A Cognitive-Behavioral Intervention for Depression and Anxiety in COPD
Mark E. Kunik MD MPH
VA Medical Center
Houston, TX
Funding Period: January 2002 - June 2006

BACKGROUND/RATIONALE:
The literature and our preliminary studies find that in COPD patients anxiety and depression affect quality of life and functioning over and above what would be expected given disease severity. Thus, in order to improve quality of life and functioning in the 20% of COPD patients with significant anxiety and/or depression symptoms, interventions are needed to help manage psychological symptoms. Considering the wealth of research that has documented the utility of cognitive behavioral therapy (CBT) in treating anxiety and depression, CBT shows promise as a self-management intervention to improve quality of life in this population.

OBJECTIVE(S):
This proposal is a randomized control trial designed to examine the efficacy of manual based CBT.

METHODS:
Subjects were recruited from the MEDVAMC through direct recruitment and use of administrative databases. Two hundred and forty-three COPD patients with comorbid anxiety and/or depression symptoms were randomized to either eight weeks of CBT/usual care or eight weeks of COPD Education/usual care. We hypothesized that COPD patients receiving CBT/usual care will show greater improvement when compared to COPD patients receiving COPD Education/usual care. Improvement is defined as increased disease specific quality of life (QOL), generic QOL, and six-minute walk distance; and decreased depression, anxiety, and health service use. Outcomes will be examined pre-treatment, mid-treatment, post-treatment and at 4, 8 and 12 months.

FINDINGS/RESULTS:
Screening for Anxiety and Depression in COPD Patients
Patients identified with chronic breathing problems were screened for depression and anxiety using the five questions from the PrimeMD. Of all patients screened with the PRIME-MD, 80% screened positive for depression, anxiety, or both. The sensitivity and specificity of the PRIME-MD for detection of anxiety and/or depression were 97.7% and 36.0%, respectively. The overall accuracy of the PRIME-MD combined screen was 80.7%. These findings indicate that practical screening instruments may help increase the recognition of anxiety and depression in medical patients.
Prevalence of Anxiety and Depression in COPD Patients
An estimated prevalence of depression or anxiety in patients with breathing problems is 34-72%. Of those patients with depression and/or anxiety, 52% had severe levels of depression and/or anxiety according to the BAI and BDI. In the subsample of patients who had COPD and were diagnosed using the SCID, 65% received an anxiety and/or depressive disorder diagnosis. Of those patients, only 31% were receiving treatment for depression and/or anxiety.
Quality of Life in Patients with COPD
In 179 veterans with COPD, multiple regression procedures found that both depression and anxiety were significantly related to negative quality of life outcomes (anxiety with both mental and physical health quality of life outcomes, and depression primarily with mental health). When co-morbid with COPD, mental health symptoms of depression and anxiety are some of the most salient factors associated with quality of life outcomes.

IMPACT:
If this hypothesis is correct, a more proactive approach can be taken to ensure that COPD patients with anxiety and depression receive appropriate care/interventions, which ultimately may improve their quality of life and functioning, and potentially reduce long-term health care use. Moreover, because a treatment manual is being utilized in the present study, replication, portability, and dissemination of the intervention will be enhanced. Positive findings in this study would highlight the need to explore generalizability of this approach across a variety of chronic medical illnesses.


PUBLICATIONS:

Journal Articles

1. Kraus CA, Kunik ME, Stanley MA. Use of cognitive behavioral therapy in late-life psychiatric disorders. Geriatrics. 2007; 62(6): 21-6.
2. Cully JA, Graham DP, Stanley MA, Kunik ME. Depressed and Anxious COPD Patients: Predictors of Psychotherapy Engagement from a Clinical Trial. Journal of Clinical Psychology in Medical Settings. 2007; 14: 160-164.
3. Kunik ME, Azzam PN, Souchek J, Cully JA, Wray NP, Krishnan LL, Nelson HA, Stanley MA. A practical screening tool for anxiety and depression in patients with chronic breathing disorders. Psychosomatics. 2007; 48(1): 16-21.
4. Cully JA, Graham DP, Stanley MA, Ferguson CJ, Sharafkhaneh A, Souchek J, Kunik ME. Quality of life in patients with chronic obstructive pulmonary disease and comorbid anxiety or depression. Psychosomatics. 2006; 47(4): 312-9.
5. Ferguson CJ, Stanley M, Souchek J, Kunik ME. The utility of somatic symptoms as indicators of depression and anxiety in military veterans with chronic obstructive pulmonary disease. Depression and Anxiety. 2006; 23(1): 42-9.
6. Burgess A, Kunik ME, Stanley MA. Chronic obstructive pulmonary disease: assessing and treating psychological issues in patients with COPD. Geriatrics. 2005; 60(12): 18-21.
7. Stanley MA, Veazey C, Hopko D, Diefenback G, Kunik ME. Anxiety and Depression in chronic obstructive pulmonary disease: a new intervention and case report. Cognitive and behavioral practice. 2005; (12): 424-436.
8. Kunik ME, Roundy K, Veazey C, Souchek J, Richardson P, Wray NP, Stanley MA. Surprisingly high prevalence of anxiety and depression in chronic breathing disorders. Chest. 2005; 127(4): 1205-11.

DRA: Chronic Diseases, Health Services and Systems, Mental Illness
DRE: Treatment
Keywords: Cardiovasc’r disease, Comorbidity, Self-care
MeSH Terms: none