Pulmonary rehabilitation may modestly improve anxiety and depression in adults with COPD
Why was this study needed?
The British Lung Foundation estimates that 1.2 million people in the UK have chronic obstructive pulmonary disease (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.
The British Lung Foundation estimates that 1.2 million people in the UK have COPD
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 per cent 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 per cent 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.
Rehab 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.
Expert view
Enya Daynes and Sally Singh, Centre of Exercise and Rehabilitation Sciences, Biomedical Research Centre (Respiratory), Glenfield Hospital, Leicester, and Department of Respiratory Sciences, University of Leicester
This was a well conducted systematic review demonstrating that for participants with COPD, pulmonary rehabilitation (PR) favourably reduces anxiety and depression. Interestingly, this has not been previously reported in the Cochrane review that conclusively established the benefits of PR. The results support the current British Thoracic Society (BTS) guidelines that recommend anxiety management and relaxation as important topics to be covered in the educational component of PR.
There were a range of interventions offered including education, counselling sessions and psychosocial interventions so it is difficult to conclude the effect size of discrete interventions. However, the majority of included studies replicate standard UK PR education approach.
There appears to be no added benefit from extended programme durations beyond eight weeks on anxiety and/or depression. Most studies used the Hospital Anxiety and Depression Scale which is commonly used in the UK.
A previous study demonstrated that the magnitude of improvement is influenced on baseline anxiety and depression scores and therefore this study may underestimate the effects. However, the challenge remains in recruiting patients to PR who have higher levels of anxiety and depression and it may be necessary to adapt programmes to accommodate these individuals.
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: Bolton, C., Bevan-Smith, E., Blakey, J., et al (2013) British Thoracic Society guideline on pulmonary rehabilitation in adults: accredited by NICE. Thorax 68:1-30; British Lung Foundation. Chronic obstructive pulmonary disease (COPD) statistics. London: British Lung Foundation; 2019. Harrison, S., Greening, N., Williams, J., Morgan, M., Steiner, M., Singh, S. (2012) Have we underestimated the effi cacy of pulmonary rehabilitation on improving mood? Respiratory Medicine 106:838-844 McCarthy, B., Casey, D., Devane, D., et al (2015) Pulmonary Rehabilitation for chronic obstructive pulmonary disease. Cochrane database Syst. Rev. 2:CD0037953. 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.
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