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NIHR Signal Pulmonary rehabilitation may modestly improve anxiety and depression in adults with chronic obstructive pulmonary disease

Published on 23 July 2019

doi: 10.3310/signal-000794

Pulmonary rehabilitation for chronic obstructive pulmonary disease (COPD) improves psychological symptoms modestly, compared with no intervention. Depression improves by about 2.5 points, and anxiety by 2.2 points on the Hospital Anxiety and Depression Scale (range 0 to 21).

This review of 10 trials is the first to show that pulmonary rehabilitation – already known to improve quality of life and exercise capacity - may also improve anxiety and depression, which are common in people with COPD.

Pulmonary rehabilitation programmes were diverse, ranging from four to 16 weeks in length, two to five sessions per week, and from 20 mins to 4 hours per session. All had exercise and education components. Some also included stress management, psychosocial interventions or counselling.

These findings do not alter 2018 NICE recommended management of COPD in adults, which includes individualised pulmonary rehabilitation.

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Why was this study needed?

The British Lung Foundation estimates that 1.2 million people in the UK have COPD, making it the second most common lung disease in the UK, after asthma.

A significant proportion of those people also have anxiety and depression.

Pulmonary rehabilitation can improve quality of life, exercise capacity, shortness of breath and fatigue in people with COPD, but its effects on anxiety and depression are less clear. These symptoms are usually treated separately using drugs or psychological therapies.

This is the first systematic review to look at whether rehabilitation, with its focus on tailored exercise programmes, also improves symptoms of anxiety or depression in people with COPD.

What did this study do?

This systematic review and meta-analysis identified and pooled results from 10 randomised control trials (734 participants) testing whether pulmonary rehabilitation improved anxiety or depression symptoms for people with COPD, compared with usual care.

Usual care was defined as the absence of any formal intervention with the potential to improve anxiety or depression.

Most rehabilitation programmes took place in a hospital outpatient clinic. Exercise was part of all these programmes, either aerobic or strength training, usually in a group setting.

Included trials were small (less than 100 participants) and were classed as having a moderate risk of bias, which means the size of the treatment effect is less certain. One trial was conducted in the UK, and six in Turkey, lessening direct applicability to the UK as the programme content and the health systems are different. Nevertheless, a positive effect is encouraging.

What did it find?

  • Compared with usual care, rehabilitation reduced depression symptoms by an average of 2.5 points (95% confidence interval [CI] 1.9 to 3.1) on the Hospital Anxiety and Depression Scale [HADS] (range 0 to 21).
  • Compared with usual care, rehabilitation reduced anxiety symptoms by an average of 2.2 points (95% CI 1.0 to 3.5) on the HADS (range 0 to 21).
  • The benefits did not vary significantly by programme duration, age, sex, or COPD severity.
  • At the start of the studies, participants had mild anxiety symptoms (HADS score 5 to 10 at baseline) and/or mild depression symptoms (HADS-D score 4 to 9).

What does current guidance say on this issue?

The current 2018 NICE guideline states that pulmonary rehabilitation should be offered to all people who view themselves as “functionally disabled” by COPD, including those needing recent hospital care. 

Rehabilitation programmes should be held at a time and place that suit patients, and include “multicomponent, multidisciplinary interventions” (physical training, disease education, nutritional, psychological and behavioural interventions) tailored to the individual’s needs.

Patients should be advised of the benefits of pulmonary rehabilitation and the commitment needed to gain them.

What are the implications?

This review does not merit any specific changes in practice because rehabilitation is already a part of the current recommended pathway for managing COPD in adults. However, it does suggest that pulmonary rehabilitation may have modest additional benefits.

Programmes incorporate physical training, disease education, and nutritional, psychological and behavioural components. Therefore, implementation of all these aspects can be a challenge.

The optimal duration of programmes, number of sessions offered per week, and type of staff required to deliver the most effective programmes remain unclear.

Citation and Funding

Gordon CS, Waller JW, Cook RM et al. Effect of pulmonary rehabilitation on symptoms of anxiety and depression in chronic obstructive pulmonary disease: a systematic review and meta-analysis. CHEST. 2019;156(1):80-91.

The lead author of the study received a Lung Foundation Australia/Boehringer-Ingelheim COPD Research Fellowship (2016-2018) unrelated to the present study.

Bibliography

British Lung Foundation. Chronic obstructive pulmonary disease (COPD) statistics. London: British Lung Foundation; 2019.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NG115. London: National Institute for Health and Care Excellence; 2018.

NICE. Managing COPD: pathway. London: National Institute for Health and Care Excellence; 2019.

Why was this study needed?

The British Lung Foundation estimates that 1.2 million people in the UK have COPD, making it the second most common lung disease in the UK, after asthma.

A significant proportion of those people also have anxiety and depression.

Pulmonary rehabilitation can improve quality of life, exercise capacity, shortness of breath and fatigue in people with COPD, but its effects on anxiety and depression are less clear. These symptoms are usually treated separately using drugs or psychological therapies.

This is the first systematic review to look at whether rehabilitation, with its focus on tailored exercise programmes, also improves symptoms of anxiety or depression in people with COPD.

What did this study do?

This systematic review and meta-analysis identified and pooled results from 10 randomised control trials (734 participants) testing whether pulmonary rehabilitation improved anxiety or depression symptoms for people with COPD, compared with usual care.

Usual care was defined as the absence of any formal intervention with the potential to improve anxiety or depression.

Most rehabilitation programmes took place in a hospital outpatient clinic. Exercise was part of all these programmes, either aerobic or strength training, usually in a group setting.

Included trials were small (less than 100 participants) and were classed as having a moderate risk of bias, which means the size of the treatment effect is less certain. One trial was conducted in the UK, and six in Turkey, lessening direct applicability to the UK as the programme content and the health systems are different. Nevertheless, a positive effect is encouraging.

What did it find?

  • Compared with usual care, rehabilitation reduced depression symptoms by an average of 2.5 points (95% confidence interval [CI] 1.9 to 3.1) on the Hospital Anxiety and Depression Scale [HADS] (range 0 to 21).
  • Compared with usual care, rehabilitation reduced anxiety symptoms by an average of 2.2 points (95% CI 1.0 to 3.5) on the HADS (range 0 to 21).
  • The benefits did not vary significantly by programme duration, age, sex, or COPD severity.
  • At the start of the studies, participants had mild anxiety symptoms (HADS score 5 to 10 at baseline) and/or mild depression symptoms (HADS-D score 4 to 9).

What does current guidance say on this issue?

The current 2018 NICE guideline states that pulmonary rehabilitation should be offered to all people who view themselves as “functionally disabled” by COPD, including those needing recent hospital care. 

Rehabilitation programmes should be held at a time and place that suit patients, and include “multicomponent, multidisciplinary interventions” (physical training, disease education, nutritional, psychological and behavioural interventions) tailored to the individual’s needs.

Patients should be advised of the benefits of pulmonary rehabilitation and the commitment needed to gain them.

What are the implications?

This review does not merit any specific changes in practice because rehabilitation is already a part of the current recommended pathway for managing COPD in adults. However, it does suggest that pulmonary rehabilitation may have modest additional benefits.

Programmes incorporate physical training, disease education, and nutritional, psychological and behavioural components. Therefore, implementation of all these aspects can be a challenge.

The optimal duration of programmes, number of sessions offered per week, and type of staff required to deliver the most effective programmes remain unclear.

Citation and Funding

Gordon CS, Waller JW, Cook RM et al. Effect of pulmonary rehabilitation on symptoms of anxiety and depression in chronic obstructive pulmonary disease: a systematic review and meta-analysis. CHEST. 2019;156(1):80-91.

The lead author of the study received a Lung Foundation Australia/Boehringer-Ingelheim COPD Research Fellowship (2016-2018) unrelated to the present study.

Bibliography

British Lung Foundation. Chronic obstructive pulmonary disease (COPD) statistics. London: British Lung Foundation; 2019.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NG115. London: National Institute for Health and Care Excellence; 2018.

NICE. Managing COPD: pathway. London: National Institute for Health and Care Excellence; 2019.

Effect of pulmonary rehabilitation on symptoms of anxiety and depression in chronic obstructive pulmonary disease: a systematic review and meta-analysis

Published on 30 April 2019

Gordon, C. S.,Waller, J. W.,Cook, R. M.,Cavalera, S. L.,Lim, W. T.,Osadnik, C. R.

Chest , 2019

BACKGROUND: Pulmonary rehabilitation (PR) improves exercise capacity and quality of life in people with chronic obstructive pulmonary disease (COPD), yet its effect upon anxiety and depression symptoms is less clear. Existing data is difficult to apply to clinical PR due to diverse interventions and comparators. This review evaluated the effectiveness of PR on anxiety and depression symptoms in people with COPD. METHODS: A systematic review and meta-analysis (PROSPERO CRD42018094172) was conducted according to PRISMA guidelines on randomised controlled trials comparing PR (>/=4 weeks duration) to usual care. Four electronic databases were searched to February 2018 using terms related to COPD, PR, anxiety and depression. Data were extracted by two assessors using standardised templates. Study quality was appraised via PEDro scale and evidence rated according to GRADE. Data were analysed in RevMan 5.3, with pooled effect estimates reported as standardized mean differences (SMD). The effect of program duration (</=8 vs >8 weeks) was explored via subgroup analysis. RESULTS: 11 studies comprising 734 participants (median PEDro score 4/10) were included. Compared to usual care, PR conferred significant benefits of a moderate magnitude for anxiety symptoms (SMD -0.53; 95%CI -0.82 to -0.23) and large magnitude for depression symptoms (SMD -0.70; 95%CI -0.87 to -0.53). The certainty of evidence for each outcome was 'moderate'. Effects were not moderated by program duration. CONCLUSION: PR confers significant, clinically relevant benefits upon anxiety and depression symptoms. As further studies involving 'no treatment' control groups are not indicated, these robust estimates of treatment effects are likely to endure.

Expert commentary

This well-conducted systematic review concludes that pulmonary rehabilitation improves anxiety and depression in people with chronic obstructive pulmonary disease.

Despite psychological morbidity being prominent in this population, it is rarely attended to. Most clinicians who assess psychological symptoms do so using the Hospital Anxiety and Depression Scale, arguably a crude measure containing somatic items that overlap with disease symptoms.

Consequently, this review may have overestimated the impact of PR on anxiety and depression. Furthermore, those with severe psychological symptoms are unlikely to attend PR. We need to identify means of supporting people with COPD to attend interventions, which could positively influence mood.

Samantha L Harrison, Reader in Respiratory Rehabilitation, School of Health and Social Care, Teesside University

The commentator declares no conflicting interests