424

Anxiety and Depression in Chronic Obstructive Pulmonary Disease:

A N e w Intervention and Case Report
Melinda A. Stanley, Baylor College of Medicine, Houston Center for Quahty of Care and
Utzlzzatzon Studzes, a n d Michael E. DeBakey Veterans Affairs Medzcal Center
C o n n i e Veazey, Northwestern State University of Louisiana
D e r e k H o p k o , Unwersity of Tennessee-Knoxville
G r e t c h e n Diefenbach, The Institute of Lw~ng
Mark E. Kunik, Baylor College of Medzcine, Mzchael E. DeBakey Veterans Affazrs Medical Center, a n d
Veterans Affairs South Central Mental Illness Research, Educatzon, and Clinical Center

Anxzety and depmsston coexistfrequently zn chronzc obstructwepulmona~:y dzsease and compound the tmpact of the dzsease on qual-
ity of bfe and functzonal status Howev~ httle attentzon has been gwen to the development of treatment strategtesfor thzs subset of
patzents. The current artzcle describes the development of a new, mult~component cognztzve behavzoral treatmentfor reduczng anxzety
and depresswn among patzents wtth respiratory dzsease (CBT-RADAR). Outcome data from a group of 5 patzents who partzczpated
zn an ongoing clzn~cdlthai are revzewedto dlu~trate the strengths and hmztatlons of thzs mterventwn

(COPD) i s a rates are evident using self-report case identification

C
H R O N I C OBSTRUCTIVE PULMONARY DISEASE

serious and progressive medical illness with a pro-
found impact on life function, economic burden, and
mortality. Physical symptoms include shortness of breath,
chest pain, cough, weakness, fatigue, poor exercise toler-
ance, nutritional abnormalities, and damage to the heart
and brain. The disease affects 14 to 20 million people and
is the fourth leading cause of death in the United States
(Centers for Disease Control, 2003). Hospital readmis-
sion occurs frequently, and general rates of service use
are high (Centers for Disease Control, 2005). Associated
economic costs are estimated at $24 billion per year (Sul-
livan, Ramsey, & Lee, 2000). Quality of life and functional
status are severely impaired as a result of both the physi-
cal symptoms and limitations of COPD and frequently
coexistent psychological difficulties.
Coexistent anxiety and depression are particularly
common in COPD (Borson, Claypoole, & McDonald, 1998,
Brenes, 2003). In many cases, the symptoms of COPD over-
lap with those of anxiety or depression (e.g., sleep dis-
turbance, decreased energy, shortness of breath, and cat-
astrophic thoughts about physical symptoms) and
differential diagnosis is difficult. Nevertheless, anxiety
and depressive diagnoses have been established via chni-
cal interview in 16% to 34% of patients with COPD
(Karajgi, Rlfkin, Doddi, & Kolh, 1990; Yellowlees, Alpers,
Bowden, Bryant, & Ruffin, 1987). Higher prevalence
Cognitive and Behavioral Practice 12, 4 2 4 - 4 3 6 , 2005
1077-7229/05/424-43651 00/0
Copyright 2005 by Association for Advancement of Behavmr
Therapy. All rights of reproduction m any form reserved
strategies (Aydin & Ulusahin, 2001; Moore & Zebb, 1999;
van Manen et al., 2002; Yohannes, Baldwin, & Connolly,
2003). Subclinical anxiety or depressive symptoms (de-
fined as the presence of clinically significant anxiety or
depression regardless of psychiatric diagnostic status)
also are more common, with reported prevalence as high
as 50% (Borson et al, 1998; Brenes, 2003). The presence
of anxiety a n d / o r depressive symptoms in COPD, even
without confirmed psychiatric diagnosis, compounds the
impact of the disease on quality of life and functional sta-
tus even when controlling for disease severity (Brenes,
2003; Kim et al., 2000; Moore & Zebb, 1998; Peruzza et
al., 2003; Yohannes et al., 2003). For patients with COPD,
anxiety and depressive symptoms are associated vnth
more frequent hospital admissions (Yohannes, Baldwin,
& Connolly, 2000), greater duration of hospitalization
(Yohannes et al., 2000), increased avoidance of potenually
therapeutic activities that require exeruon Cgellowlees et al.,
1987), and poorer outcomes following emergency treat-
ment (Dahl6n &Janson, 2002).
Usual care for COPD typically focuses on manage-
ment of physiological symptoms, with long-acting bron-
chodilators, inhaled cortlcosteroids, and oxygen therapy
associated with symptom reduction (Sin, McAlister, Man,
& Anthonxsen, 2003). Comprehensive, multidisciphnary
rehabalitataon programs (i.e., "pulmonary rehabilitation")
that incorporate exercise training, patient/family educa-
tion, and psychosocial intervention (e.g., stress manage-
ment) may significantly improve health status and quality
of life (American Thoracic Society, 1999). The impact of
psychosocial components of rehabilitation, however, is
 Anxiety and Depression in COPD
not always clear. Some studies show positive effects of
stress management (e.g., education, relaxation, cognitive
interventions, etc.) for reducing anxiety and depressive
symptoms and increasing functional status among pa-
tients with COPD (Blake, Vandiver, Braun, Bertuso, &
Straub, 1990; de Godoy & de Godoy, 2003; Gift, Moore,
& Soeken, 1992), while other studies demonstrate no
unique benefits of stress management over and above tra-
ditional rehabilitation strategies (Emery, Schein, Hauck,
& MacIntyre, 1998; Sassi-Dambron, Eakin, Ries, & Kap-
lan, 1995). None of these studies, however, focused on
the treatment of patients with clinically significant anxi-
ety a n d / o r depressive symptoms. A more systematic ef-
fort toward investigating the potenual benefits of psycho-
social treatment for anxiety and depressive symptoms in
patients with COPD is needed. The potential importance
of such an effort aimed at improving quality of life for pa-
tients with COPD, even when full diagnostic criteria for
anxiety and depression are not met, is underscored by
data documenting the impact of subthreshold cases of
anxiety or depression on functional status, health care,
and increased risk for developing a psychiatric disorder
(Cuijpers & Smit, 2004; de Beurs et al., 1999; Katon, Lin,
Russo, & Uniitzer, 2003).
Only two controlled studies and a series of case studies
have examined the efficacy of pharmacological treat-
m e n t for anxiety a n d / o r depressive symptoms in COPD,
with some support for the utility of sertraline and bus-
pirone (Argyropoulou, Patakas, Koukou, Vasiliadis, &
Georgopoulos, 1993; Borson et al., 1992; Papp et al.,
1995; Smoller, Pollack, Systrom, & Kradin, 1998). How-
ever, because other research has indicated no benefits of
pharmacological treatment (Borson et al., 1998), more
controlled trials are needed to evaluate the efficacy and
effectiveness of antidepressant and antianxiety medica-
tions. Moreover, given the complications and potential
limitauons of prescribing psychotropic medications for
patients with a serious medical illness, nonpharmacologi-
cal treatments for managing anxiety and depression in
COPD should be considered.
In this domain, the potential benefits of cognitive be-
havior therapy (CBT) for treating anxiety and depression
in COPD are of particular interest given the established
efficacy of this approach (Barlow, 2003; DeRubeis & Crits-
Christoph, 1998; Martell, Addis, &Jacobson, 2001). The
direct, collaborative, short-term nature of CBT to symp-
tom management is well suited to both medically ill and
aging populations (e g., Zeiss & Steffan, 1996), and re-
cent surveys indicate that older medical patients often
prefer and benefit from CBT (Are~in & Miranda, 1997;
Landreville, Landry, Bailtargeon, Guerette, & Matteau,
2001; Stanley, Hopko, et al., 2003; Umitzer et al., 2002).
Insufficient attention, however, has been given to the de-
velopment of a cognitive behavioral intervention to tar-
425
get the treatment of anxiety a n d / o r depressive symptoms
as experienced by patients with COPD (Rose et al., 2002).
In one study, patients with COPD and coexistent anxiety
were treated with psychotherapy that focused on educa-
tion about the role of anxiety in breathlessness and coping
skills (e.g., relaxation training) aimed at anxiety reduction
(Eiser, West, Evans,Jeffers, & Quirk, 1997). Increased exer-
cise tolerance was demonstrated relative to a control con-
dition, but sample size was small and pretreatment group
differences were evident. Furthermore, the psychosocial
intervention was limited in scope. A broader and more
comprehensive treatment model that simultaneously ad-
dressed clinically significant anxiety and depressive symp-
toms in the context of the symptoms and consequences of
severe respiratory difficulties would be useful in delineat-
ing the benefit of CBT for people with COPD.
Very little psychosocial outcome work has focused spe-
cifically on the concurrent treatment of anxiety and de-
pressive symptoms, despite high rates of coexistence and
evidence that changes in anxiety and depression co-occur
following treatment (Persons, Roberts, & Zalecki, 2003).
In patients with chronic medical illness, where differen-
tial diagnosis of mental health problems is complicated
and the presence of anxiety a n d / o r depressive symptoms
may further impair functional status, a broad treatment
designed to accommodate a variety of symptom patterns
representing anxiety, depressmn, and somatic complaints
would be optimal (Lenze et al., 2001). In a preliminary
study exploring this hypothesis, 53 patients with COPD
were assigned randomly to receive a single 2-hour group
session of CBT or COPD-education, with six subsequent
weekly follow-up calls (Kunik et al., 2001 ). Outcome data
suggested a decrease in anxiety and depressive symptoms
from pre- to posttreatment in CBT, relative to COPD-
education, and adequate patient satisfaction in both groups.
Sample size was small, however, and patients were not se-
lected based on the presence of coexistent anxiety a n d /
or depressive symptoms. In addition, CBT components
were limited to those typically utilized for the treatment
of anxiety (education, relaxation, cognitive strategies,
and fear-based exposure). The role of other potentially
important interventions for anxious a n d / o r depressed
patients with medical illness (e.g., problem-solving, sleep
hygiene, behavioral activation) was not explored.
This article describes a more comprehensive approach
to treating anxiety a n d / o r depressive symptoms in pauents
with severe respiratory difficulties. The notion of integrated
treatment for anxiety and depression has been advocated in
recent theoretical articles and case reports (Barlow, Allen &
Choate, 2004; Hopko, Lejuez, & Hopko, 2004; Westra,
2004). The treatment described here, currently under-
going efficacy testing in a randomized controlled trial
(RCT), integrates two intervention models with docu-
mented efficacy and potential utility for medical patients:
426
* CBT-GAD/PC. a cognitive behavioral approach for
treating anxiety m older medical patients (Stanley,
Diefenbach, & Hopko, 2004)
Behavioral activation (BA): a key c o m p o n e n t of
CBT treatments for depression (Hopko, Lejuez,
Ruggiero, & Eifert, 2003; Jacobson, Martell, & Di-
midjian, 2001; Lejuez, Hopko, & Hopko, 2002; Mar-
tell et al., 2001)
CBT-GAD/PC incorporates a range of coping skills (edu-
cation/awareness, relaxation training, cognitive therapy,
problem-solving skills training, a n d sleep m a n a g e m e n t
skalls) to target symptoms of generalized anxiety dxsorder
(GAD) in later life. Initial o u t c o m e data suggest improve-
m e n t s following CBT-GAD/PC, relative to usual care, for
both anxiety a n d depressive symptoms in older medical
patients (Stanley, Hopko, et al., 2003). However, a key
c o m p o n e n t of CBT for depression, namely, BA t a r g e u n g
non-fear-related behaviors, was n o t i n c l u d e d given the
focus of CBT-GAD/PC o n anxiety. I n light of r e c e n t data
highlighting BA as the potential primary m e c h a n i s m of
change in r e d u c i n g depression symptoms (Hopko et al.,
2003; Martell et al., 2001), a n d because patients with res-
piratory difficulties often experience significant decreases
m ability to carry out previously rewarding activities
(whether due to real or i m a g i n e d physical limitations),
systematic i n c o r p o r a t i o n of c o n t e m p o r a r y BA strategies
was d e e m e d i m p o r t a n t for the d e v e l o p m e n t of a compre-
hensive i n t e r v e n t i o n for patients with coexistent COPD
a n d anxiety/depressive symptoms.
This article describes CBT-RADAR, a new multi-
c o m p o n e n t cognitive behavioral i n t e r v e n t i o n for reduc-
ing anxiety a n d depression a m o n g patients with respira-
tory disease. CBT-RADAR allows pauents to develop a
b r o a d "toolbox" of slolls that can be used to m a n a g e clin-
ically significant anxiety, depressive a n d somatic symptoms,
a n d ultimately increase the quality of llfe a n d functional
status of individuals with chronic illness All t r e a t m e n t
c o m p o n e n t s can be administered in a direct b u t collabo-
rative m a n n e r over a relatively brief t r e a t m e n t interval
(eight sessions). A group format was selected to reduce
potentml costs a n d increase social support. Here, the
t r e a t m e n t m o d e l is described along with five case exam-
ples from a n o n g o i n g RCT to illustrate the use of CBT-
RADAR a m o n g patients with COPD.
Method
Participants
Participants i n c l u d e d five male veterans recruited for
an RCT of CBT-RADAR relative to a COPD-education
control c o n d i t i o n Full r e c r u i t m e n t procedures are de-
tailed elsewhere (Kumk et al., 2005). Patients were in-
cluded in the RCT based o n an initial t e l e p h o n e screen,
Stanley et al.
s u b s e q u e n t c o n f i r m a t i o n of COPD via portable spirome-
try (a device that measures how well lungs exhale), a n d
identification of clinically significant anxiety a n d / o r de-
pressive symptoms according to a score of 16 or higher
o n the Beck Anxiety Inventory (BAI; Beck & Steer, 1993)
a n d / o r a score of 14 or higher o n the Beck Depression
Inventory-II (BDI-II: Beck, Steer, & Brown, 1996).1 Eligi-
ble patients also d e m o n s t r a t e d adequate cognitive func-
t i o n i n g as d e t e r m i n e d by a Mini Mental State Examina-
tion score of 24 or higher (MMSE; Folstein, Folstein, &
McHugh, 1975). After they were d e t e r m i n e d eligible for
inclusion, patients were interviewed using the Structured
Diagnostic Interview for D S M - I V (SCID; First, Spitzer,
Gibbon, & Williams, 1996) to characterize the sample ac-
cording to psychiatric diagnostic status for secondary out-
come analyses in the RCT. Patients were assigned randomly
in small groups to CBT-RADAR or COPD-education. T h e
five patients to be discussed here were assigned r a n d o m l y
to o n e CBT-RADAR group within the RCT. This group
was selected as a case example given the wide range of
clinical symptoms a n d experiences represented. All pa-
tients were treated in the same g r o u p by the same thera-
pist (Veazey), with clinical supervision by the first a u t h o r
(Stanley) a n d r a n d o m review of session audiotapes by an in-
d e p e n d e n t expert in both CBT-GAD/PC a n d BA (Hopko).
Descriptive data for these five patients, i n c l u d i n g D S M - I V
dlagnosuc status according to the SCID, are p r e s e n t e d in
Table 1. Baseline scores o n all o u t c o m e measures are
i n c l u d e d in Table 2.
Bill experienced moderately severe COPD, a n d his
baseline BAI a n d BDI-II indicated anxiety a n d depressive
symptoms well above study cutoffs. Bill r e p o r t e d worry
a b o u t m a n y topics, i n c l u d i n g the state of the country
since September 11, the economy, his m o t h e r (who was
currently sick with breast cancer), his j o b security, a n d
the safety of the p l a n t in which he worked. He acknowl-
1A B~d cutoff score of 16 was selected given that scores of this
magnitude represent moderate to severe anxiety (Beck & Steer, 1993)
and because a cut point at this level balances well specificity(67) and
sensiuvlty (.62) for ldennfymg anxiety among older adult psychiatric
patients (Kabacoff, Segal, Hersen, & Van Hasselt, 1997) This score
also represents anxiety seventy that Is approximately two standard
deviations above the mean for an older normal commumty sample
(age 45-65, Gilhs, Haaga, & Ford, 1995, mean = 4 4, SD = 6.3) and
one standard dewatlon above the mean for an older medical sample
(age 60-84, Steer. Wallman,Kay,& Beck, 1994, mean = 7 2; SD = 6 78)
A BDI-II cutoff of 14 represents depressive symptoms in the mild
range according to the manual (14-19; Beck et al, 1996), but this
score corresponds with an empiricallyderived cutoff for the BDI that
differentiated community and clinically symptomatic samples of
adults (cutoff = 14 3, Seggar, Lambert, & Hansen, 2002) A score of
14 also IS shghfly higher, and therefore more conservauve, than an
empmcally denved cut point for identifying dysphonc adults accord-
lng to the BDI-II (cutoff = 13; Dozols, Dobson, &Ahnberg, 1998) and
a score that is one standard deviation above a BDI-It mean for male
primary care patients (mean = 5 8, SD = 6.9, Arnau et al, 2001)
 A n x i e t y a n d D e p r e s s i o n in C O P D 427

Table 1
Descriptive Data for Five Patients With COPD Treated With CBT~RADAR

Marital Living
Age Status Situation Occupation Other Medical Problems SCID Diagnosis Medication

Bill 54 yr. Divorced Alone Lab analyst Seasonal allergies; sleep apnea; Generalized Anxiety Disorder; Busplrone
arthritis; hlgh cholesterol;, Major Depression; Panic (1 e Buspar)
eczema; migraine headache; Disorder with Agoraphobia
obesity
Brady 66 yr Marned With wife Retired t e a c h e r / None None Fluoxetine
counselor 0.e. Prozac)
Tim 60 yr. Divorced With sister & Retired off refinery Congestive heart failure, Major Depression; Bnproprion
brother- foreman coronary artery disease, Anxiety NOS
m-law hypertension; obesity
Al 80 yr. Widowed Alone Reured artist; High blood pressure, arthrius, None None
part-time work aortic aneurysm
restoring
old photographs
and paintings
Max 57 yr. Divorced Alone Retired engineer High blood pressure Major Depression; Pamc Depacote;
Disorder with Agoraphobm, Bupropnon
Bipolar Disorder

Note All patients were white males. All medications were stable across treatment. COPD = Chronic Obstructive Pulmonary Disease; CBT-
RADAR = cognitive behawor therapy for reducing anxiety and depressmn a m o n g patients with respiratory disease.

Table 2
Scores at Baseline, Posttreatment, and 1Z-Months for Five Patients With COPD and Coexistent D e p r e s s i v e
a n d / o r Anxiety S y m p t o m s Treated With CBT-RADAR

SF-36 SF-36 N u m b e r of
Patient, CRQ CRQ Physical Mental Outpauent
Tlmepomts BAI BDI Physical Emotional Health Health Visits CSQ

Bill
Basehne 35 38 2.9 24 29 1 28.1 12 N/A
Posttreatment 16 ~ 10 a 3 7a 45a 43 9 ~ 55.4 ~ -- 31
12 m o n t h s 5a 0a 59~ 66~ 28.1 60.0 ~ 3 31
Brady
Baseline 12 24 2.9 48 27 1 36.0 1 N/A
Posttreatment 3a 7a 3.7 a 54a 20 6 57.0 ~ -- 24
12 m o n t h s 14 12 ~ 2.0 46 15 5 b 54.8 ~ 2 25
Tim
Baseline 36 23 26 32 27.6 33.0 2 N/A
Posttreatment 22 a 21 1.9 b 30 31.4 29.5 -- 28
12 m o n t h s 23 a 15 ~ 1.9 b 3.1 28 1 26.3 4 28
Al
Baseline 15 16 3.1 39 35.8 36.6 2 N/A
Posttreatment 10 10 3.0 4.5 a 34 4 39.2 -- 25
12 m o n t h s 19 12 3.2 4.7 a 33 7 39.0 3 24
Max
Baseline 35 26 3.7 28 34 9 18.8 1 N/A
Posttreatment 32 28 28b 33a 30 7 23.2 -- 30
12 m o n t h s . . . . . . . .

Note COPD = Chronic Obstructive Pulmonary Disease, CBT-RADAR = cognitive behavior therapy for reducing anxiety and depression a m o n g
patients with respiratory disease; BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory, SF-36 = Medical Outcomes Survey Short
F o r m - 3 6 (PH = Physical Health; MH = Mental Health); CRQ = Chronic Respiratory Questionnaire, CSQ = Client Satisfaction Questionnaire.
a I m p r o v e m e n t from baseline
b Meaningful worsening of symptoms from baseline.
428 Stanley et al.
e d g e d that it was difficult to stop worrying, a n d r e p o r t e d
b e i n g a worrier all his life. T h e worry h a d Intensified a n d
b e c o m e problemanc over the past 2 years. He r e p o r t e d
trouble concentraung, irritability, muscle tension, difficulty
sleeping, tiring easily, a n d avoidance o f telewsion news due
to worry. Bill also acknowledged two major depressive epi-
sodes in the prior 6 months, with depressed m o o d lasting a
little over 2 weeks each time. H e r e p o r t e d consistent anhe-
d o n i a with avoidance of prevmusly pleasurable activines
(e.g., photography), loss o f appetite, difficulty sleeping, re-
d u c e d energy, a n d feelings of worthlessness and guilt. Bill
r e p o r t e d having at least two panic attacks in the prior 6
months, d u n n g which he worried that he might be having a
heart attack. H e r e p o r t e d associated avoidance of church
serwces, large crowds, a n d crowded restaurants.
Brady h a d severe COPD, a n d h e utilized oxygen ther-
apy 24 hours a day. Baseline depressive symptom severity
was above the study cutoff, a l t h o u g h anxiety severity ac-
c o r d i n g to the BAI d i d n o t e x c e e d the cutoff. Neverthe-
less, Brady's inability to travel easily with his family members
on outings was a source o f anxiety a n d depression. H e
worried that he slowed p e o p l e down given his use o f a
scooter for transportation. Consequently, he frequently
stayed h o m e alone instead o f going o u t with his family.
Tim was f o r c e d to retire 5 years p r i o r to the assessment
due to a c o m p a n y layoff His COPD was severe, a n d he
was on oxygen t h e r a p y 24 hours a day. Baseline anxiety
a n d d e p r e s s i o n were b o t h well above study cutoffs. H e
r e p o r t e d d e p r e s s e d m o o d on almost a daily basis since re-
t i r e m e n t a n d significant social withdrawal. A l t h o u g h Tim
was socially active when he was working (he enjoyed danc-
ing a n d a t t e n d i n g high school sporting events), he felt
that he h a d b e e n "shutting down" since his retirement. At
the time o f the assessment, Tim r e p o r t e d s p e n d i n g most
o f his time watching television. H e also r e p o r t e d diffi-
culty sleeping, with f r e q u e n t awakenings d u r i n g the
mght, physical restlessness, r e d u c e d energy, a n d mild
m e m o r y problems. H e a c k n o w l e d g e d having thoughts
that he would be b e t t e r off dead, b u t he d e n i e d any plans
to kill himself. Tim also r e p o r t e d u n e x p e c t e d p a m c at-
tacks over the last several years. While he was n o t con-
c e r n e d that he was going crazy d u n n g these attacks, he
worried that he m i g h t die. These symptoms d i d n o t war-
r a n t a diagnosis o f panic disorder, as they o c c u r r e d only
at times when he was having t r o u b l e b r e a t h i n g
A1 e x p e r i e n c e d m o d e r a t e l y severe COPD. T h e arthri-
tis in his h a n d s also m a d e his art restoration work diffi-
cult. H e a d m i t t e d to b e i n g "slightly depressed," a n d his
baseline BDI-II score was above the study cutoff. A1 h a d
difficulty c o m p l e t i n g tasks in a timely m a n n e r ; he pro-
crastinated worl~ng on j o b s a n d spent a great deal o f time
sitting a n d watching television. H e expressed a desire to
increase his behaviors to accomplish tasks a n d r e p o r t e d
that he currently was seeing a "motivational counselor."
Max h a d severe COPD, a n d he was on oxygen therapy
24 hours a day. Baseline scores suggested anxiety a n d de-
pressive symptoms well above study cutoffs. Max s p e n t his
spare time watching TV a n d writing letters. Max en-
d o r s e d symptoms o f d e p r e s s e d m o o d , lack o f appetite,
p s y c h o m o t o r agitation, d e c r e a s e d energy, a n d trouble
concentrating. H e also e x p e r i e n c e d panic attacks a n d
avoided going grocery shopping, r u n n i n g o t h e r errands,
a n d a t t e n d i n g c h u r c h services a n d AA meetings. H e was
fearful that he would b e c o m e so short of b r e a t h that he
m i g h t die, a n d he was c o n c e r n e d a b o u t how p e o p l e
might perceive him d u e to his oxygen use.
Measures
A~xzety and depresswn. As n o t e d earlier, the BAI a n d
BDMI were used to establish inclusion criteria r e l a t e d to
anxiety a n d depression severity. These instruments also
were used to evaluate outcome. Both the BAI a n d BDMI
have substantial psychometric s u p p o r t for use a m o n g
o l d e r adults a n d / o r medical patients (Arnau, Meagher,
Norris, & Bramson, 2001; Steer et al., 1994; Wetherell &
Arefin, 1997), a n d b o t h are sensitive to c h a n g e following
CBT (Stanley, Beck, et al., 2003; Wetherell, Gatz, &
Craske, 2003). Meaningful i m p r o v e m e n t on the BDI was
d e f i n e d a c c o r d i n g to an empirically derived Rehable
Change I n d e x (RCI) o f 8.5 that differentiated c o m m u -
nity a d u l t samples from those identified as clinically
symptomatic (Seggar, Lambert, & Hansen, 2002). Given
that no c o m p a r a b l e RCI has b e e n established for the BAI,
a n d because some authors have r e c o m m e n d e d against
use o f this i n d e x for this m e a s u r e (Wilson, de Beurs,
Palmer, & Chambless, 1999), a c h a n g e o f o n e s t a n d a r d
deviation a c c o r d i n g to data for an elderly medical sample
(6.8; Steer et al., 1994) was used to characterize m e a n i n g -
ful i m p r o v e m e n t .
Health-related qualzty of hfe T h e C h r o n i c Respiratory
Q u e s t i o n n a i r e (CRQ; Guyatt, Berman, Townsend, Pugs-
ley,& Chambers, 1987) was designed to m e a s u r e c h a n g e
in COPD-specific quality o f life. T h e C R Q consists o f 20
items a g g r e g a t e d into four dimensions: dyspnea (five
stems); faugue (four items); emotional functioning (seven
items assessing depression, sadness, frustration, worry,
a n d anxiety) ; a n d mastery (four items that assess feelings
o f control over the disease). Response options are pre-
s e n t e d as seven-point L i k e r t scales (1 = poorestfunctmn;
7 = optzmalfunctzon). T h e C R Q is precise, valid, respon-
sive, c o m m o n l y used, a n d d e s i g n e d for clinical trials that
seek to modify e m o t i o n a l response to COPD (Guyatt,
King, Feeny, Stubbing, & Goldstein, 1999; H a r p e r et al.,
1997). As suggested by Guyatt (2003), scores were aver-
aged to create o n e m e a s u r e o f physical quality o f life
(CRQ-Physical = dyspnea a n d fatigue) a n d o n e measure
o f e m o t i o n a l quality of life ( C R Q - E m o t i o n a l = e m o t i o n
a n d mastery). Meaningful c h a n g e on C R Q scores was
 Anxiety and Depression in COPD
defined according toJaeschke, Singer, and Guyall (1989)
who identified a change of 0.5 as a minimal clinically im-
portant difference (MCID) for patients with respiratory
problems.
Functwnal status. The Medical Outcomes Survey Short
F o r m - 3 6 (SF-36; Ware, 1999) has been validated for use
m patients with COPD (Harper et al., 1997; Mahler &
MacKowlak, 1995) and is widely used to measure quality
of life in medical populations. Since patients with COPD
c o m m o n l y have coexisting illnesses, this scale was in-
cluded to assess intervention effects on well being that
might not be detected by a disease-specific quality o f life
instrument. The SF-36 has eight subscales measuring per-
ceived physical functioning, role disability due to physical
health problems, bodily pain, vitality, social functioning,
role disability due to emotional health problems, and per-
ceptions of mental and general health. Two summary scores
were created to assess functional status related to physical
health (PH) and mental health (MH) functioning, as de-
scribed in Ware (1999). Raw scale scores were transformed
to T-scores, where 50 indicates average functioning (SD =
10). Meaningful improvement for SF-36 PH and MH scores
was determined based on RCI's established by Ferguson,
Robinson, and Splaine (2002; SF-PH = 7.5; SF-MH -- 9.7).
Pat~entsat~sfactzon. Patient satisfaction was assessed
with the Client Sausfaction Questionnaire (CSQ: Larsen,
Attkisson, Hargreaves, & Nguyen, 1979), a widely used 8-
item, empirically derived, self-report measure (e.g., Att-
kisson & Zwick, 1982). Psychometric properties for the
CSQ are adequate (Attkisson & Greenfield, 1999), and
the instrument has been used in prior trials of CBT for
anxiety in later-life medical patients (Stanley, Hopko, et
al., 2003). Scores range from 8 to 32.
Procedures
All procedures for the RCT were approved by the Bay-
lor College of Medicine Institutional Review Board, and
recruitment procedures are detailed in Kunik et al.
(2005). All patients at the Houston VAMC with a diagno-
sis o f a chronic breathing disorder during the prior year
were targeted for recruitment. Eligible and interested pa-
tients were screened by telephone for the presence of
breathing difficulties, anxiety, and depressive symptoms.
Patients were included based on d o c u m e n t e d COPD and
chnically significant anxiety (BAI --> 16) a n d / o r depres-
sive symptoms (BDMI --> 14) as noted earher. Here, treat-
m e n t procedures and outcomes are described for one
group of five patients treated within the o n g o i n g RCT for
CBT-RADAR. Treatment consisted o f eight (1-hour)
weekly sessions, with posttreatment assessments conducted
after the final treatment session. Follow-up assessments
were conducted 12 months after treatment ended. At
baseline and follow-up, patients were queried about the
n u m b e r of outpatient visits over the prior 3 months.
4Z9
Treatment
Sesston I. Orientation, motwationalexer c~ses, educatzon, and
awareness. The initial session focused on therapy orienta-
tion, a discussxon of ethical issues associated with group
therapy, and an overvaew of roles and expectations for lead-
ers and participants. Patients were gwen notebooks to orga-
nize session handouts and home practice exercises. Next,
patients were led through motivational exercises during
which they discussed tile pros and cons of participation.
The remainder of this session involved group discus-
sion of the symptoms of COPD, anxiety, and depression,
with attention to physical symptoms, thoughts, behaviors,
and quality of life. During this discussion, some attempt
was made to consider separately the symptoms character-
istic of anxiety (e.g., expected danger, avoidance) and de-
pression (e.g., perceived loss, withdrawal), but these dis-
tinctions were not considered essential. More important
was an emphasis on recognizing the physical symptoms of
anxiety or depression (e.g., muscle tension; rapid pulse;
anhedonia; decreased appetite), despite potential over-
lap with the symptoms o f COPD (e.g., difficulty breath-
ing, fatigue), and idenufying specific thoughts and be-
haviors associated with negative m o o d states. Themes of
this discussion frequently involved thoughts and behav-
iors related to aging and illness (e.g., patients perceiving
themselves as no longer being "head of the household"),
loss of i n d e p e n d e n c e (e.g., due to inability to drive), and
physical limitations associated with breathing difficulties.
In a review of behavioral symptoms, the group leader
emphasized that overt behaviors occur to (a) avozd nega-
tive outcomes (those that are feared, unrewarding, or
both) a n d / o r (b) obtaln relief (by avoiding something
that is anxiety producing or by elicitlng environmental
rewards such as attention or sympathy from others).
Again, some attempt was made to dxfferentiate behaviors
characteristic of anxiety versus depression, but it was
m o r e important for patients to begin to notice behaviors
that may create relief from anxiety/depression in the
short run but actually produce m o r e anxious or depres-
sive symptoms in the long run. Examples of behavioral
symptoms typical for patients with COPD included pro-
crastinatlon (e.g., putting off beginning a prescribed ex-
ercise program due to fear of increased breathing diffi-
culties), lethargic behaviors (e.g., staying in bed or in
front o f the TV for excessive periods), safety checking
(e.g., repeatedly checking one's own respiration or heart
rate), failure to replace previously enjoyable activities
(e.g., deep sea fishing, hiking) with alternative activities
that were less physically d e m a n d i n g but still pleasurable
(e.g., lake fishing, walking), a n d / o r r e d u c e d social activi-
ties due to embarrassment about breathing problems.
At the e n d o f Session 1, patients were asked to identify
one or two times each day when they could plan to com-
plete practice exercises and were encouraged to record
430 Stanley et al.
one or two experiences p e r day of anxiety o r depression,
noting associated physical, cognitive, a n d behavioral symp-
toms. Patients also were asked to r e c o r d daily activities over
a 1-week p e r i o d to p r o v i d e a baseline assessment that
would guide subsequent behavioral activation assignments.
Session 2. Relaxatum skzlls; creatzon of activz~ hierarchy. As in
all s u b s e q u e n t sessions, Session 2 b e g a n with a review o f
c o m p l e t e d practice exercises, with f u r t h e r attention to
motivational techniques as needed. Two simple relaxation
training exercises were then conducted: one focused on
d e e p b r e a t h i n g a n d the o t h e r on postural changes. The
d u r a t i o n o f the b r e a t h i n g cycle was r e d u c e d given signif-
icant respiratory difficulty in this population. Imaginal
exercises were c o n d u c t e d to facilitate covert practice o f
these c o p i n g strategies in anxiety-producing situations.
Next, p a u e n t s b e g a n to create a hierarchy o f activities
d e s i g n e d b o t h to increase pleasure a n d / o r accomplish-
m e n t a n d to provide e x p o s u r e to anxiety-producing situ-
ations. These different types o f activities typically are n o t
c o m b i n e d in o t h e r m o d e l s o f t r e a t m e n t focused o n re-
d u c i n g the symptoms o f anxiety o r depression. Here,
however, the goal was to e n c o u r a g e patients to begin to
face anxiety-producing situations a n d at the same time to
integrate activities d e s i g n e d to p r o d u c e e n v i r o n m e n t a l
rewards. In the spirit o f newer i d i o g r a p h i c m o d e l s o f be-
havioral activation ( H o p k o et al., 2003), a n d d u e to a fo-
cus o n b o t h activation a n d exposure, attention was given
to behaviors likely to create a sense o f a c c o m p l i s h m e n t
a n d / o r pleasure in light o f individual patient goals, values,
a n d fears. Patients were asked to t h i n k a b o u t potential
new activities across a wide range o f life domains, includ-
ing i n t e r p e r s o n a l relationships, e m p l o y m e n t / v o l u n t e e r
work, h o b b i e s / r e c r e a t i o n , health issues (e.g., diet, exer-
cise), a n d spirituality. S e l f - m o n i t o n n g records were re-
viewed, a n d a pleasant events activity checklist was pro-
vided to h e l p patients b r a i n s t o r m a b o u t possible new
activities. Patients were asked to think o f behaviors across
a range o f difficulty levels, identifying some that m i g h t be
"easy," "medium," a n d "hard" to do, a n d to focus only on
behaviors that were observable a n d measurable.
A m a j o r focus o f the discussion was on ways that previ-
ously pleasurable o r rewarding activities m i g h t be modi-
fied in light o f physical limitations (e.g., mowing the lawn
gradually over 2 days r a t h e r than in o n e m o r n i n g ) . As
part o f Session 2 h o m e practice exercises, patients were
asked to c o n t i n u e to think o f potential new activities.
They also were asked to c o n t i n u e m o n i t o r i n g experi-
ences with anxiety o r d e p r e s s e d m o o d a n d to c o n d u c t
one imaginal practice exercise each day using newly
a c q u i r e d relaxation skills.
Sesston 3: Creatzng the actiwty hterar ehy T h e p r i m a r y
goal o f this session was to create a full activity hierarchy
for each g r o u p m e m b e r , with clearly d e s i g n a t e d "easy,"
"medium," a n d "hard" acuwties. Discussion c e n t e r e d on
m a k i n g sure that activities r e p r e s e n t e d a sufficient range
o f difficulty a n d that the list i n c l u d e d acuvlties that would
p r o d u c e e n v i r o n m e n t a l r e i n f o r c e m e n t a n d activities that
i n c o r p o r a t e d e x p o s u r e to anxiety-producing situations.
O n c e these lists were created, each p a t i e n t was asked to
select o n e "easy" activity to c o m p l e t e d u r i n g the u p c o m -
ing week. T h e g r o u p l e a d e r h e l p e d to ensure that the se-
lected activities were m a n a g e a b l e , a n d she assisted pa-
uents in d e t e r m i n i n g the frequency a n d d u r a t i o n o f the
p l a n n e d behavior. Patients also were asked to c o n t i n u e
awareness m o n i t o r i n g a n d relaxation p r a c n c e d u r i n g the
u p c o m i n g week.
Sesszons 4 to 5: Changing thoughts and increaszng actzwly. In
b o t h Sessions 4 a n d 5, the focus was on increasing activity
a n d t e a c h i n g cognitive skills. F o r the latter, the REACT
acronym (Stanley et al., 2004) was used, where R = recog-
nizing thoughts; E = evaluating thoughts; A = alternative
t h o u g h t g e n e r a u o n ; C = c o p i n g statements; a n d T =
t h o u g h t stopping. Given the complexity o f these skills,
a n d a c o n t i n u e d c o n c u r r e n t focus o n behavioral activa-
tion a n d exposure, this m a t e r i a l was t a u g h t a n d prac-
ticed over two sessions. Session 4 focused p r i m a r i l y on
the first three steps in this process: l d e n t i f ~ n g thoughts
a n d treating t h e m as hypotheses r a t h e r t h a n facts, recog-
nizing logical errors in thinking, a n d substituting alte:-
native, m o r e realistic thoughts. D u r i n g Session 5, patients
were taught to use c o p i n g statements a n d t h o u g h t stop-
ping, with imaginal practice exercises to facilitate covert
practice.
In addition, Sessions 4 a n d 5 c o n t i n u e d to focus o n in-
creasing activity. At the start o f each session, following a
b r i e f review o f awareness a n d r e l a x a u o n practice, partici-
pants discussed their e x p e r i e n c e s with activation a n d / o r
e x p o s u r e exercises. F o r patients who were able to com-
plete a new activity, a discussion o f o u t c o m e s ensued, with
particular attention to the resultant impact on m o o d (i.e.,
w h e t h e r c o p i n g skills were effective for m a n a g i n g anxiety
d u r i n g exposure-based activities; w h e t h e r patients no-
riced i m p r o v e d m o o d following behaviors designed to in-
crease rewards). If anxiety a n d / o r depression were n o t
r e d u c e d as a result o f increased activity, the g r o u p l e a d e r
assisted participants in d e c i d i n g if it would be p r e f e r a b l e
to r e p e a t the activity o r to select an alternative activity.
W h e n activities were c o m p l e t e d successfully, with concur-
r e n t positive consequences for m o o d , the g r o u p l e a d e r
a n d p a t i e n t worked t o g e t h e r to d e c i d e on a new activity,
sometimes by increasing the frequency o r d u r a t i o n o f the
previous activity a n d sometimes by a d d i n g a new activity
at either the same o r increased level o f difficulty
H o m e practice exercises for b o t h sessions involved
c o n t i n u e d attention to awareness a n d relaxation strate-
gies. T h e p r i m a r y focus of the exercise was on the use o f
REACT skills to modify t h i n k i n g a n d o n progressive in-
creases in activities to r e d u c e negauve m o o d .
 Anxiety and Depression in COPD
Session 6: Problem-solving and incr easing actiw~. Session
c o n t i n u e d with reviews o f awareness, relaxation, REACT
skills, a n d increasing activity. T h e b u l k of this session,
however, focused o n t e a c h i n g problem-solving skills,
using the acronym SOLVED (Stanley et al., 2004), where
S = select a p r o b l e m a n d identify goals; O = o p e n your
m i n d to all possible solutions; L = list p r o s / c o n s o f each
potential solution; V = verify the best solution a n d create
a plan; E = e n a c t the plan; a n d D = d e t e r m i n e w h e t h e r
the p l a n worked. T h e p o t e n t i a l role o f cognitive change
in this process was h i g h l i g h t e d given that p e o p l e with
anxiety a n d d e p r e s s i o n often have difficulty perceiving
that life p r o b l e m s are solvable. This issue is particularly
salient for patients with c h r o n i c medical illness, who may
n o t have the same physical resources to solve p r o b l e m s as
they h a d in the past. T h e r e m a i n d e r o f the discussion fol-
lowed the SOLVED steps, using examples o f life prob-
lems identified from awareness exercises.
T h e goal was for patients to leave this session with at
least o n e p r o b l e m a n d potential solution identified. If
steps for carrying o u t the solution were identified, the pa-
tient was asked to take these actions in the u p c o m i n g
week. Patients also were asked to identify at least o n e new
p r o b l e m a n d to c o m p l e t e the SOLVED exercise with this
p r o b l e m b e f o r e the n e x t session. O t h e r h o m e practice
i n c l u d e d c o n t i n u i n g with awareness m o n i t o r i n g , use o f
relaxation a n d REACT skills, a n d at least o n e a d d i t i o n a l
behavioral activation o r e x p o s u r e assignment.
Session 7: Sleep management sk~lls and ,ncr easing actiw~. A
review o f h o m e practice exercises h e r e e m p h a s i z e d the
utility o f the SOLVED t e c h n i q u e a n d identification o f ad-
ditional behavioral activation a n d / o r e x p o s u r e exercises
for the u p c o m i n g week. By this point, the goal was for pa-
tients to i n c o r p o r a t e c h o s e n activities m o r e regularly into
their lives. T h e focus o f the r e m a i n d e r o f Session 7 was on
teaching s l e e p - m a n a g e m e n t skills using the SLEEP acro-
nym, as in Stanley et al. (2004), where S = set a r e g u l a r
bedtime; L = limit use o f the b e d (to sleep o r sex) to re-
duce associations between the b e d a n d behaviors that are
n o n p r o d u c t i v e for sleep; E = exit the b e d if n o t asleep m
15 to 20 minutes; E = eliminate naps (by substituting
some alternative behavior to c o m b a t daytime sleepiness
such as a walk, a t e l e p h o n e call, a trip to the store, etc.) o r
limit daytime sleeping to o n e h o u r b e f o r e 3:00 P.M.; P =
p u t y o u r feet o n the floor at the same time every m o r n -
ing, give o r take 30 minutes. These skills may be particu-
larly i m p o r t a n t for patients with c h r o n i c medical illness
because their levels o f activity often are r e d u c e d , result-
ing in increased d i s r u p t i o n o f sleep. A l t h o u g h increasing
activity can be useful for i m p r o v e d regulation o f sleep,
specific sleep hygiene skills often are necessary.
H o m e practice for Session 7 involved c o n t i n u e d aware-
ness m o n i t o r i n g a n d practice wath relaxation, REACT,
a n d SOLVED skills, as well as c o n t i n u e d attention to
431
increasing activity a n d exposure. In addition, patients
were asked to a t t e n d to the c u r r e n t sleep patterns a n d at-
t e m p t to modify sleep-related behaviors to improve sleep
hygiene.
Session 8." Review of skills an d continued practice; plannzng
for mazntenance ofgazns. In this session, h o m e practice ex-
ercises were reviewed, as were all c o p i n g skills now in the
"toolbox." Plans were m a d e for c o n t i n u e d practice a n d
follow-up assessments to be c o n d u c t e d over the subse-
q u e n t year.
Results
T h e RCT comparing CBT-RADAR and COPD-education
is n o t yet complete, so c o m p r e h e n s i v e t r e a t m e n t out-
c o m e d a t a are n o t yet available. Here, quantitative a n d
qualitative d a t a are p r e s e n t e d in a case r e p o r t f o r m a t to
describe p a t i e n t o u t c o m e s a n d to h i g h l i g h t p o t e n t i a l
strengths a n d weaknesses o f the intervention. Max's d a t a
are missing from 12-month follow-up d u e to a hospitaliza-
tion that p r e v e n t e d h i m f r o m c o m p l e t i n g the protocol.
Table 2 includes individual p a t i e n t scores at baseline,
posttreatment, a n d 12-month follow-up for six o u t c o m e
measures (BAI; BDI-II; CRQ-Physical; C R Q - E m o t i o n a l ;
SF-36 PH; SF-36 MH) a n d satisfaction ratings (CSQ) at
p o s t t r e a t m e n t a n d follow-up. Meamngful i m p r o v e m e n t
o n o u t c o m e s at p o s t t r e a t m e n t a n d follow-up are n o t e d ,
with definitions as d e s c r i b e d earlier (see Measures). All
patients r e p o r t e d the ability to learn a n d use r e l a x a t i o n
strategies, a n d all showed g o o d u n d e r s t a n d i n g o f c o p i n g
statements a n d t h o u g h t stopping. O t h e r t r e a t m e n t com-
p o n e n t s were used with m i x e d success by different g r o u p
m e m b e r s , as d e s c r i b e d below.
Bill. Bill r e p o r t e d clinically m e a n i n g f u l i m p r o v e m e n t
across all outcomes at posttreatment. Maintenance o f gains
o r further i m p r o v e m e n t were a p p a r e n t at follow-up for all
measures except the SF-36 PH, which r e t u r n e d to baseline
levels. At follow-up, BAI a n d BDI-II scores no longer m e t
study inclusion criteria, m e n t a l health f u n c t i o n i n g was
o n e s t a n d a r d deviation above the m e a n , a n d n u m b e r o f
o u t p a t i e n t visits was r e d u c e d . Bill r e p o r t e d consistently
high levels o f satisfaction with the intervention.
D u r i n g g r o u p sessions, Bill readily identified symp-
toms o f anxiety a n d depression, a n d he easily m a d e con-
nections between his c u r r e n t b r e a t h i n g difficulties, lack
o f activity, a n d negative mood. H e c o m p l e t e d h o m e prac-
tice exercises a n d r e p o r t e d particular benefit from REACT
skills. H e was able to differentiate thoughts a n d feelings,
identify logical errors, a n d substitute alternative thoughts,
particularly in situations r e l a t e d to his m o t h e r ' s d e c l i n i n g
h e a l t h a n d functional difficulties. F o r example, Bill expe-
r i e n c e d sigmficant guilt after his m o t h e r fell in a n u r s i n g
h o m e , with associated thoughts that she would n o t have
fallen if he h a d u r g e d h e r to move in with him. H e was
432 S t a n l e y e t al.
able to use REACT skills to r e d u c e feelings o f guilt in this
instance. In a n o t h e r s i t u a u o n , Bill r e p o r t e d negative
m o o d following receipt o f an insurance letter stating that
his m o t h e r owed money. H e was able to identify a n d
modify thoughts (e.g., "This is the worst thing that could
ever h a p p e n " ; "I c a n n o t imagine how I wall h a n d l e this";
a n d "I should be able to h a n d l e this without any prob-
lems"), with resultant i m p r o v e d m o o d a n d ability to man-
age t h e situation. Bill's p r i m a r y b e h a v i o r a l activation
goals i n c l u d e d b e c o m i n g m o r e physically active a n d
c l e a n i n g / o r g a n i z i n g his h o m e . H e imtially set a goal o f
walking 2 days p e r week, b u t e n c o u n t e r e d some difficul-
ties with m a i n t a i n i n g this r e g u l a r r o u t i n e when he h a d
t r o u b l e getting to a local school track to walk. SOLVED
skills were used to assist Bill with establishing a m o r e reg-
ular i n - h o m e exercise p r o g r a m that involved the use o f
videotapes. H e also was able to begin cleaning a n d orga-
nizing his h o m e before the e n d o f active treatment. Bill
r e p o r t e d n o p r o b l e m s with sleep, so htfle attention was
given to the use o f SLEEP skills in his case.
Brady. Brady d e m o n s t r a t e d clinically m e a n i n g f u l im-
p r o v e m e n t at p o s t t r e a t m e n t on five o f six o u t c o m e s (BAI,
BDI-II, C R Q - E m o t i o n a l , a n d SF-36 MH). At follow-up,
improvements in depressive symptom severity a n d mental
health f u n c t i o n i n g were m a i n t a i n e d , the BDI-II score re-
m a i n e d below study cutoff, a n d SF-36 M H was in the nor-
mal range. Anxiety severity (BAI) a n d C R Q scores, how-
ever, r e t u r n e d to baseline levels, p e r h a p s as a result o f
d e c l i n i n g physical health status (SF-36 PH) It is notable,
however, that n u m b e r o f o u t p a t i e n t visits r e m a i n e d virtu-
ally the same from b a s e h n e to follow-up. Brady r e p o r t e d
satisfaction with the intervention.
Brady initially h a d difficulty c o m p l e t i n g h o m e prac-
tice exercises, a n d a d d i t i o n a l m o u v a t i o n a l exercises were
used to h i g h l i g h t the pros a n d cons of this acuvity. Brady
also missed two sessions d u e to illness, t h o u g h he was able
to m a k e u p this time in individual a p p o i n t m e n t s with the
g r o u p leader. In Session 1, Brady readily r e c o g n i z e d the
c o n n e c t i o n between anxiety a n d worsening o f respiratory
symptoms, a n d he identified situations such as catching
the bus o n time, which l e d to b o t h increased anxiety a n d
e x a c e r b a t i o n o f b r e a t h i n g difficulties. H e subsequently
was able to identify anxiety-related thoughts associated
with a c c o m p a n y i n g his family on outings (e.g., "What if
t h e r e ~s a c u r b that my s c o o t e r c a n n o t g e t over?" "What
~f the aisles at a craft show are too narrow for m e to pass
with my scooter?"). H e d e m o n s t r a t e d some iniual diffi-
culty with identifying logical e r r o r s a n d alternative
thoughts. However, by Session 8, Brady r e p o r t e d benefits
o f REACT skills for c o p i n g with the possibility that his
wife was d e v e l o p i n g symptoms o f d e m e n u a . With r e g a r d
to increasing acuvity, Brady iniually r e p o r t e d that he
w a n t e d to start some type o f exercise p r o g r a m a n d find a
new hobby, such as ceramics. His first goal involved
riding a stationery bicycle for 6 minutes a day, b u t he was
u n a b l e to follow t h r o u g h with this assignment d u e to ill-
ness. H e was e n c o u r a g e d to focus on a n d identify alterna-
tive positive events that would require less exertion. Sub-
sequently, he was able to obtain information about ceramic
a n d o t h e r r e c r e a t i o n classes a n d to m a k e some initial
steps toward a n o t h e r goal o f r e s u m i n g v o l u n t e e r work
with prison inmates. SOLVED skills were used to h e l p
Brady identify m a n a g e a b l e steps toward this latter goal.
Brady r e p o r t e d no sleep difficulties.
T,m. Tim's self-report data suggested a m e a n i n g f u l re-
duction m anxiety seventy (BAI) at posttreatment. This
i m p r o v e m e n t was m a i n t a i n e d at 12-month follow-up, at
which time severity o f d e p r e s s e d m o o d also showed a
m e a n i n g f u l r e d u c t i o n . Both BAI a n d BDI-II scores at
follow-up r e m a i n e d above study cutoffs, b u t improve-
m e n t in these areas was particularly n o t a b l e in light o f de-
terioration in physical quahty o f life (CRQ-Physical) a n d
a shght increase in n u m b e r o f o u t p a u e n t wsits. Tim re-
p o r t e d high satisfaction with the intervention, a n d he
p a r t i c i p a t e d well in the group. H e consistently was sup-
portive o f o t h e r g r o u p m e m b e r s , b u t he h a d difficulty ap-
plying c o p i n g skills to his own situauons a n d c o m p l e t i n g
practice assignments. With some e n c o u r a g e m e n t , h e was
able to discuss how his c u r r e n t living situation (with his
sister a n d brother-in-law) was a p r i m a r y source o f depres-
sion a n d anxiety, a n d he r e c o g n i z e d that he b l a m e d him-
self for his p o o r health a n d the loss o f his j o b . H e was en-
c o u r a g e d to identify o t h e r factors c o n t r i b u t i n g to these
events, i n c l u d i n g c o m p a n y downsizing a n d the laying off
o f o l d e r employees, which were n o t u n d e r his control.
However, Tim h a d consistent difficulty with identifying
logical errors a n d substituting alternative thoughts.
With significant h e l p from o t h e r g r o u p m e m b e r s a n d
the therapist, Tim set an initial behavioral goal o f riding a
stationery bicycle, a n d h e m a d e some progress in this re-
gard. Behavioral activation also was discussed as a poten-
tial c o p i n g strategy for his d e p r e s s e d m o o d related to his
living situation, as he felt that he was m a k i n g no contribu-
tion to the h o u s e h o l d . T h e g r o u p h e l p e d Tim b r a i n s t o r m
potential ways in which he could b e g i n to m a k e m o r e
contributions, such as h e l p i n g with yard work o r r u n n i n g
errands. Nevertheless, he was n o t able to sustain his ini-
tial efforts to exercise o r to follow t h r o u g h with any o f
these alternauve activities. Tim also r e p o r t e d sleep prob-
lems. H e lived in a small r o o m in his sister's house, a n d
he spent most o f his day in the same r o o m where he slept.
H e s p e n t the majority o f his time watching television a n d
often fell asleep in his chair D u r i n g a discussion o f
SLEEP skills, the g r o u p suggested ways that Tim m i g h t
get o u t o f his r o o m d u r i n g the day a n d limit naps. T i m
was u n a b l e to follow t h r o u g h with these suggestions. In
the final g r o u p session, Tim i n d i c a t e d that he d i d n o t
want to make any m o r e changes, saying, "I am set m my
 Anxiety and Depression in COPD
ways." Although motivational exercises were repeated
t h r o u g h o u t the treatment phase, Tim may have bene-
fited from more indiwdual attention to bolster motiva-
tion and readiness for change.
Al. A1 reported meaningful improvement in emotional
quality of life at posttreatment and 12-month follow-up.
No other improvement was noted, although he reported
satisfaction with the treatment. N u m b e r of outpatient vis-
its did not change appreciably from baseline to follow-up.
A1 was an enthusiastic group participant, appearing to
grasp concepts easily and offering insight about other
participants' difficulties. Early on, A1 identified physical
symptoms related to depression (hypersomnia, lack of
energy), associated negative thoughts ("I cannot perform
as efficiently as I used to"; "My aneurysm may rupture at
any moment"; "I am worthless for not getting things done"),
and lethargic behaviors (watching television all day). He
expressed a strong desire at the start of group to change
his behavior to accomplish goals related to his art restora-
tion work. However, A1 had difficulty completing h o m e
practice exercises, despite significant attention to motiva-
tional exercises and ways m which he might schedule this
activity into his normal daily routine (e.g., while he drank
his m o r n i n g coffee). He also missed one session due to
illness, had difficulty with the more complex cognitive
coping skills (e.g., identifying logical errors, substituting
alternative thoughts), and was unable to reach his initial
identified goal of establishing a walking routine. How-
ever, a group discussion o f REACT skills as they might be
useful for helping A1 change depressive-related thoughts
seemed particularly useful in increasing his motivation to
b e c o m e more active. Some of this discussion focused on
reducing a l l / n o n e thinking and reestablishing work ex-
pectations that were manageable in light of Al's medical
problems. Before b e c o m i n g medically ill, Al worked be-
tween 12 and 15 hours per daywithout tiring. This type of
schedule no longer was possible. In response to this dis-
cusslon, A1 decided that he would like to make a greater
c o m m i t m e n t to behavioral activation, and he modified
his activity plan to involve playing the piano, a pleasur-
able activity he had given up m a n y years prior. By the end
of group sessions, Al had begun to play the piano twice a
day. He also reported modification of his sleep schedule
to incorporate a consistent wake time and to limit day-
time naps to 1 h o u r in the early afternoon.
Max. Max's self-report data indicated meaningful im-
provement in emotional quality of life (CRQ-Emotional),
but deteriorating physical quahty of life (CRQ-Physical)
at posttreatment. No changes occurred in anxiety or de-
pression. However, self-reported sattsfaction with the in-
tervention was high. Max was able to discuss in the group
that his anxiety had worsened over the prior 6 months to
the point where he rarely left his apartment. He de-
scribed anxiety related to his financial situation; i.e., he
433
was helping his daughter financially, and this was placing
a strain on him, but he felt obligated to assist her as he de-
p e n d e d u p o n her to help him run errands. He also iden-
tified anxiety-related thoughts resulting from his oxygen
use (e.g., he was not attractive to women; other people
t h o u g h t negatively of him), and he was able to use cogni-
tive strategies to modify some o f these thoughts. His be-
havioral goals included resuming his attendance of AA
meetings and church. Initially, he was able to attend AA
and speak with several people in the lobby whom he had
not seen for some time, but he was not able to go into the
formal meetings. Later, he was able to join the group
meetings. He also reported benefits of SLEEP skills for
improving his sleep hygiene, including setting a regular
wake time and eliminating naps. However, despite these ap-
parent changes in coping strategies, Max failed to report
benefits of the group on most posttreatment measures.
Discussion
CBT-RADAR was developed to reduce anxiety and de-
pressive symptoms for patients with COPD. Case report
data from five patients participating in an ongoing RCT
suggested significant variability in response and ability to
use coping skills. O n e patient (Bill) reported meaningful
improvements in almost all variables over both treatment
and follow-up. A n o t h e r patient (Brady) demonstrated
meaningful improvements over the treatment interval,
but not all gains were maintained over follow-up, poten-
tially due to declining physical health status. A third pa-
tient (Tim) showed improvement with regard to anxiety
and depressive symptoms, a result that is notable in light
of deteriorating physical quality of life. Two patients (A1,
Max) demonstrated improvement only in disease-specific
emotional quality of life. Qualitative data also suggested
significant x-ariability in patient outcomes and abilities to
use various coping skills. All patients were able to learn re-
laxation and simple cognitive skills (i.e., coping statements;
thought stopping), but other skills (e.g., more complicated
cognitive interventions; problem-solving, behavioral acti-
vation; a n d s l e e p - m a n a g e m e n t skills) were difficult for
some patients to u n d e r s t a n d a n d / o r i m p l e m e n t a n d
therefore not consistently useful for all individuals.
Although conclusions await examination o f data from
the full clinical triM, one major strength o f the interven-
tion is the breadth o f treatment, with coping skills repre-
senting a wide range of skills with demonstrated efficacy
for improving anxiety and depression (Barlow et al.,
2004). The large n u m b e r of coping skills in CBT-RADAR
allows for the potential utility of the intervention a m o n g
heterogeneous groups of patients with variable symptom
presentations and abilities. The range of treatment tech-
niques vary in difficulty, as well as with regard to expected
outcomes related to anxiety, depression, or both. Coping
434 Stanley et al.
skills also r e p r e s e n t attention to a r a n g e of response mo-
dalities for b o t h anxiety a n d depressive symptoms (e.g.,
cogniuve, somatic, behavioral). A n o t h e r strength o f the
i n t e r v e n t i o n is the e x p e c t e d utihty for m a n a g i n g m e n t a l
h e a l t h symptoms even in the absence o f formally diag-
nosed disorders, a l t h o u g h t h r e e o f the five l n c t u d e d pa-
taents h a d symptoms that m e t criteria for an anxiety a n d /
o r depressive disorder. Nevertheless, the t r e a t m e n t is not
directed toward improving symptoms o f any specafic D S M -
/V diagnostic category; rather, the focus is on modifying
cognitions a n d behaviors c o m m o n to a range o f anxiety
a n d depressive disorders. In these domains, CBT-RADAR
is a novel a p p r o a c h , perhaps the first o f its type to target
the needs o f patients with coexistent COPD a n d m e n t a l
h e a l t h symptoms. Finally, despite variability in t r e a t m e n t
response, self-reported p a u e n t satisfaction was uniformly
high at p o s t t r e a t m e n t a n d over long-term follow-up.
Nevertheless, limitations of the interventaon can be
identified in light o f variable p a t i e n t response, some o f
which may have resulted from insufficient flexibility an
t r e a t m e n t p r o c e d u r e s to m e e t individual p a t i e n t needs.
A d m i n i s t r a t i o n o f CBT-RADAR in a g r o u p f o r m a t likely
c o n t r i b u t e d to this restricted flexibility. F o r example,
even when a parUcular skill was n o t a p p r o p r i a t e for every
p a t i e n t (e.g., n o t all patients h a d sleep difficulties a n d
t h e r e f o r e d i d n o t n e e d SLEEP skills), the g r o u p f o r m a t
called for reviewing the skill in some detail, thus limiting
time that m i g h t have b e e n used m o r e effecuvely to rein-
force alternative skills that were m o r e relevant. In o t h e r
cases, even t h o u g h certain skills were too c o m p l e x to be
useful for all patients (e.g., adentifying logical errors a n d
substituting alternative thoughts), the g r o u p f o r m a t re-
q m r e d u m e for reviewing a n d practicing these skills to
m a k e t h e m available for patients who were able to bene-
fit. Lakewise, b r i e f mouvational exercises may have b e e n
insufficient for some patients, a n d the assignment o f be-
havioral activation tasks hkely r e q u i r e d a m o r e adiographic
a p p r o a c h than was feasible here given the complexity of
the m u l t i c o m p o n e n t intervention. I n c o r p o r a t i n g some-
what m o r e substantave motivataonal a p p r o a c h e s (Miller &
Rollnick, 2002) a n d a m o r e t h o r o u g h functional analysas
o f behavior, as suggested by Martelt et al. (2001), may
have b e e n useful in thas regard. Fmally, the g r o u p f o r m a t
limited flexibility with r e g a r d to scheduling appoint-
ments to m e e t individual p a u e n t n e e d s (e.g., transporta-
tion a n d o t h e r logistical difficulues; cancellations d u e to
medical illness).
O t h e r potential limatations o f CBT-RADAR as at pres-
ently was a d m i n i s t e r e d i n c l u d e d the lack o f p a t i e n t het-
e r o g e n e i t y with r e g a r d to gender, ethnlcity, o r race; the
tack o f b o o s t e r sessions for patients who may have
n e e d e d a l o n g e r practice interval to m a i n t a i n gains (e.g.,
Brady); a n d the omxssion o f attention to medical adher-
ence. Given some evidence o f gender- a n d ethnic-related
differences in p r e s e n c e o f COPD diagnosis, associated
functional capacity, a n d t r e a t m e n t response for patients
with b r e a t h i n g disorders ( C h a p m a n , Tashkin, & Pye,
2001; Hankinson, O d e n c r a n t z , & Fedan, 1999; Leidy &
Traver, 1995; Rose et al., 2002; Vollmer et al., 2000), at-
t e n t i o n to the i m p a c t o f CBT-RADAR across a diverse
sample o f patients is essential. In addition, m e d i c a l care
for patients in this r e p o r t was p r o v i d e d by o t h e r clinics
wathin the VA system, a n d no attention was given to this
issue in CBT-RADAR. This lack o f attention to medical
a d h e r e n c e may explain a n o t h e r significant s h o r t c o m i n g
o f the i n t e r v e n t i o n - - i t s inability to have an i m p a c t on
health-related quality o f hfe. In future studies, t r e a t m e n t
p r o c e d u r e s will n e e d to be m o d i f i e d to i n c o r p o r a t e an
i m p r o v e d m a i n t e n a n c e phase a n d increased attention to
medical care m a n a g e m e n t . I n c o r p o r a t i o n of specific strat-
egies from p u l m o n a r y rehabilitation programs a i m e d at
i m p r o v i n g physical o u t c o m e s would a p p e a r to be an-
o t h e r useful direction.
Despite these limitations a n d the n e e d for r e f i n e m e n t
o f t r e a t m e n t p r o c e d u r e s , CBT-RADAR appears to be a
potentially useful intervention for treating anxiety a n d
depressive symptoms for patients with COPD. T h e pri-
m a r y goal o f r e d u c i n g m e n t a l h e a l t h symptoms in
p a u e n t s with chronic illness was attained for t h r e e o f five
patients, a n d the variable response across individuals was
consistent with o u t c o m e s following the use o f o t h e r em-
pirically s u p p o r t e d i n t e r v e n u o n s (Chambless & Ollen-
dick, 2001). Data from the full clinical trial will evaluate
m o r e fully the utility o f this intervention relative to an ed-
ucation control condition, a n d a d d i t i o n a l analyses will
e x a m i n e the i m p a c t o f the intervention on service use
a n d differential response for patients with a n d without
psychiatric diagnoses o f anxiety a n d / o r depression. Fu-
ture studies will e x a m i n e a d d i t i o n a l benefits that may re-
sult from an i m p r o v e d version o f CBT-RADAR, which al-
lows for increased flexibility a n d i d i o g r a p h i c attention to
p a t i e n t needs. T h e utility o f t r e a t m e n t variants for pa-
tients with o t h e r chronic medical illnesses also will be o f
interest, as will be investigations into the utility o f CBT-
RADAR as p a r t o f a collaborative care m o d e l to provide
i n t e g r a t e d care for patients with coexistent medical a n d
psychological difficulties.
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This work was supported by a Health Services Research and
Development grant (HSR&D, Project II R00-097) to the last author
and by a grant from the Nauonal Institute of Mental Health (R01-
MH53932) to the first author
Address correspondence to Melmda A StanleTg Ph D., M e n m n g e r
Department of Psychiatry and Behaworal Sciences, Baylor College of
Medicine, 2002 Holcombe Blvd (152), Houston, TX 77030; e-mail
mstanley@bcm tmc edu
Recezved June 10, 2004
Accepted March 2, 2005