Cognitive behavioural therapy helps ease anxiety in COPD patients

Cognitive behavioural therapy (CBT) intervention delivered by respiratory nurses is effective in reducing anxiety symptoms and utilisation of healthcare resources in patients with chronic obstructive pulmonary disease (COPD), thus providing a cost-effective strategy for treating anxiety — a symptom often comorbid with COPD, a study shows.

“One of the main symptoms of COPD is breathlessness. This is very frightening and often leads to feelings of anxiety. Many healthcare professionals do not currently screen COPD patients for symptoms of anxiety, even though it can have an impact on their overall health,” said lead author Dr Karen Heslop-Marshall of Newcastle University in Newcastle upon Tyne, UK. Underdiagnosis and undertreatment of anxiety often comorbid with COPD can adversely affect patient outcomes.

In the multicentre pragmatic study, 279 patients (mean age 66.5 years, 46 percent male) with COPD and anxiety (Hospital Anxiety and Depression Scale [HADS]-Anxiety Subscale score of ≥8) were randomized 1:1 to CBT in addition to self-help leaflets or leaflets alone as control. Fifty-nine percent of the 1,518 patients screened for study entry scored ≥8 on the HADS-Anxiety Subscale, indicating that anxiety is common among this patient population with COPD. [ERJ Open Res 2018;doi:10.1183/23120541.00094-2018]

While both the CBT and self-help leaflet groups saw reductions in the primary endpoint of anxiety symptoms at 3 months from baseline (change from baseline, 3.4; p<0.001 vs 1.88; p<0.001), the improvement was significantly greater with the addition of CBT than with self-help leaflets alone (mean difference between groups, 1.88; p<0.001). This exceeds the minimal clinically important difference (MCID) of 1.32.

There was also significant reduction in depression symptoms with CBT vs control at 3 and 6 months, although the difference did not reach the MCID.

In addition, fewer hospital admissions (0.6 vs 1.01) and emergency department (ED) visits (0.37 vs 0.81) were required in the CBT group compared with the control group, which translate to a greater cost-effectiveness in favour of CBT. The addition of CBT led to an average saving of GBP 1,089 per patient for respiratory hospital admissions (p=0.076) and GBP 63 per patient for ED attendances (p=0.036) compared with control.   

“Although the CBT intervention initially resulted in added costs, as respiratory nurses required training in CBT skills, this was balanced by the savings made thanks to less frequent need of hospital and A&E services,” Heslop-Marshall pointed out.

Furthermore, patients in the CBT group had significantly greater gains in quality-adjusted life-years (QALYs) than the control group (mean difference, 0.079; p=0.008), which according to the authors, indicates that CBT intervention was more effective than using self-help leaflets alone while being less expensive.

“Reducing the levels of anxiety patients experience has a significant impact on their quality of life as well as their ability to keep physically active and may improve survival in the long-term. Our research shows that front-line respiratory staff can deliver this intervention efficiently and effectively,” concluded Heslop-Marshall and co-authors.

“Further studies are needed to identify how to incorporate CBT into routine clinical care and identify if the intervention can be successfully replicated for those treated in primary care,” they suggested.