There are many examples of the mind-body connection.
Capitalizing on this principle, health care providers are increasingly using wholistic approaches to treat chronic medical conditions.
One new approach may have a significant impact for people who have chronic obstructive pulmonary disease (COPD). For these patients, the sensation of “air hunger” or not being able to breathe, is terrifying.
The anticipation of episodes of difficulty breathing may increase anxiety that triggers exacerbations of this chronic condition, in which spasm of small breathing passages limit the ability to breathe normally.
New research now demonstrates that cognitive behavioral therapy (CBT) administered by respiratory nurses is not only cost effective, but also reduces symptoms of anxiety in chronic obstructive pulmonary disease (COPD) patients.
The research was published earlier this week in ERJ Open Research.
COPD is a chronic condition and is chiefly the result of irritants in cigarette smoke, but also exposure to secondhand smoke or air pollution. It leads to inflammation in the lungs, spasm of breathing passages known as bronchioles, and ultimately leads to destruction of lung tissue, making it difficult to breathe. Inhaled corticosteroids, long-acting beta-agonists (LABA), and long-acting muscarinic antagonists (LAMA) are often used as a mainstay of therapy.
Because anxiety is relatively common often among patients with COPD, this can translate to less physical activity, resulting in loss of muscle tone (de-conditioning), but also lead to isolation and deteriorating health overall.
CBT is a type of “talk therapy”, which aims to understand the link between a patient’s situation, physical symptoms and complaints, and their emotions, thoughts, and behavior. Current guidelines for treatment of anxiety and depression recommend CBT, counseling, self-help, medication, or a combination of these approaches.
The research found that when patients in the study underwent short structured CBT sessions with respiratory nurses, they felt better overall, experienced less anxiety, had fewer COPD exacerbations and made fewer ER visits.
Dr Karen Heslop-Marshall, a Nurse Consultant at Newcastle-upon-Tyne NHS Foundation Trust and Newcastle University, UK, and lead researcher on the study, explained in a press release that one of the main symptoms of COPD is breathlessness.
“This is very frightening, and often leads to feelings of anxiety,” she explained. “Many healthcare professionals do not currently screen COPD patients for symptoms of anxiety, even though it can have an impact on their overall health.”
“Feeling anxious has a negative impact on patients’ quality of life and leads to more frequent use of healthcare resources. We wanted to test whether one-to-one CBT sessions delivered by respiratory nurses could reduce symptoms of anxiety and whether this could be a cost-effective intervention,” she added.
236 patients with a diagnosis of mild to severe COPD participated in the study. Each patient was screened for anxiety using the HADS-Anxiety Subscale, a questionnaire that asks patients about their feelings of anxiety and depression over the past week. Scores of between 8 and 10 are considered to show mild symptoms, 11-14 indicate moderate symptoms, and greater than 15 indicate more severe symptoms.
All of the patients who participated in the study scored 8 or higher on the HADS scale. And overall, 59% of those screened for entry into the study had elevated HADS scores, suggesting anxiety is quite common in COPD.
Over a three-month period, patients were either given written information (self-help pamphlets) on how to manage anxiety, or provided with the pamphlets along with CBT. In the CBT sessions, the nurses taught patients how to develop coping strategies to deal with the anxiety caused by breathlessness, as well as guidance on ways to improve levels of physical activity.
All patients in the study received standard medical care for COPD, including lung function testing and the same medications. Eligible patients at higher risk for deterioration also received pulmonary rehabilitation, which is a supervised exercise program designed for COPD patients.
At the end of 3 months, patients completed the HADS-Anxiety questionnaire again to understand if the different treatment regimens affected anxiety level.
The researchers found that CBT was more effective in reducing anxiety symptoms in COPD patients compared to written information alone. The HADS-Anxiety scale scores of CBT patients improved by an average of 3.4, while patients who received written information only improved by an average of 1.9.
The researchers also found that for each patient who attended CBT, there was an average savings of £1,089 per hospital admission and £63 for emergency room visits.
Interestingly, the study did not show any correlation between a patients’ lung function, measured by how much air a person can breathe out in one second (FEV1), and their anxiety score. The researchers believe this suggests that even patients with mild COPD may feel quite anxious, and so would likely benefit from CBT.
“ We found that one-to-one CBT sessions delivered by respiratory nurses could reduce symptoms of anxiety and that this could be a cost-effective intervention,” explained Heslop-Marshall. “Although the CBT intervention initially resulted in added costs, as respiratory nurses required training in CBT skills, this was balanced by the savings made thanks to less frequent need of hospital and A&E services.”
“Reducing the levels of anxiety patients experience has a significant impact on their quality of life as well as their ability to keep physically active and may improve survival in the long-term. Our research shows that front-line respiratory staff can deliver this intervention efficiently and effectively ,” she added.
One limitation of the study is that it was not possible to blind participants as to what method of treatment they received, which may ultimately have influenced their responses to the second HADS questionnaire. The researchers were also unable to determine which specific element of the CBT intervention– coping strategies to address frightening thoughts, pacing, breathing control, distraction, or encouraging physical activity– was most effective at reducing feelings of anxiety.
A unique aspect of this study is the use of nurses skilled in respiratory care to assess mental health needs in this special population with both medical and psychological issues. The authors assert that barriers to accessing mental health services in this population such as perceived stigma, along with these patients making medical care a greater priority, made it ripe for the introduction of this unique approach for addressing mental health issues.
Dr. Thierry Troosters of Katholieke Universiteit Leuven, Belgium, President-Elect of the European Respiratory Society, and not involved in the research, explained in a press release that “COPD is a major burden to individuals, societies and healthcare systems across the world. This is partly due to the continued exposure to risk factors for COPD, such as smoking and air pollution, and partly due to aging populations.”
“This research highlights how using a multidisciplinary approach in the treatment of COPD can reduce the burden on patients and healthcare services ,” offered Troosters. “Treating patients for co-existing conditions such as anxiety contributes greatly to improving their overall health, and these methods can be cost-effective,” he added.
“Care provided by dedicated and properly trained healthcare professionals also allows for early referral of patients with more serious mental health conditions to even more specialized care tracks,” he concluded.
Implementing such a program in the U.S. might prove to be challenging, but given the expanding role of nurse practitioners and physician assistants, it’s not out of the question.