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Review
Maria Panagioti 1
Charlotte Scott 1
Amy Blakemore 1,2
Peter A Coventry 3
National Institute for Health
Research School for Primary Care
Research, Centre for Primary
Care, Institute of Population
Health, Manchester Academic
Health Science Centre, University
of Manchester, 2Department of
Psychiatry, Manchester Mental Health
and Social Care Trust, Manchester
Royal Infirmary, 3National Institute
for Health Research Collaboration
for Leadership in Applied Health
Research and Care Greater
Manchester and Manchester Academic
Health Science Centre, University of
Manchester, Manchester, UK
1
Abstract: More than one third of individuals with chronic obstructive pulmonary disease
(COPD) experience comorbid symptoms of depression and anxiety. This review aims to provide
an overview of the burden of depression and anxiety in those with COPD and to outline the
contemporary advances and challenges in the management of depression and anxiety in COPD.
Symptoms of depression and anxiety in COPD lead to worse health outcomes, including impaired
health-related quality of life and increased mortality risk. Depression and anxiety also increase
health care utilization rates and costs. Although the quality of the data varies considerably, the
cumulative evidence shows that complex interventions consisting of pulmonary rehabilitation
interventions with or without psychological components improve symptoms of depression and
anxiety in COPD. Cognitive behavioral therapy is also an effective intervention for managing depression in COPD, but treatment effects are small. Cognitive behavioral therapy could
potentially lead to greater benefits in depression and anxiety in people with COPD if embedded
in multidisciplinary collaborative care frameworks, but this hypothesis has not yet been empirically assessed. Mindfulness-based treatments are an alternative option for the management of
depression and anxiety in people with long-term conditions, but their efficacy is unproven in
COPD. Beyond pulmonary rehabilitation, the evidence about optimal approaches for managing depression and anxiety in COPD remains unclear and largely speculative. Future research
to evaluate the effectiveness of novel and integrated care approaches for the management of
depression and anxiety in COPD is warranted.
Keywords: chronic obstructive pulmonary disease, depression and anxiety, health outcomes,
pulmonary rehabilitation, cognitive behavioral therapy, multidisciplinary case management
Introduction
Prevalence and symptoms of depression and anxiety
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2014 Panagioti etal. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution Non Commercial (unported,v3.0)
License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further
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http://dx.doi.org/10.2147/COPD.S72073
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Panagioti etal
Prevalence of depression
and anxiety in COPD
A recent meta-analysis that included 39,587 individuals with
COPD and 39,431 controls found that one in four COPD
patients experienced clinically significant depressive symptoms compared with less than one in eight of the controls
(24.6%, 95% confidence interval [CI] 20.028.6 versus
11.7%, 95% CI 9.015.1).9 These estimates are consistent
with the findings of previous qualitative and quantitative
reviews that assessed the prevalence of depressive symptoms
in COPD.1012 Clinical anxiety has also been recognized as a
significant problem in COPD, with an estimated prevalence
of up to 40%.12,13 Additionally, COPD patients are ten times
more likely to experience panic disorder or panic attacks
compared with general population samples.14 Of note, the
great variability of methods used to assess depression and
anxiety in the literature makes it difficult to reach a consensus
about the prevalence of depression and anxiety in COPD.
Future research should quantify whether prevalence rates
for depression and anxiety in COPD are significantly different among samples identified by self-rated or standardized
interview methods.
The causes of depression and anxiety in COPD are likely
to be multifactorial, but importantly disease severity does
not appear to affect the levels of anxiety and depression in
COPD patients.15 Rather, subjective ratings of health-related
quality of life (HRQoL), dyspnea, and reduced exercise
capacity potentially underlie the development of symptoms of
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Sample
size
Mean
age, years
Males
(%)
COPD severity
(GOLD stage)
Where
recruited
Blumenthal
et al86
Bucknall et al87
158
50
44
Severe (stage 3)
Secondary care
464
69.1
37
Secondary care
de Blok et al88
21
64.1
43
de Godoy
and de Godoy89
DoneskyCuenco et al90
Effing et al91
30
60.5
73
I, severe (stage 3)
C, severe (stage 3)
I, moderate (stage 2)
C, severe (stage 3)
Severe (stage 3)
41
70
28
Primary care
142
63.4
59
Eli et al92
Emery et al93
78
79
58.9
66.6
85
47
I, moderate (stage 2)
C, severe (stage 3)
I, moderate (stage 2)
C, severe (stage 3)
Severe (stage 3)
Severe (stage 3)
Gift et al94
26
68.5
31
Moderate (stage 2)
Primary care
Griffiths et al95
200
68.3
60
Severe (stage 3)
Gell et al96
40
67
94
Severe (stage 3)
Hospes et al97
39
62.2
60
Moderate (stage 2)
Secondary care
Hynninen et al98
51
61
49
Moderate (stage 2)
Secondary care
Kapella et al99
23
63
83
Community
Kayahan et al100
45
66
87
I, moderate (stage 2)
C, moderate (stage 2)
Moderate (stage 2)
Kunik et al101
53
71.3
83
Severe (stage 3)
Secondary care
Kunik et al102
238
66.3
97
Severe (stage 3)
Primary care
Lamers et al103
187
71
60
Primary care
Livermore et al104
41
73.4
44
Mild to moderate
(stage 1 to 2)
Moderate (stage 2)
Lolak et al105
83
67.7
37
Severe (stage 3)
Secondary care
Lord et al106
28
67.4
Severe (stage 3)
Secondary care
McGeoch et al107
159
71
Not
stated
59.5
Moderate (stage 2)
Primary care
zdemir et al108
50
62.5
100
Moderate (stage 2)
Tertiary care
Paz-Daz et al109
24
64.5
73
Severe (stage 3)
Secondary care
Ries et al114
119
62.6
73
Severe (stage 3)
Primary care
Sassi-Dambron
et al110
Spencer et al111
89
67.4
55
Moderate (stage 2)
Secondary care
59
66
46
Moderate (stage 2)
Secondary care
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Tertiary care
Secondary care
Secondary care
Tertiary care
Primary care
Tertiary care
Secondary care
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Depressed
at baseline
Anxious
at baseline
Depression
assessment
Anxiety
assessment
No
No
BDI
STAI
Yes
Yes
HADS
HADS
No
No
BDI
N/A
I, 40.3 (12.6)
C, 35.6 (11.3)
I, 10 (4.5)
C, 9.3 (4.6)
N/A
Yes
Yes
BDI
BAI
No
No
CES-D
STAI
No
No
HADS
HADS
No
No
No
No
HADS
SCL-depression
HADS
SCL-anxiety
No
No
N/A
STAI
I, 13.4 (8.3)
C, 10.9 (7.4)
I, 8.5 (3.9)
C, 8.3 (4.1)
I, 12.6 (95% CI 7.517.7)
C, 12.9 (95% CI 8.517.2)
I, 13.7 (8.9)
C, 14.9 (11.5)
I, 9.5 (4.5)
C, 12.6 (9.4)
I, 4.4 (3.5)
C, 4.6 (4)
Not reported
I, 59.2 (7.6)a
I, 55.5 (5.3)b
C, 60 (7.7)
N/A
No
No
HADS
HADS
No
No
SCL-90-R
SCL-90-R
No
No
BDI
N/A
Yes
Yes
BDI-II
BAI
Unknown
Unknown
POMS-D
POMS-A
No
No
HAM-D
HAM-A
No
No
GDS
BAI
Yes
Yes
BDI-II
BAI
Yes
No
BDI-II
SCL
No
No
HADS
HADS
No
No
HADS
HADS
No
No
HADS
HADS
No
No
HADS
HADS
No
No
HADS
HADS
No
No
BDI
STAI
No
No
CES-D
N/A
No
No
CES-D
STAI
No
No
HADS
HADS
I, 7.3 (3.2)
C, 7.5 (4.3)
I, 1.3 (0.8)
C, 0.6 (0.6)
I, 8.4 (5.2)
C, 9.1 (8.3)
I, 20.7 (8.6)
C, 20.5 (9.7)
I, 9.9 (10.3)
C, 10.4 (8.2)
I, 5.43 (4.8)
C, 7.18 (6.5)
I, 11.5 (0.3)
C, 7.7 (5.4)
I, 23.4 (12.5)
C, 21.1 (12)
I, 17.1 (6.5)
C, 18.3 (7.2)
I, 3.9 (2.1)
C, 4.1 (2.8)
I, 6.6 (4)
C, 4.9 (3)
I, 5.7 (2.8)
C, 5.8 (3.6)
I, 4.6 (3.7)
C, 4.1 (2.9)
I, 6 (3)
C, 7.0 (4.6)
I, 14 (8)
C, 18 (8)
I, 14.0 (8.7)
C, 15.3 (10)
I, 14.2 (10.2)
C, 11.9 (7.6)
I, 4 (2)
C, 5 (3)
I, 12.9 (6.9)
C, 10.9 (9.8)
I, 30.2 (8)
C, 33.8 (9)
I, 4.6 (3.3)
C, 4.8 (4)
Not reported
I, 54.3 (7.2)a
I, 54.0 (5.3)b
C, 53.4 (4.5)
I, 45 (9)
C, 37 (6)
I, 8.6 (4.7)
C, 8.9 (4.3)
I, 1.0 (0.5)
C, 0.6 (0.7)
N/A
I, 17.5 (7.3)
C, 17.5 (9.5)
I, 9.4 (8.2)
C, 8.6 (3.7)
I, 8.91 (6.9)
C, 7.91 (6.6)
I, 15.3 (9.2)
C, 10 (6.8)
I, 22.67 (14.2)
C, 23 (13.9)
I, 20.6 (6.2)
C, 20.4 (7.3)
I, 5.2 (2.9)
C, 5.9 (2.7)
T, 6 (4.3)
C, 6.35 (3.8)
I, 6.3 (3.1)
C, 5.3 (2.6)
I, 6.2 (4.2)
C, 5.3 (3.6)
I, 6.8 (3.2)
C, 7.1 (4.9)
I, 35 (26)
C, 33 (25)
N/A
I, 33.8 (9.7)
C, 34.1 (9.5)
I, 6 (3)
C, 6 (3)
(Continued)
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Table 1 (Continued)
Reference
Sample
size
Mean
age, years
Males
(%)
COPD severity
(GOLD stage)
Where
recruited
Taylor et al112
116
69.5
46
Moderate (stage 2)
Primary care
Yeh et al113
10
65.5
60
Moderate (stage 2)
Secondary care
Alexopoulos
et al68
Gurgun et al65
138
68.5
Severe (stage 3)
Tertiary care
46
64.7
Not
stated
95.6
Severe (stage 3)
Tertiary care
Jiang et al69
100
64.9
5
69.75
Tertiary care
Wadell et al66
48
55.8
56
Walters et al67
182
67
52.5
Moderate (stage 2)
Primary care
Tertiary care
Notes: aComparison 1, exercise, education, and stress management. bComparison 2, education and stress management.
Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; CES-D, Centre for Epidemiologic Studies Depression Scale; C, Control group; CI, confidence
interval; COPD, chronic obstructive pulmonary disease; GDS, Geriatric Depression Scale; GOLD, Global Initiative for Chronic Obstructive Lung Disease; HADS, Hospital
Anxiety and Depression Scale; HAM-A, Hamilton Anxiety Rating Scale; HAM-D, Hamilton Depression Rating Scale; I, intervention group; N/A, not applicable; POMS-A,
Profile of Mood States Anxiety scale; POMS-D, Profile of Mood States Depression scale; SCL, Symptom Checklist; SCL-90-R, Symptom Checklist-90-Revised; SD, standard
deviation; STAI, State Trait Anxiety Inventory.
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Depressed
at baseline
Anxious
at baseline
Depression
assessment
Anxiety
assessment
No
No
HADS
HADS
No
No
CES-D
N/A
I, 6.1
C, 6.7
N/A
Yes
N/A
HAM-D
N/A
No
No
HADS
HADS
No
No
HADS
STAI
I, 5.4
C, 4.8
I, 14 (1146)
C, 12 (217)
(median, range)
I, 24.72 (3.86)
C, 24.80 (3.46)
I, 8.4 (3.1)a
I, 6.8 (3.6)b
C, 8.8 (4.5)
I, 7.16 (3.02)
C, 7.08 (2.92)
No
No
HADS
HADS
No
No
HADS, CES-D
HADS
I, 5.1 (3.3)
C, 4.2 (2.9)
HADS: I, 4.6 (3.1)
C, 5.1 (3.6)
CES-D: I, 4.6 (3.1)
C, 5.1 (3.6)
I, 5.8 (3.5)
C, 4.5 (2.8)
I, 6.7 (4.1)
C, 7 (4.1)
Methods
The methods used to search, select, extract, and analyze data
resembled that reported in the original systematic review.62
To avoid repetition, we will only briefly present some key
methodological aspects of this updated systematic review.
Eligibility criteria
Studies had to fulfill the following criteria to be included in
the review (see Coventry etal62 for more details):
Study design cluster or individual randomized controlled trials
Population individuals with COPD confirmed by postbronchodilator spirometry of forced expiratory volume in
1 second/forced vital capacity ratio of 70%, and a forced
expiratory volume in 1 second of 80%
N/A
I, 9.1 (5.6)a
I, 6.8 (4.9)b
C, 8.8 (4.5)
Trait anxiety:
I, 42.91 (6.78)
C, 42.46 (7.04)
Data analysis
Meta-analyses using random effects models were undertaken
to assess the effectiveness of different types of complex
interventions on reducing symptoms of depression and
anxiety in those with COPD. Effect sizes were expressed
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Intervention
Control group
Lifestyle
components
Psychological
components
Alexopoulos
et al68
Problem-solving techniques
Usual care
Education
Problem-solving techniques
Blumenthal
et al86
Telephone-based
coping skills training
General education
Relapse prevention
Problem-solving techniques
CBT relaxation
Bucknall et al87
Supported self-management
General education,
skills training
de Blok et al88
de Godoy
and de Godoy89
CBT, physiotherapy,
exercise and education
Miscellaneous
(empowerment and
increased self-efficacy)
Biofeedback miscellaneous
(physical activity counselling,
motivational interviewing)
CBT relaxation
Miscellaneous (logotherapy)
DoneskyCuenco
et al 200990
Effing et al91
Yoga training
Eli et al92
PR
Emery et al93
Treatment
a.Exercise, education
and stress management
Treatment
b.Education and stress
management
Progressive muscle relaxation
with prerecorded tapes
Multidisciplinary PR
Gift et al94
Griffiths et al95
Psychotherapeutic exercise;
self- management education
General education
Exercise skills training,
behavior therapy
General education
Exercise
Skills training
Exercise
Skills training
Miscellaneous (relaxation)
General education
Skills training
Exercise
Problem-solving techniques
General education
Exercise
Skills training
General education
Group discussion
Exercise
Miscellaneous
(psychological counseling)
Participants instructed to
sit quietly for 20 minutes
Standard medical management
N/A
General education
Exercise
Skills training
CBT relaxation
Miscellaneous
(stress management)
Gell et al96
PR including breathing
training and exercise
Usual care
Gurgun et al65
Usual care
General education
Exercise
Skills training
Exercise, education
Usual care
Exercise
Hynninen et al98
CBT
N/A
Jiang et al69
Skills training
CBT, relaxation
Kapella et al99
Uncertainty management
with CBT
CBT
COPD education
N/A
CBT
Kayahan et al100
PR
Usual care
General education
Exercise
Skills training
Relaxation
Hospes et al97
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Relaxation
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Sessions (n)
Session length
(minutes)
Delivered by
Delivery method
Follow-up
30 (for discharge
session)
Social workers
28 weeks
12
30
Clinical psychologists,
social workers
22
40
Respiratory nurses
Individual, face-to-face
52 weeks
30
Physical therapists
9 weeks
24 exercise sessions
24 physiotherapy sessions
12 psychotherapy sessions
24
Not reported
Respiratory physicians
Group, face-to-face
12 weeks
60
Group, face-to-face
12 weeks
120 education
sessions
Respiratory nurse
and physiotherapist
Group, face-to-face,
and remote
28 weeks
90
Nurse
Individual, face-to-face,
and remote
4 weeks
37 exercise classes
16 lectures
10 stress management sessions
240
(all modules)
Respiratory specialists
and clinical psychologist
Group, face-to-face
10 weeks
20
Individual, face-to-face
4 weeks
18
120
Group, face-to-face
6 weeks
Phase 1, 16 sessions
Phase 2, 40 sessions
30
Occupational therapist,
physiotherapist, dietetic staff,
specialist respiratory nurse, and
a smoking cessation counselor
Not reported
Group, face-to-face
16 weeks
16
6080
Not stated
Not stated
8 weeks
30
Individual, face-to-face
12 weeks
60
Group, face-to-face
4 weeks
35
Telephone
40 weeks
Not reported
Group, face-to-face
6 weeks
24
150
8 weeks
12 weeks
(Continued)
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Table 2 (Continued)
Reference
Intervention
Control group
Lifestyle
components
Psychological
components
Kunik et al101
CBT
COPD education
N/A
CBT
Kunik et al102
COPD education
N/A
CBT
Usual care
Skills training
Singing teaching
Usual care and education
on the use of a written
self-management plan
Water-based PR
Usual care
Usual GP care
N/A
General education
Exercise
Skills training
Skills training
General education
Skills training
Problem-solving
techniques CBT
CBT
Relaxation (Bernstein
and Borkovec method)
Usual care
Exercise
N/A
Usual care
Ries114
Exercise rehabilitation
program
Pulmonary rehabilitation
Miscellaneous (relaxation
techniques)
Relaxation miscellaneous
(psychological support)
Sassi-Dambron
et al110
Dyspnea self-management
training
Exercise
Skills training
General education
Exercise
Skills training
General education
Group discussion
Skills training
Spencer et al111
Supervised outpatient-based
exercise plus unsupervised
home exercise
Disease-specific selfmanagement program
Unsupervised exercise
Exercise
Usual care
Skills training
Wadell et al66
PR
Usual care
Exercise, education
Walters et al67
Usual care
Education,
skills training
Exercise
Lamers et al103
Livermore et al104
Lolak et al105
Lord et al106
McGeoch et al107
zdemir et al108
Paz-Daz et al109
Taylor et al112
Yeh et al113
Usual care
Relaxation
N/A
Relaxation (progressive
muscle relaxation)
Miscellaneous (self-talk
and panic control)
N/A
Abbreviations: CBT, cognitive and behavioral therapy; COPD, chronic obstructive pulmonary disease; GP, general practitioner; N/A, not applicable; PR, pulmonary
rehabilitation.
Results
The updated searches yielded 736 citations excluding
duplicates. Of these, 714 citations were excluded at the title
and abstract screening stage. The full texts for 22 citations
were retrieved and checked against the eligibility criteria of
the review. Following full-text screening, we identified five
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Sessions (n)
Session length
(minutes)
Delivered by
Delivery method
Follow-up
120
60
Group, face-to-face
and individual, remote
Group, face-to-face
6 weeks
8
Average of 4 contacts
60
Board-certified
gero-psychiatrist
Psychology interns and
postdoctoral fellows
Primary care nurses
Individual, face-to-face
12 week
4
12
60
60
Clinical psychologist
Multidisciplinary PR team
Individual, face-to-face
Group, face-to-face
6 weeks
8 weeks
12
1
60
60
Group, face-to-face
Individual, face-to-face
7 weeks
24 weeks
12
35
Group, face-to-face
4 weeks
24
85
Singing teacher
Practice nurse or respiratory
educator in association
with GP
Physiotherapist
and chest physician
Not reported
Group, face-to-face
8 weeks
12
240
Not reported
Group, face-to-face
8 weeks
Not reported
Graduate student
in psychology and
a clinical nurse
Group, face-to-face
6 weeks
52
50
Physiotherapist
Group, face-to-face
12 weeks
150
Group, face-to-face
8 weeks
24
210
COPD nurse
Face-to-face
8 weeks
16
30
Telephone
24 weeks
24
60
Community health
nurses
Tai Chi instructors
Group, face-to-face
12 weeks
4 weeks
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Reference
Forest plot
%
weight
CBT
Blumenthal96
Hynninen98
Kapella99
Kunik101
Kunik102
Lamers103
Livermore104
Alexopoulos68
Jang69
Walters67
Subtotal (l2=9.7%, P=0.353)
13.49
5.94
2.26
5.72
13.68
13.93
4.77
12.75
10.79
16.67
100.00
Self-management education
Bucknall87
Emery93,b
McGeoch107
Sassi-Dambron110
Taylor112
Subtotal (l2=0.0%, P=0.668)
34.72
8.68
27.92
14.01
14.67
100.00
2.60
4.06
10.66
7.67
6.14
11.81
4.86
4.87
5.63
5.34
6.02
3.11
9.81
5.97
3.24
3.04
5.16
100.00
Relaxation
Donesky-Cuenco90
Lord94
Yeh113
Subtotal (l=0.0%, P=0.552)
43.64
41.65
14.71
100.00
1.5
1
Intervention
0.5
0.5
1
Control
1.5
1300
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%
weight
12.54
10.52
7.08
10.40
12.57
12.62
9.77
11.57
12.93
100.00
Bucknall87
Emery93,a
26.78
12.90
McGeoch107
24.68
Sassi-Dambron110
Taylor112
Subtotal (l2=48.1%, P=0.103)
17.66
18.00
100.00
5.65
10.71
8.27
7.68
11.47
6.42
7.13
6.89
7.62
4.81
7.52
4.60
4.36
6.87
100.00
Donesky-Cuenco90
Gift94
35.14
31.42
Lord106
Subtotal (l2=0.0%, P=0.945)
33.44
100.00
Reference
Forest plot
CBT
Blumenthal86
Hynninen98
Kapella99
Kunik101
Kunik102
Lamers103
Livermore104
Jang69
Walters67
Subtotal (l2=81.4%, P=0.000)
Self-management education
1.5
0.5
Intervention
0.5
1
Control
1.5
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Acknowledgments
PC is funded by the National Institute for Health Research
Collaboration for Leadership in Applied Health Research
and Care for Greater Manchester. The views expressed in this
paper are those of the authors and not necessarily those of
the National Institute for Health Research, National Health
Service, or the Department of Health. We thank Liz Baker
and Dr Cassandra Kenning for supporting searches and the
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Disclosure
The authors report no conflicts of interest in this work.
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