34 | Nursing in Practice | Spring 2023 |
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How common are symptoms of anxiety and depression in COPD ? Estimated prevalence rates of anxiety and depression vary . One randomised controlled trial in north-east England screened 1,500 stable COPD outpatients at a secondary care clinic and found 59 % had symptoms of anxiety based on a Hospital Anxiety and Depression scale ( HADS ) score of greater than 7 . 8
How do physical and mental health symptoms interact ? Research has demonstrated the impact of anxiety and depression on people with COPD , in terms of physical functioning , breathlessness , quality of life , exacerbation rates , use of healthcare resources , length of hospital stays , readmission rates and mortality . 9
It has also been shown that people with COPD who have psychological symptoms are less able to manage physical symptoms and less likely to be physically active or attend pulmonary rehabilitation ( an evidence-based intervention ). 10
Adherence to rehabilitation , psychological and antidepressant pharmacological treatments in depressed patients has been linked to a decreased risk of hospitalisation . 7
What can nurses do to help ? The first step in addressing symptoms of anxiety or depression is to screen for them using a validated tool at the patient ' s annual review – and more frequently if needed . The Patient Health Questionnaire-2 ( PHQ-2 ) or General Anxiety Disease questionnaire ( GAD-2 ) can be used as brief screening tools . If any symptoms are identified , questionnaires such as HADS can then be used to explore symptoms further .
It has been found that cognitive behavioural therapy ( CBT ) delivered by respiratory nurses can help alleviate symptoms of anxiety , and in turn improve patients ' self-management . Nurses can develop their skills in CBT , which can be used with all patients living with long-term conditions , but may not feel confident to do it without appropriate training . 11
How does CBT work ? CBT is an evidence-based , patient-centred , individualised and structured form of psychological therapy that explores the links between a patient ’ s situation and their physical symptoms , thoughts , emotions and behaviours . Once unhelpful links are identified , this information can be used to explore and challenge negative thoughts or behaviours – such as the fear of becoming breathless , over-reliance on drug treatment or oxygen , and reluctance to engage in physical activity .
A starting point for patients with respiratory problems is to identify what triggers breathlessness – both physical factors such as exertion and psychological factors such as fear or panic . Skilled nurses can then work with the patient to develop a self-management plan to address these physical and psychological difficulties so they can reduce the impact of breathlessness . 13 Alternatively , patients can be referred to a local CBT service or targeted resources such as pulmonary rehabilitation services if the nurse does not have the necessary skills .
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Can CBT help to counter physical inactivity ? Reduced physical activity is common among people with COPD , and is a strong predictor for all-cause mortality in this group of patients . 14 Barriers to physical activity include : 14
• Older age .
• Being female .
• Reduced lung function .
• Having comorbidities .
• Increased COPD symptoms ( fear of breathlessness and injury , severe fatigue , anxiety and depression ).
• More advanced GOLD ( Global Initiative for Chronic
Obstructive Lung Disease ) stage .
• More frequent exacerbations .
• Oxygen use .
• Lack of motivation .
• Environmental factors , such as the season and weather . Behavioural activation interventions that form part of CBT can help address physical inactivity . For example , an approach comprising motivational interviews , monitoring and feedback using a pedometer and goal setting could be used to increase physical activity levels and reduce deconditioning . 15
Why should nurses gain CBT skills ?
Frontline clinicians know COPD patients experience symptoms of anxiety and depression . After all , breathlessness is a frightening symptom experienced by most respiratory patients . However , it is less well recognised that taking steps to address psychological distress will also help achieve important physical outcomes , such as reducing breathlessness and
12 , 16 admissions . Even a basic knowledge of CBT will help nurses understand COPD patients ' experiences and develop more helpful ways of dealing with difficulties . Basic training in CBT skills can enhance practice nurses ' ability to recognise and explore areas that could be changed to manage or reduce symptoms of anxiety or depression . This training is available through the Pivotal training course .
Are there any digital programmes that can help ? Digital self-management programs are now available , such as BreathTec . This is a personalised , interactive programme to help patients with asthma , COPD , bronchiectasis and interstitial lung disease to manage their condition . Key components include managing breathlessness , staying active and maintaining good mental health . Such programs can enhance selfmanagement interventions delivered by nurses in clinical practice .
Summary Self-management is an important part of COPD care . The overall benefits are greater where a focus on mental health is included and CBT may be a valuable component in this respect . The challenge facing clinicians , managers and commissioners is to embed this model in routine clinical care while maintaining a clear pathway to refer more complex psychological problems to mental health teams .
Dr Karen Heslop-Marshall is a nurse consultant at Newcastle upon Tyne Hospitals NHS Foundation Trust
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References 1 Newham J , Presseau J , Heslop-Marshall K et al . Features of self-management interventions for people with COPD associated with improved health-related quality of life and reduced emergency department visits : a systematic review and meta-analysis . Int J Chron Obstruct Pulmon Dis 2017 ; 12:1705-20 2 Askey R . Exploring the benefits of a psychoeducation session for patients with chronic obstructive pulmonary disease ( COPD ) and co-morbid depression and / or anxiety . Mental health 2020 . DOI : 10.7748 / mhp . 2020 . e1435 3 Schrijver J , Lenferink A , Brusse-Keizer M et al . Self-management interventions for people with chronic obstructive pulmonary disease . Cochrane Database Syst Rev 2022 ; 1 : CD002990 4 GOLD . Global Strategy for the Diagnosis , Management and Prevention of COPD . 2022 . goldcopd . org 5 Foley T . Bridging the Gap : the financial case for a reasonable rebalancing of health and care resources . London , Royal College of Psychiatrists . 2013 . bit . ly / 3SVmC4L 6 Livermore N , Butler J , Sharpe L et al . Panic Attacks and Perception of Inspiratory Resistive Loads in Chronic Obstructive Pulmonary Disease . Am J Respir Crit Care Med 2008 ; 178 ( 1 ): 7 – 12 7 Volpata E , Toniolo S , Pagnini F et al . The Relationship Between Anxiety , Depression and Treatment Adherence in Chronic Obstructive Pulmonary Disease : A Systematic Review . Int J Chron Obstruct Pulmon Dis 2021:16:2001-21 8 Heslop-Marshall K , De Soyza A . Are we missing anxiety in people with chronic obstructive pulmonary disease ( COPD )? Ann Depress Anxiety 2014 ; 1 ( 5 ): 1023 9 Yohannes A , Alexopoulos G . Depression and anxiety in patients with COPD . Eur Respir Rev 2014 ; 23 ( 133 ): 345-9 10 Bolton C , Bevan-Smith E , Blakey J et al . British Thoracic Society guideline on pulmonary rehabilitation in adults . Thorax 2013 ; 68:2:1-30 . bit . ly / 3muYk5B 11 Heslop-Marshall K , Pilkington M , Knighting K et al . Nurse-led cognitive behavioural therapy for respiratory patients . Nursing Times 2021 ; 117 ( 2 ) 47-48 12 Heslop-Marshall K , Baker C , Carrick- Sen D et al . Randomised controlled trial of cognitive behavioural therapy in COPD . ERJ Open Res 2018 ; 4:00094-2018 13 Heslop-Marshall K . Using cognitive behavioural therapy techniques in COPD . Pract Nurs 2018 ; 29 ( 12 ): 594-97 14 Xiang X , Huang L , Fang Y et al . Physical activity and chronic obstructive pulmonary disease : a scoping review . BMC Pulm Med 2022 ; 22 ( 1 ): 301 15 Armstrong M , Hume E , McNeillie L et al . Behavioural modification interventions alongside pulmonary rehabilitation improve COPD patients ’ experiences of physical activity . Respir Med 2021 ; 180:106353 16 Heslop-Marshall K , Burns G . The role of cognitive behavioural therapy in living well with COPD . Breathe 2019 ; 15 ( 2 ): 95-97
Resources
• Pivotal Health CBT training .
pivotalhealth . org . uk
• BreathTec online treatment programme . breathtec . co . uk
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