to their condition, and it’s a known fact that they can have a significant impact on breathlessness, quality of life, exacerbation rates, and consequently on how often they use healthcare resources, readmission and mortality rates.1
These psychological difficulties can make patients less able to manage their symptoms and be less physically active as they could otherwise be. So, to effectively support individuals with COPD, it is important that these comorbidities are identified and treated along with pulmonary rehabilitation and other pharmaceutical interventions.7
Traditionally, treatment for anxiety and depression is provided as a separate intervention by mental health professionals, however, we must come to accept that in this case, the issue of psychological ill health is the remit of respiratory healthcare professionals.
CBT to relieve anxiety, breathlessness and depression in the COPD patient
I have a long standing academic interest in the symptoms of COPD, and I identified anxiety and depression as key symptoms experienced by patients with COPD during my Masters’ Degree. I then had the chance to take part in a Randomised Controlled Trial of basic CBT skills for nurses working with palliative care patients, which honed my skills and helped me learn more about how CBT can help chronic and terminal patients. These basic skills were so beneficial to my patients that I also undertook a postgraduate diploma on the subject.
It was these experiences that made me think that a simple CBT intervention could have a positive impact on my patients, so with the team at Newcastle upon Tyne NHS Trust, we developed and trialled a nurse-led clinic for COPD patients which incorporates CBT to manage breathlessness, anxiety and depression.
By delivering this in a one-stop clinic, we are not just preventing additional appointments and potential delays to patients, but as respiratory specialists, we can help patients to identify if symptoms are due to anxiety or their COPD.
Next we needed a solid base of evidence, as if this intervention was successful, it should be shared across the NHS as a relatively simple and cost effective way to improve patients’ quality of life and reduce the costs and risks of multiple admissions.
Delivering a one-stop clinic trial
We designed a pragmatic randomised controlled trial to address our hypothesis that one to one CBT sessions, delivered by respiratory nurses, could lead to a reduction in anxiety symptoms as measured by the Hospital Anxiety and Depression Scale (HADS) Anxiety Subscale (9), and submitted it to the NIHR for funding for a PhD Clinical Academic Fellowship.
Our proposal was successful, and we moved to recruit 279 patients with COPD and symptoms of anxiety. Patients were randomized to CBT (between 2-6 sessions either in clinic or at home) or self-help leaflets. We measured anxiety, depression and quality of life were at the start, at three, six and 12 months.
We also performed a cost effectiveness analysis from a National Health Service hospital perspective and estimated the effect on Quality Adjusted Life Years (QALYs) using the EuroQol-5D questionnaire.
The results were very positive and have been published in the European Respiratory Journal. We saw that at three months the anxiety levels reduced in the CBT group compared to the group receiving self-help leaflets. Group mean change from baseline to three months in the HADS Anxiety Subscale was 3.4 for the CBT group and 1.88 in the leaflet group. At 12 months there was a statistically significant reduction in symptoms of anxiety.
Importantly, after a full health economic analysis, we also recorded a significantly lower number of hospital admissions and A&E attendances in the CBT group at 12 months, showing that CBT intervention was more cost effective than leaflets.
Where next
Following the success of the trial, we now expanded our nurse-led service to all patients with a lung conditions who are experiencing breathlessness, symptoms of anxiety and depression.
We have proved that brief CBT sessions delivered by respiratory nurses can be an effective and economical way to reduce anxiety in patients with COPD and reduce health care resource use. It is also a step forward to improve COPD patients’ access to mental health support.
Looking at the future, we are now in the process of developing a web-based treatment for breathlessness, targeting physical activity and mood, which will be suitable for patients with asthma, bronchiectasis, COPD and ILD. This will be available in the summer of 2021.