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The Impact of Anxiety and Depression on Outcomes of Pulmonary Rehabilitation in Patients With COPD
Abstract
Anxiety and depression are prevalent comorbidities in COPD and are related to a worse course of disease. The present study examined the impact of anxiety and depression on functional performance, dyspnea, and quality of life (QoL) in patients with COPD at the start and end of an outpatient pulmonary rehabilitation (PR) program.
Before and after PR, 238 patients with COPD (mean FEV(1) % predicted = 54, mean age = 62 years) underwent a 6-min walking test (6MWT). In addition, anxiety, depression, QoL, and dyspnea at rest, after the 6MWT, and during activities were measured.
Except for dyspnea at rest, improvements were observed in all outcome measures after PR. Multiple regression analyses showed that before and after PR, anxiety and depression were significantly associated with greater dyspnea after the 6MWT and during activities and with reduced QoL, even after controlling for the effects of age, sex, lung function, and smoking status. Moreover, before and after PR, anxiety was related to greater dyspnea at rest, whereas depression was significantly associated with reduced functional performance in the 6MWT.
This study demonstrates that anxiety and depression are significantly associated with increased dyspnea and reduced functional performance and QoL in patients with COPD. These negative associations remain stable over the course of PR, even when improvements in these outcomes are achieved during PR. The results underline the clinical importance of detecting and treating anxiety and depression in patients with COPD.
... therefore, it is necessary for clinicians to address these impairments in this population in order to enhance walking capacity. Other factors, such as depression and general health status, which are commonly seen in individuals with cOPD [18], should also be considered as potentially interfering with walking performance [3,19]. impaired walking ability could further contribute to an elevated risk of depression and decreased quality of life (Qol) [20]. ...
... Depressive symptoms have been significantly associated with the distance walked by people with cOPD [19,43], but others contradict our results [59]. the present study showed that 35% of moderate to severe depressive symptoms were found among patients who walked <350 m, compared to only 15% in those who walked ≥350. in addition, depressive symptoms were significantly associated with walking distance during the 6MWt. Despite the severity of depressive symptoms among participants in our study, almost all patients had at least minimal symptoms of depression. ...
Background/Objective(s)
Chronic obstructive pulmonary disease (COPD) can precipitate a deterioration of an individual’s physical performance and overall health. Evidence suggests that, along with pulmonary functions, several other factors are related to the significant impairment of walking performance in individuals with COPD. This study compared the depressive symptoms, health status, upper and lower extremity functions, and peak oxygen uptake (VO2peak) in a group of individuals with COPD based on walking performance using a cutoff distance of 350 m in the six-minute walking test (6MWT). The study also investigated the associations between these factors and walking performance.
Materials and Methods
Participants performed the 6MWT according to the guidelines and were classified into high (>350 m; n = 40) or low (<350 m; n = 30) walking performance groups according to distance. The forced expiratory volume (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio were recorded. Participants completed the Patient Health Questionnaire-9 (PHQ-9), St. George’s Respiratory Questionnaire (SGRQ), and the Upper and Lower Extremity Functional Index (UEFI/LEFI). Predicted VO2peak was measured using the Duke Activity Status Index (DASI).
Results
Seventy participants with a mean age of 63 ± 11 years (20% female) were enrolled in this study. Patients with high walking performance demonstrated significantly better health status than those with low walking performance (SGRQ: 49 ± 25 vs. 56 ± 21, p = 0.03). Participants with low walking performance had lower predicted VO2peak compared to their higher performing counterparts (p = 0.002). The overall model was significant (F(8, 61) = 7.48, p = 0.0006), with PHQ-9, SGRQ, UEFI/LEFI, VO2peak, and FEV1/FVC explaining approximately 49.5% of the variance in the 6MWT distance.
Conclusion
This study shed light on the association of depressive symptoms, health status, extremity function, and VO2peak with walking performance, providing valuable insights that may impact the management and care of individuals with COPD.
... In one study, depression negatively correlated with 6MWD at baseline and follow-up, but associations between baseline depression and Δ6MWD following PR were not reported. 13 Two other studies found no association between depression and Δ6MWD following PR after controlling for anxiety. 14,15 An additional small study (n = 39) found no association between depression and 6MWD at PR entry or at exit. ...
... Although some research has demonstrated that depression may negatively correlate with physical functioning at a single timepoint 13 and predict PR non-completion, 8,17 the present study found no association between baseline depression and either outcome. [14][15][16]19 Depression screening and support are standard of care in AACVPR-certified PR programs, and the present results suggest that to experience the full benefits of PR, patients with symptoms of depression may not need additional services that go above and beyond these standards. ...
Purpose
This study examined whether health-related quality of life (HRQL) and depression assessed prior to pulmonary rehabilitation (PR) participation (ie, at baseline) predicted change in 6-min walk distance (6MWD) from baseline to end of PR.
Methods
Patients with pulmonary disease were consecutively referred/enrolled in a PR program from 2009-2022 (N = 503). Baseline 6MWD was assessed along with self-report measures of HRQL (St George's Respiratory Questionnaire [SGRQ]) and depression (Geriatric Depression Scale [GDS]). The SGRQ total score was used to assess overall HRQL, and SGRQ subscales assessed pulmonary symptoms, activity limitations, and psychosocial impacts of pulmonary disease. Multiple linear regression was used to examine whether baseline SGRQ scores and depression predicted Δ6MWD.
Results
Baseline SGRQ total score ( F (1,389) = 8.4, P = .004) and activity limitations ( F (1,388) = 4.8, P = .03) predicted Δ6MWD. Patients with an SGRQ activity limitation score ≤ 25th percentile showed the most 6MWD improvement (mean = 79.7 m, SE = 6.7), and significantly more improvement than participants scoring between the 50-75th percentiles (mean = 54.4 m, SE = 6.0) or >75th percentile (mean = 48.7 m, SE = 7.5). Patients scoring between the 25-50th percentiles (mean = 70.2 m, SE = 6.1) did not differ significantly from other groups. The SGRQ symptoms and impacts subscales were unrelated to Δ6MWD ( F (1,388) = 1.2-1.9, P > .05), as was depression ( F (1,311) = 0.0, P > .85).
Conclusions
Patients with greater HRQL at baseline may experience greater physical functioning improvement following PR. Additional support for patients with lower HRQL (eg, adjunctive self-management interventions) may enhance PR outcomes, particularly for patients who report greater activity limitations. Alternatively, early referral to PR (ie, when less symptomatic) may also benefit physical function outcomes.
... A large body of literature has shown associations between trait negative affectivity (especially fear/anxiety and depression) and increased breathlessness severity (5, 10-13, [45][46][47][48]. Unsurprisingly, similar effects have also been found in the reviewed studies. ...
... (37) observed a contradictory negative correlation between fear1 In conditioning studies, a neutral cue (conditioned stimulus CS) is repeatedly presented with an aversive stimulus [unconditioned stimulus US, here inspiratory resistive loads(46,48) or breathing obstructions (23, 47)] causing fear and anxiety. After an acquisition phase, the neutral cue becomes aversive and able to elicit fear and anxiety, even when the breathlessness stimulus is not jointly presented. ...
Breathlessness is an aversive bodily sensation impacting millions of people worldwide. It is often highly detrimental for patients and can lead to profound distress and suffering. Notably, unpredictable breathlessness episodes are often reported as being more severe and unpleasant than predictable episodes, but the underlying reasons have not yet been firmly established in experimental studies. This review aimed to summarize the available empirical evidence about the perception of unpredictable breathlessness in the adult population. Specifically, we examined: (1) effects of unpredictable relative to predictable episodes of breathlessness on their perceived intensity and unpleasantness, (2) potentially associated neural and psychophysiological correlates, (3) potentially related factors such as state and trait negative affectivity. Nine studies were identified and integrated in this review, all of them conducted in healthy adult participants. The main finding across studies suggested that unpredictable compared to predictable, breathlessness elicits more frequently states of high fear and distress, which may contribute to amplify the perception of unpredictable breathlessness, especially its unpleasantness. Trait negative affectivity did not seem to directly affect the perception of unpredictable breathlessness. However, it seemed to reinforce state fear and anxiety, hence possible indirect modulatory pathways through these affective states. Studies investigating neural correlates of breathlessness perception and psychophysiological measures did not show clear associations with unpredictability. We discuss the implication of these results for future research and clinical applications, which necessitate further investigations, especially in clinical samples suffering from breathlessness.
... The N1 is frequently used to quantify respiratory sensory information processing since it can reflect both the properties of the stimulus (bottom-up processing) and attention to it (top-down processing) Davenport, 2010, 2008). Late RREP peaks also reflect attention but correspond more to higher-order cognitive processing of respiratory stimuli, with a stronger association with negative affectivity (von Leupoldt et al., 2013(von Leupoldt et al., , 2011. Research using the single inspiratory occlusion paradigm has found that individuals with GAD exhibited lower P3 amplitudes when compared to healthy controls . ...
... The decreased P3 amplitude observed in individuals with GAD suggests that they may allocate more of their attentional resources to their concerns and worries instead of the occlusions . Further, the reduction in P3 amplitude has previously been associated with negative affective states (von Leupoldt et al., 2011(von Leupoldt et al., , 2010. The inconsistency with previous findings linking the reduced P3 component to the GAD group may be due to different characteristics of individuals with GAD. ...
... Although the prevalence of anxiety and depression in COPD varies greatly in the literature, it has been reported to be as high as~10% to 45% [10] and~10% to 57% [11], respectively. Negative mood has also been correlated with increased perception of dyspnea severity [12,13] which has implications for disease burden and treatment adherence [11,14]. Consequently, dyspnea and mood can affect patients' cognitive and physical function, especially when these factors interact. ...
... Overlapping need for cortical resources may lead to impairments in both cognitive performance and dyspnea tolerance. Although dyspnea has been suggested as an independent contributor to respiratory-associated cognitive impairment [13,20,21], evidence of cognitive interference from dyspnea is inconsistent. Inspiratory threshold loading (ITL) while completing a fear recognition task impaired facial recognition [22] but did not have an effect on accuracy of the Stroop Colour and Word Test (SCWT), which assesses executive function [23]. ...
Objectives
Dyspnea is a common and multidimensional experience of healthy adults and those with respiratory disorders. Due to its neural processing, it may limit or interfere with cognition, which may be examined with a dual-task paradigm. The aim of this study was to compare single-task performance of Stroop Colour and Word Test (SCWT) or inspiratory threshold loading (ITL) to their combined dual-task performance. Secondly, whether mood was related to dyspnea or cognitive performance was also evaluated.
Materials & methods
A virtual pre-post design examined single (SCWT and ITL) and dual-task (SCWT+ITL) performance. For ITL, a Threshold Trainer™ was used to elicit a “somewhat severe” rating of dyspnea. The SCWT required participants to indicate whether a colour-word was congruent or incongruent with its semantic meaning. The Depression, Anxiety and Stress Scale-21 (DASS-21) was completed to assess mood. Breathing frequency, Borg dyspnea rating, and breathing endurance time were ascertained.
Results
Thirty young healthy adults (15F, 15M; median age = 24, IQR [23–26] years) completed the study. SCWT+ITL had lower SCWT accuracy compared to SCWT alone (98.6%, [97.1–100.0] vs 99.5%, [98.6–100.0]; p = 0.009). Endurance time was not different between ITL and SCWT+ITL (14.5 minutes, [6.9–15.0]) vs 13.7 minutes, [6.1–15.0]; p = 0.59). DASS-21 scores positively correlated with dyspnea scores during ITL (rho = 0.583, p<0.001) and SCWT+ITL (rho = 0.592, p<0.001).
Conclusions
ITL significantly reduced dual-task performance in healthy young adults. Lower mood was associated with greater perceived dyspnea during single and dual-task ITL. Considering the prevalence of dyspnea in respiratory disorders, the findings of this dual task paradigm warrant further exploration to inform dyspnea management during daily activities.
... Symptoms of depression and anxiety can have substantial negative impacts on disease management and outcomes in COPD [7,14,23]. Feelings of depression and anxiety in COPD have been linked to a higher symptom burden [29], higher smoking rates [30], higher exacerbation frequency [31,32], (re)hospitalisations [33,34] and mortality [35,36], as well as reductions in treatment adherence [37], HRQoL [38], physical activity levels [30], functional exercise capacity [39] and less favourable outcomes of pulmonary rehabilitation (PR) [39]. Similarly, disease-specific fears (e.g. ...
... Symptoms of depression and anxiety can have substantial negative impacts on disease management and outcomes in COPD [7,14,23]. Feelings of depression and anxiety in COPD have been linked to a higher symptom burden [29], higher smoking rates [30], higher exacerbation frequency [31,32], (re)hospitalisations [33,34] and mortality [35,36], as well as reductions in treatment adherence [37], HRQoL [38], physical activity levels [30], functional exercise capacity [39] and less favourable outcomes of pulmonary rehabilitation (PR) [39]. Similarly, disease-specific fears (e.g. ...
Psychological distress is prevalent in people with COPD and relates to a worse course of disease. It often remains unrecognised and untreated, intensifying the burden on patients, carers and healthcare systems. Nonpharmacological management strategies have been suggested as important elements to manage psychological distress in COPD. Therefore, this review presents instruments for detecting psychological distress in COPD and provides an overview of available nonpharmacological management strategies together with available scientific evidence for their presumed benefits in COPD. Several instruments are available for detecting psychological distress in COPD, including simple questions, questionnaires and clinical diagnostic interviews, but their implementation in clinical practice is limited and heterogeneous. Moreover, various nonpharmacological management options are available for COPD, ranging from specific cognitive behavioural therapy (CBT) to multi-component pulmonary rehabilitation (PR) programmes. These interventions vary substantially in their specific content, intensity and duration across studies. Similarly, available evidence regarding their efficacy varies significantly, with the strongest evidence currently for CBT or PR. Further randomised controlled trials are needed with larger, culturally diverse samples and long-term follow-ups. Moreover, effective nonpharmacological interventions should be implemented more in the clinical routine. Respective barriers for patients, caregivers, clinicians, healthcare systems and research need to be overcome.
... Due to the heterogeneity of the disease, both pharmacological and non-pharmacological treatment options used in COPD patients might not be optimal for all patients (1). Multimodal pulmonary rehabilitation is applied frequently, however, concomitant problems with mental health negatively affect the efficacy and adherence in patients (27)(28)(29). In addition, psychotropic drug treatment of mental health problems in COPD specifically is challenging, considering the low efficacy and safety issues (7,30). ...
... The enriched diet (rough dashed line) or an isocaloric, isonitrogenous control diet (fine dashed line) was applied from the first LPS trigger onward until sacrifice at day 58. Behavioral and cognitive tests were performed at two time windows: just before the first LPS trigger (T1; days [25][26][27] and at the end of the study (T2; days [55][56][57]. The open field and T-maze spontaneous alternation tests were used to assess novelty-induced behavior and cognition, respectively. ...
One cluster of the extrapulmonary manifestations in chronic obstructive pulmonary disease (COPD) is related to the brain, which includes anxiety, depression and cognitive impairment. Brain-related comorbidities are related to worsening of symptoms and increased mortality in COPD patients. In this study, a murine model of COPD was used to examine the effects of emphysema and repetitive pulmonary inflammatory events on systemic inflammatory outcomes and brain function. In addition, the effect of a dietary intervention on brain-related parameters was assessed. Adult male C57Bl/6J mice were exposed to elastase or vehicle intratracheally (i.t.) once a week on three consecutive weeks. Two weeks after the final administration, mice were i.t. exposed to lipopolysaccharide (LPS) or vehicle for three times with a 10 day interval. A dietary intervention enriched with omega-3 PUFAs, prebiotic fibers, tryptophan and vitamin D was administered from the first LPS exposure onward. Behavior and cognitive function, the degree of emphysema and both pulmonary and systemic inflammation as well as blood-brain barrier (BBB) integrity and neuroinflammation in the brain were assessed. A lower score in the cognitive test was observed in elastase-exposed mice. Mice exposed to elastase plus LPS showed less locomotion in the behavior test. The enriched diet seemed to reduce anxiety-like behavior over time and cognitive impairments associated with the presented COPD model, without affecting locomotion. In addition, the enriched diet restored the disbalance in splenic T-helper 1 (Th1) and Th2 cells. There was a trend toward recovering elastase plus LPS-induced decreased expression of occludin in brain microvessels, a measure of BBB integrity, as well as improving expression levels of kynurenine pathway markers in the brain by the enriched diet. The findings of this study demonstrate brain-associated comorbidities – including cognitive and behavioral impairments – in this murine model for COPD. Although no changes in lung parameters were observed, exposure to the specific enriched diet in this model appeared to improve systemic immune disbalance, BBB integrity and derailed kynurenine pathway which may lead to reduction of anxiety-like behavior and improved cognition.
... We found a slight lower 6-min walk distance but not in muscle strength in the depressed COPD patients [9,16,25,71,72], which might be explained by the lower daily physical activity level. In line, a 6-week exercise regimen previously found to lead to improved depressive symptoms [13]. ...
... Depression in COPD was not associated with changes in BMI or body composition in line with previous studies [9,16,18], though one study did identify higher levels of depression in underweight COPD patients [15] and others found an association with increased BMI [13,14]. However, depression was associated with a reported lower quality of life and elevated CAT scores, consistent with previous studies regarding mildly depressed COPD patients [13,15,16,18,72]. Additionally, while CD on average had mild cognitive impairment (MoCA score of 24.9), there was no significant difference in cognitive function as assessed by STROOP and TMT tests between the CD and CN, consistent with one study showing only a trending association between cognitive impairment and depression [27] and another study finding only borderline significance for the copy drawing test, which assesses visuospatial and praxis skills [28]. ...
Background:
Depression is one of the most common and untreated comorbidities in chronic obstructive pulmonary disease (COPD), and is associated with poor health outcomes (e.g. increased hospitalization/exacerbation rates). Although metabolic disturbances have been suggested in depressed non-diseased conditions, comprehensive metabolic phenotyping has never been conducted in those with COPD. We examined whether depressed COPD patients have certain clinical/functional features and exhibit a specific amino acid phenotype which may guide the development of targeted (nutritional) therapies.
Methods:
Seventy-eight outpatients with moderate to severe COPD (GOLD II-IV) were stratified based on presence of depression using a validated questionnaire. Lung function, disease history, habitual physical activity and protein intake, body composition, cognitive and physical performance, and quality of life were measured. Comprehensive metabolic flux analysis was conducted by pulse stable amino acid isotope administration. We obtained blood samples to measure postabsorptive kinetics (production and clearance rates) and plasma concentrations of amino acids by LC-MS/MS. Data are expressed as mean [95% CI]. Stats were done by graphpad Prism 9.1.0. ɑ < 0.05.
Results:
The COPD depressed (CD, n = 27) patients on average had mild depression, were obese (BMI: 31.7 [28.4, 34.9] kg/m2), and were characterized by shorter 6-min walk distance (P = 0.055), physical inactivity (P = 0.03), and poor quality of life (P = 0.01) compared to the non-depressed COPD (CN, n = 51) group. Lung function, disease history, body composition, cognitive performance, and daily protein intake were not different between the groups. In the CD group, plasma branched chain amino acid concentration (BCAA) was lower (P = 0.02), whereas leucine (P = 0.01) and phenylalanine (P = 0.003) clearance rates were higher. Reduced values were found for tyrosine plasma concentration (P = 0.005) even after adjustment for the large neutral amino acid concentration (= sum BCAA, tyrosine, phenylalanine and tryptophan) as a marker of dopamine synthesis (P = 0.048).
Conclusion:
Mild depression in COPD is associated with poor daily performance and quality of life, and a set of metabolic changes in depressed COPD that include perturbation of large neutral amino acids, specifically the BCAAs. Trial registration clinicaltrials.gov: NCT01787682, 11 February 2013-Retrospectively registered; NCT02770092, 12 May 2016-Retrospectively registered; NCT02780219, 23 May 2016-Retrospectively registered; NCT03796455, 8 January 2019-Retrospectively registered.
... The results of this study showed that patients' lung function indexes of FEV1 and the ratio of FEV1/FVC were significantly improved after 3 and 6 months of intervention, and the effect of the intervention was significantly better than that of the control group (P < 0.05). Studies have shown that poor lung function increases the number of acute exacerbations as well as hospitalization and mortality rates in patients with COPD [13,14] , and the quality of life of patients is also seriously affected by poor lung function. In this study, the O2O health management combined with the peer education management model was implemented. ...
Objective: To explore the effect of online-to-offline (O2O) education combined with the peer education management model in patients with chronic obstructive pulmonary disease (COPD). Methods: Using convenience sampling, 72 patients with COPD who were hospitalized in the respiratory medicine department of a tertiary-level hospital from March to December 2021 were selected as study subjects. Randomized grouping was carried out using the random number table method, the control group was given routine COPD health education in the department, and the intervention group applied O2O trinity health management combined with peer education on the basis of routine care. After 6 months of follow-up after discharge, the two groups were observed and compared for changes in pulmonary function, depression status, self-care ability, and quality of life. Results: At 3 and 6 months after the intervention, the lung function indexes and depression status of the two groups of patients improved significantly, and the improvement effect was more significant in the intervention group (P < 0.05); after the intervention, the self-care ability scores of the patients in the intervention group were significantly higher than those of the control group (P < 0.05); the quality-of-life scores of the two groups of patients decreased at 3 months after discharge, in which the quality-of-life scores in the intervention group was significantly lower than that of the control group (P < 0.05). Conclusion: O2O education combined with the peer education management model can effectively improve the lung function of patients with COPD, depression, self-care ability, and quality of life.
... In respiratory diseases (e.g., chronic obstructive pulmonary disease, COPD), subjective perception of dyspnea is an important clinical indicator to be monitored during disease progression [4]. Furthermore, COPD patients suffering from comorbid anxiety disorders often report more symptoms, such as breathlessness and chest tightness, than those without [5][6][7][8]. Understanding the cortical processing and cortical control of respiratory sensations can provide valuable insights into the subjective experiences of individuals with respiratory conditions and potentially guide therapeutic interventions to alleviate corresponding symptoms. ...
Background
Human respiratory sensory gating is a neural process associated with inhibiting the cortical processing of repetitive respiratory mechanical stimuli. While this gating is typically examined in the time domain, the neural oscillatory dynamics, which could offer supplementary insights into respiratory sensory gating, remain unknown. The purpose of the present study was to investigate central neural gating of respiratory sensation using both time- and frequency-domain analyses.
Methods
A total of 37 healthy adults participated in this study. Two transient inspiratory occlusions were presented within one inspiration, while responses in the electroencephalogram (EEG) were recorded. N1 amplitudes and oscillatory activities to the first stimulus (S1) and the second stimulus (S2) were measured. The perceived level of breathlessness and level of unpleasantness elicited by the occlusions were measured after the experiment.
Results
As expected, the N1 peak amplitude to the S1 was significantly larger than to the S2. The averaged respiratory sensory gating S2/S1 ratio for the N1 peak amplitude was 0.71. For both the evoked- and induced-oscillations, time-frequency analysis showed higher theta activations in response to S1 relative to S2. A positive correlation was observed between the perceived unpleasantness and induced theta power.
Conclusions
Our results suggest that theta oscillations, evoked as well as induced, reflect the “gating” of respiratory sensation. Theta oscillation, particularly theta-induced power, may be indicative of the emotional processing of respiratory mechanosensation. The findings of this study serve as a foundation for future investigations into the underlying mechanisms of respiratory sensory gating, particularly in patient populations.
... High CO 2 triggers anxiety and panic, especially in adults with anxiety disorders, increasing the risk of ventilatory pump failure in COPD. Anxiety also leads to poor pulmonary rehabilitation (PR) adherence and worse outcomes, including more aversive dyspnea, worse quality of life (QOL) and 6-min walk distance (6MWD), and greater perceived functional impairment post-PR [8]. PR is the standard of care for COPD, and includes exercise training and self-management education. ...
Background
Although dyspnea is a primary symptom of chronic obstructive pulmonary disease (COPD), its treatment is suboptimal. In both COPD and acute anxiety, breathing patterns become dysregulated, contributing to abnormal CO2, dyspnea, and inefficient recovery from breathing challenges. While pulmonary rehabilitation (PR) improves dyspnea, only 1–2% of patients access it. Individuals with anxiety who use PR have worse outcomes.
Methods
We present the protocol of a randomized controlled trial designed to determine the feasibility and acceptability of a new, four-week mind-body intervention that we developed, called “Capnography-Assisted Learned, Monitored (CALM) Breathing,” as an adjunct to PR. Eligible participants are randomized in a 1:1 ratio to either CALM Breathing program or Usual Care. CALM Breathing consists of 10 core, slow breathing exercises combined with real time biofeedback (of end-tidal CO2, respiratory rate, and airflow) and motivational interviewing. CALM Breathing promotes self-regulated breathing, linking CO2 changes to dyspnea and anxiety symptoms and targeting breathing efficiency and self-efficacy in COPD. Participants are randomized to CALM Breathing or a Usual Care control group.
Results
Primary outcomes include feasibility and acceptability metrics of recruitment efficiency, participant retention, intervention adherence and fidelity, PR facilitation, patient satisfaction, and favorable themes from interviews. Secondary outcomes include breathing biomarkers, symptoms, health-related quality of life, six-minute walk distance, lung function, mood, physical activity, and PR utilization and engagement.
Conclusion
By disrupting the cycle of dyspnea and anxiety, and providing a needed bridge to PR, CALM Breathing may address a substantive gap in healthcare and optimize treatment for patients with COPD.
... Mood disorders like major depression and dysthymia, and anxiety disorders (generalized anxiety disorder, phobias and panic disorders) are common in patients with COPD (3) and earlier diagnosis and treatment would be very beneficial (4). Prevalence vary widely, due in part to the use of varied measurement tools and to the different degrees of illness severity across studies. ...
Depression, anxiety and cognitive impairments are common among patients with chronic obstructive pulmonary disease and these psychological aspects are associated with poor treatment adherence and worse outcomes. Identifying the psychological symptoms and developing appropriate treatment strategies are very important for this category of patients. This paper tries to synthesize the current understanding of patients with chronic obstructive pulmonary disease and comorbid psychological symptoms.
... That included significantly increased dyspnea, reduced functional performance, and quality of life. These results show the importance of diagnosing and treating anxiety and depression in patients with COPD [43]. ...
Patients with COPD (chronic obstructive pulmonary disease) are at a higher risk of comorbid conditions such as anxiety and/or depression, which in turn increase their symptom burden and rehospitalizations compared to the general population. It is important to investigate the pathophysiology and clinical implications of mental health on patients with COPD. This review article finds that COPD patients with anxiety and/or depression have a higher rehospitalization incidence. It reviews the current screening and diagnosis methods available. There are pharmacological and non-pharmacologic interventions available for treatment of COPD patients with depression based on severity. COPD patients with mild depression benefit from pulmonary rehabilitation and cognitive behavioral therapy, whereas patients with severe or persistent depression can be treated with pharmacologic interventions.
... Although several factors have been proposed to contribute to poor functional performance in COPD patients [11][12][13], the effects of psychological factors, such as anxiety and depression, on physical performance and the overall health status of COPD patients is controversial. Some studies have shown that anxiety and depression negatively impact physical functioning among patients with COPD [14,15], while another study found that the levels of anxiety and depression of COPD patients were not correlated with the distance walked during functional performance tests [16]. ...
The role of anxiety and depression in functional performance during walking in patients with chronic obstructive pulmonary disease (COPD) is controversial. In this cross-sectional study, we aimed to assess the effects of anxiety, depression, and health-related quality of life (HRQOL) on the functional performance of this patient population. Seventy COPD patients aged 63 ± 11 years participated in the study. To measure their functional performance, the six-minute walk test (6MWT) was used. Anxiety and depression were assessed using two questionnaires: the Anxiety Inventory for Respiratory Disease (AIR) scale and the Hospital Anxiety and Depression Scale (HADS). The St. George's Respiratory Questionnaire (SGRQ) was used to assess HRQOL. Based on their anxiety levels, the patients were divided into a no anxiety group and a high anxiety group. There were no significant differences between the two groups in terms of pulmonary function profile or smoking status. The mean AIR and HADS (depression) scores were high (12.78 ± 4.07 and 9.90 ± 3.41, respectively). More than one-third of the patients (46%) reported high anxiety levels (above the standard cutoff score of 8). The mean score of the aggregated HADS scale was significantly higher in the high anxiety group (20.87 ± 6.13) than in the no anxiety group (9.26 ± 4.72; p = 0.01). Patients with high anxiety had poorer functional performance (6MWT: 308.75 ± 120.16 m) and HRQOL (SGRQ: 56.54 ± 22.36) than patients with no anxiety (6MWT: 373.76 ± 106.56 m; SGRQ: 42.90 ± 24.76; p < 0.01). The final multivariate model explained 33% of the variance in functional performance after controlling for COPD severity (F = 8.97). The results suggest that anxiety, depression, and poor health status are significantly associated with poor functional performance. This study highlights the need to screen patients with COPD at all stages for anxiety and depression.
... Brain-related comorbidities have been associated with an increased disease progression and mortality (15)(16)(17). In addition, patients with COPD suffering from mental health disorders often show poor treatment adherence and efficacy (18,19). It is therefore of importance to increase the focus on and understanding of these comorbidities when treating patients with COPD. ...
Brain-related comorbidities are frequently observed in chronic obstructive pulmonary disease (COPD) and are related with an increased disease progression and mortality. To date, it is unclear which mechanisms are involved in the development of brain-related problems in COPD. In this study, a cigarette smoke and lipopolysaccharide (LPS) exposure murine model was used to induce COPD-like features and assess the impact on brain and behavior. Mice were daily exposed to cigarette smoke for 72 days, except for days 42, 52 and 62, on which mice were intratracheally exposed to the bacterial trigger LPS. Emphysema and pulmonary inflammation as well as behavior and brain pathology were assessed. Cigarette smoke-exposed mice showed increased alveolar enlargement and numbers of macrophages and neutrophils in bronchoalveolar lavage. Cigarette smoke exposure resulted in lower body weight, which was accompanied by lower serum leptin levels, more time spent in the inner zone of the open field, and decreased claudin-5 and occludin protein expression levels in brain microvessels. Combined cigarette smoke and LPS exposure resulted in increased locomotion and elevated microglial activation in the hippocampus of the brain. These novel findings show that systemic inflammation observed after combined cigarette smoke and LPS exposure in this COPD model is associated with increased exploratory behavior. Findings suggest that neuroinflammation is present in the brain area involved in cognitive functioning, and that blood-brain barrier integrity is compromised. These findings can contribute to our knowledge about possible processes involved in brain-related comorbidities in COPD, which is valuable for optimizing and developing therapy strategies.
... A prospective study showed that anxiety increases the number of symptom-related exacerbations and prolonged hospital stays, and depression may increase the risk of exacerbations and hospitalizations (Xu et al., 2010;Yohannes and Alexopoulos, 2014;von Leupoldt et al., 2011). Different from the prospective study, this study is a retrospective study of the number of hospitalizations in the past 2 years after admission. ...
Depression and anxiety are common in patients with COPD (chronic obstructive pulmonary disease), and anxiety and depression can increase the risk of hospitalization and the acute exacerbation of chronic obstructive pulmonary disease. The relationship between the frequency of hospitalization for acute exacerbation of COPD (AECOPD) and the anxiety and depression of patients is not fully understood. This study aims to analyze the relationship between the frequency of hospitalizations and anxiety and depression of patients of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). A collection of 309 AECOPD patients admitted to the emergency department in our hospital from 2019 to 2020 were divided into anxiety group A and depression group D according to the Hospital Anxiety and Depression Scale (HADS) score and divided into A1 and D1 negative groups (≤7 Score), A2 and D2 suspicious groups (8–10 points), A3 and D3 confirmed groups (≥11 points) for paired analysis of anxiety and depression correlation and difference and comparison of the frequency of hospitalization in each group within 2 years. The results found that anxiety and depression were significantly positively correlated (r = 0.654, p = 0.000). Intra-group comparison shows that the difference between the anxiety-diagnosed and non-diagnosed groups and the depression subgroups are statistically p < 0.05; the comparison between the anxiety subgroup and the depression subgroup showed that there was a statistical difference between the confirmed group and the non-diagnosed group (p < 0.01). In short, AECOPD anxiety is positively correlated with depression, and depression is affected by the frequency of hospitalization earlier and gradually, and anxiety should be prioritized in the acute phase.
... An 8-week program of comprehensive PR and a combination of progressive muscle relaxation and PR program also reduced depression and anxiety significantly [39][40][41]. As anxiety and depression result in increased dyspnea, reduced functional performance, and quality of life in patients with COPD [42], PR may be an effective program for reducing symptoms of anxiety and depression [38]. ...
Introduction: Chronic Obstructive Pulmonary Disease (COPD) impairs patients` quality of life and clinical outcomes. Pulmonary rehabilitation (PR) program can improve the functional capacity in patients with chronic lung disease. Thus, the study aimed to evaluate the effect of the PR program on the quality of life, anxiety, depression, and pulmonary function of patients with COPD. Materials and Methods: In this single-group before-and-after clinical trial, adult patients with COPD and recent history of exacerbation were recruited. The intervention was a PR program, including training of breathing exercises at home and aerobic exercise program, twice a week about 30 to 60 min for 8 weeks. The program was prepared according to the patient’s tolerance by a sports medicine specialist in a pulmonary rehabilitation clinic. The primary outcome was quality of life measured by the St. George’s Respiratory Questionnaire (SGRQ). Secondary outcomes were assessing anxiety, depression, pulmonary function, COPD status, the ability to walk, and shortness of breathing. All outcomes were measured before and one week after the program. Results: Twenty-two eligible patients of both genders (68% male and 32% female) with a Mean±SD age of 65.09±9.72 years finished the program. Quality of life was improved significantly following the intervention (51.49 [16.68] vs 4275 [15.63]; P<0.001]. Anxiety and depression (P<0.001), pulmonary function parameters, such as forced expiratory volume in 1 second (FEV1) (P<0.001) and FEV1/ forced vital capacity (FVC) ratio (P=0.015), COPD status (P=0.001), the ability of walk1ing (P<0.05), and shortness of breath (P=0.001) were improved significantly after the intervention. Conclusion: The PR program resulted in clinical improvement in patients with COPD. Thus, we recommend that it be used besides medical management.
... The study by Zeng et al. (98) identified age, severity of disease, and quality of life as significant predictors for physical performance measured by 6-minute-walking-distance in patients with COPD with a medium effect size of f ² = 0.21. In a regression model, von Leupoldt et al. (99) showed that depression is one out of 6 predictors (e.g., age, gender, forced expiratory volume in 1 s) for the completed 6MWT in COPD-patients in outpatient rehabilitation with a small effect size of f ² = 0.06 (71). Due to the heterogeneity of study results, a medium effect size of f ² = 0.15 can be assumed for the calculation of sample size to present associations between physical performance and mental health. ...
Background: In 2020, the novel coronavirus disease (COVID-19) developed into a worldwide pandemic. The course of COVID-19 is diverse, non-specific, and variable: Affected persons suffer from physical, cognitive, and psychological acute and long-term consequences. The symptoms influence everyday life activities, as well as work ability in the short or long-term. Healthcare professionals are considered particularly vulnerable to COVID-19 compared to the general population. In Germany, COVID-19 is recognized as an occupational disease or a work-related accident under certain conditions. Disease-specific rehabilitation is recommended for patients following acute COVID-19 to recover physical and neuropsychological performance and to improve work ability. Currently, there are limited findings on the short-term or long-term impact of COVID-19 as a recognized occupational disease or work-related accident, as well as on rehabilitation programs and associated influencing factors. Thus, the present research project will investigate these questions.
Methods: For this observational cohort study, post-acute patients with COVID-19 as a recognized occupational disease or work-related accident according to the insurance regulations for COVID-19 will be recruited at the BG Hospital for Occupational Disease in Bad Reichenhall, Germany. All participants will complete a comprehensive multimodal and interdisciplinary inpatient rehabilitation program for a duration of at least 3 weeks, beginning after their acute COVID-19 infection and depending on their individual indication and severity of disease. Participants will complete medical, functional, motor, psychological, and cognitive measurements at four time points (at the beginning (T1) and end (T2) of inpatient rehabilitation; 6 (T3) and 12 (T4) months after the beginning of inpatient rehabilitation).
Discussion: The present research project will help to assess and describe long-term effects of COVID-19 as a recognized occupational disease or work-related accident on physical and neuropsychological health, as well as on everyday activities and work ability of affected insured persons. In addition, this study will investigate influencing factors on severity and course of COVID-19. Furthermore, we will examine rehabilitation needs, measures, occurring specifics, and the feasibility of the rehabilitation procedure and disease development in the patients. The results of the intended study will further advance common recommendations for targeted and tailored rehabilitation management and participation in inpatient rehabilitation.
Clinical Trial Registration: www.drks.de, identifier: DRKS00022928.
... An 8-week program of comprehensive PR and a combination of progressive muscle relaxation and PR program also reduced depression and anxiety significantly [39][40][41]. As anxiety and depression result in increased dyspnea, reduced functional performance, and quality of life in patients with COPD [42], PR may be an effective program for reducing symptoms of anxiety and depression [38]. ...
Introduction: Chronic Obstructive Pulmonary Disease (COPD) impairs patients` quality of life and clinical outcomes. Pulmonary rehabilitation (PR) program can improve the functional capacity in patients with chronic lung disease. Thus, the study aimed to evaluate the effect of the PR program on the quality of life, anxiety, depression, and pulmonary function of patients with COPD.
Materials and Methods: In this single-group before-and-after clinical trial, adult patients with COPD and recent history of exacerbation were recruited. The intervention was a PR program, including training of breathing exercises at home and aerobic exercise program, twice a week about 30 to 60 min for 8 weeks. The program was prepared according to the patient’s tolerance by a sports medicine specialist in a pulmonary rehabilitation clinic. The primary outcome was quality of life measured by the St. George’s Respiratory Questionnaire (SGRQ). Secondary outcomes were assessing anxiety, depression, pulmonary function, COPD status, the ability to walk, and shortness of breathing. All outcomes were measured before and one week after the program.
Results: Twenty-two eligible patients of both genders (68% male and 32% female) with a Mean±SD age of 65.09±9.72 years finished the program. Quality of life was improved significantly following the intervention (51.49 [16.68] vs 4275 [15.63]; P
... Since ICS are known to have some systemic uptake and have an overlap with OCS in other side-effects, it could be hypothesized that ICS could to some extent be absorbed to the systemic circulation trigger the same CNS-effects as oral corticosteroids. Depression is also known to be more prevalent in COPD patients than in the general population [15], and is associated with higher rates of exacerbations [16,17], impaired quality of life [18] and increased mortality [19]. As COPD patients have an increased risk of depression and there is a theoretical basis for suspecting psychiatric side-effects to ICS treatment, it is relevant to investigate whether ICS is associated with psychiatric symptoms in patients with COPD. ...
Psychiatric side effects are well known from treatment with systemic corticosteroids. It is, however, unclear whether inhaled corticosteroids (ICS) have psychiatric side effects in patients with COPD. We conducted a nationwide cohort study in all Danish COPD outpatients who had respiratory medicine specialist-verified COPD, age ≥40 years, and no previous cancer. Prescription fillings of antidepressants and risk of admissions to psychiatric hospitals with either depression, anxiety or bipolar disorder were assessed by Cox proportional hazards models. We observed a dose-dependent increase in the risk of antidepressant-use with ICS cumulated dose (HR 1.05, 95% CI 1.03–1.07, p = 0.0472 with low ICS exposure, HR 1.10, 95% CI 1.08–1.12, p < 0.0001 with medium exposure, HR 1.15, 95% CI 1.11–1.15, p < 0.0001 with high exposure) as compared to no ICS exposure. We found a discrete increased risk of admission to psychiatric hospitals in the medium and high dose group (HR 1.00, 95% CI 0.98–1.03, p = 0.77 with low ICS exposure, HR 1.07, 95% CI 1.05–1.10, p < 0.0001 with medium exposure, HR 1.13, 95% CI 1.10–1.15, p < 0.0001 with high exposure). The association persisted when stratifying for prior antidepressant use. Thus, exposure to ICS was associated with a small to moderate increase in antidepressant-use and psychiatric admissions.
... However, MESQUITA et al. [44] reported that people with COPD with more baseline symptoms of anxiety and depression had a higher likelihood of achieving meaningful change in 6MWD compared with those with fewer comorbidities. Yet in other studies, although symptoms of anxiety and depression were reduced after PR, depression was associated with reduced 6MWD and HRQoL before PR and following a PR programme [45], and mood disturbance was likely to decrease clinically significant improvements in PR [35]. ...
... Chez les patients présentant des troubles anxiodépressifs, les résultats de la réhabilitation respiratoire (RR) sont moins favorables. Ainsi, von Leupoldt et al. [21], chez 238 patients atteints de BPCO, montrent qu'avant et après la RR, l'anxiété et la dépression étaient significativement associées à une dyspnée accrue et une réduction des performances fonctionnelles et de la qualité de vie. D'autre part, en cas de présence d'anxiété ou de dépression, le sevrage tabagique (ST) est plus difficile [22,23], la communication avec les soignants plus délicate et l'observance thérapeutique moindre [24]. ...
Résumé
La BPCO est une maladie respiratoire chronique, souvent associée à des manifestations extrapulmonaires. Les comorbidités, parmi lesquelles l’anxiété, la dépression et les troubles cognitifs, aggravent sa progression et la qualité de vie. La prévalence de ces troubles est importante.Pourtant, ils sont souvent méconnus et insuffisamment pris en charge. Dans le développement des troubles psychiatriques, de nombreuses preuves soulignent le rôle majeur de l’inflammation systémique, sans oublier le rôle de la maladie chronique, du terrain génétique, des conséquences du tabagisme, de l’hypoxémie, du stress oxydatif, et du microbiote intestinal. À côté des prises en charge classiques, comme les bronchodilateurs, la réhabilitation respiratoire et le sevrage tabagique, l’inflammation systémique constitue une cible thérapeutique intéressante, avec recours aux anti-inflammatoires, aux anti-cytokines, et aux interventions nutritionnelles.
... We found that participants who exceeded the MCID in ISWT with supplement had a higher baseline depression score (although still within normal range), and higher than in the non-responder group by more than the MCID of 1.4 points [28]. In COPD patients, depression has a negative impact on PR outcomes such as exercise capacity and dyspnoea which might unfavourably affect the distance walked in ISWT during the baseline visit [29]. Our PR programme involved exercise and education, including stress management. ...
Background
Pulmonary rehabilitation (PR) is a cost-effective management strategy in chronic obstructive pulmonary disease (COPD) which improves exercise performance and health-related quality of life. Nutritional supplementation may counter malnutrition and enhance PR outcomes but rigorous evidence is absent. We aimed to investigate the effect of high protein-supplementation (Fortisip Compact Protein, FCP) during PR on exercise capacity.
Methods
A double-blind randomised controlled trial comparing FCP with preOp (a carbohydrate control supplement) in COPD patients participating in a PR programme. Participants consumed the supplement twice a day during PR and attended twice-weekly PR sessions, with pre- and post-PR measurements including the incremental shuttle walk test (ISWT) at 6-weeks as the primary outcome. Participants’ experience using supplements was assessed.
Results
Sixty-eight patients were recruited; (FCP: 36 and control: 32). The trial was stopped early due to COVID-19. Although statistical significance was not reached, there was the suggestion of a clinically meaningful difference in ISWT at 6 weeks favouring the intervention group (intervention: 342 m±149; n=22 versus control: 305 m±148; n=22, p=0.1). Individuals who achieved an improvement in ISWT had larger mid-thigh circumference at baseline (responder: 62 cm±4 versus non-responder: 55 cm±6; p=0.006). 79% were satisfied with the taste and 43% would continue taking the FCP.
Conclusion
Although the data did not demonstrate a statistically significant difference in ISWT, high protein supplementation in COPD during PR may result in a clinically meaningful improvement in exercise capacity and was acceptable to patients. Large, adequately powered studies are justified.
... Although, pulmonary rehabilitation programs can lead to a reduction in dyspnea, which in turn can reduce symptoms of stress or anxiety [23]. The proven impact of anxiety associated with dyspnea on increasing the disability degree has made the assessment and treatment of anxiety an integral part of clinical practice in the treatment of COPD [24]. The genetic determinants of depression in the course of COPD are also being sought. ...
Background and Objectives: The relationship between physical health and mental health has been considered for years. A number of studies have shown a correlation between depressive states and the progress of somatic diseases. It seems that the proper cooperation of specialists may result in the improvement of the patient's well-being and a positive effect on the course of the rehabilitation process. The aim of this study was to assess the symptoms of depression, anxiety, and stress in patients with chronic obstructive pulmonary disease (COPD) as well as the assessment of the relationship of psychological symptoms with sociodemographic factors and physical condition. Materials and Methods: The study enrolled 51 COPD patients who underwent a three-week pulmonary rehabilitation program. After admission to the rehabilitation department, the subjects were asked to complete the Hospital Anxiety and Depression Scale (HADS) questionnaire, the Perception of Stress Questionnaire (PSQ), and a sociodemographic questionnaire. Results: Anxiety states were diagnosed in 70% of respondents and depressive states were diagnosed in 54% of patients. Some of the respondents (14%) also showed a tendency to experience various grounded stresses. Additionally, there were correlations between the mental state and the results of fitness and respiratory tests. Conclusions: Patients with COPD are at risk for mental disorders, which may adversely affect their general health and significantly limit their physical and respiratory efficiencies. The development of widely available therapeutic solutions to reduce symptoms associated with depression, anxiety, and stress seems to be an important challenge for the management of patients with COPD.
... Depression occurs at elevated rates in the LGBTQ+ community, compared to the general population (Budge et al., 2013;Roberts et al., 2013) and negatively impacts the lives of LGBTQ+ individuals across demographic categories (Mills et al., 2004;Mustanski et al., 2010;Roberts et al., 2013). LGBTQ+ individuals also experience higher levels of anxiety than their heterosexual, cisgender counterparts (Ameringen et al., 2003;Leupoldt et al., 2011). Elevated levels of anxiety are associated with lower school enrollment, increased fear of negative evaluation, physical health issues, and risk behaviors (Crawford et al., 2009;Fredriksen-Goldsen et al., 2013;Pachankis & Goldfried, 2006;Yarns et al., 2016). ...
In the rural state of Oklahoma, suicide rates are nearly double the U.S. national average. Self-harm behaviors are among the risk factors for suicide and are believed to regulate negative emotions such as depression and anxiety. LGBTQ+ transitional youth in rural areas are likely to experience elevated rates of depression, anxiety, and stress, relative to heterosexual, cisgender populations. In an effort to identify emotional and behavioral dynamics that may underlie self-harm in a rural state, 316 LGBTQ+ transitional youth in Oklahoma were recruited. Participants completed measures of negative affect, emotion regulation, outness, and self-harm. A cluster analysis was conducted to identify distress-related trends in the data and identified clusters of high, moderate, and low distress groups. Chi-square analyses identified associations among groups based on gender expression, gender identity, sexual orientation, education, and homelessness. A regression equation identified predictors of self-harm. Cluster analysis results informed hierarchical organization of a linear regression equation in which the study team controlled for between-group differences and outness. In the final regression model [F (10, 305) = 14.20, p < .001], distress, emotion dysregulation, education variables, homelessness, and outness predicted self-harm behaviors. Implications of study findings for the distribution of resources and guidance for healthcare professionals and community advocates are discussed.
... Mental and emotional conditions affect the threshold of dyspnea sensitivity. Anxiety and depression augment dyspnea [91]. Respiration is affected by the limbic and paralimbic systems, especially the amygdala [92,93]. ...
Dyspnea is defined as a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. It is a common symptom among patients with respiratory diseases that reduces daily activities, induces deconditioning, and is self-perpetuating. Although clinical interventions are needed to reduce dyspnea, its underlying mechanism is poorly understood depending on the intertwined peripheral and central neural mechanisms as well as emotional factors. Nonetheless, experimental and clinical observations suggest that dyspnea results from dissociation or a mismatch between the intended respiratory motor output set caused by the respiratory neuronal network in the lower brainstem and the ventilatory output accomplished. The brain regions responsible for detecting the mismatch between the two are not established. The mechanism underlying the transmission of neural signals for dyspnea to higher sensory brain centers is not known. Further, information from central and peripheral chemoreceptors that control the milieu of body fluids is summated at higher brain centers, which modify dyspneic sensations. The mental status also affects the sensitivity to and the threshold of dyspnea perception. The currently used methods for relieving dyspnea are not necessarily fully effective. The search for more effective therapy requires further insights into the pathophysiology of dyspnea.
... Psychological distress accompanying chronic disease, especially depression, has an adverse impact on the treatment and prognosis of chronic disease. An increasing evidence has shown that elevated psychological symptoms, including depression, anxiety, and stress have been found to be associated with declined quality of life, poorer medication adherence, adverse health outcomes and mortality in patients with chronic diseases and interventions were suggested to be developed to reduce psychological symptoms (Bujang et al., 2015;Hoogendoorn et al., 2019;Lesman-Leegte et al., 2009;von Leupoldt et al., 2011). ...
Aims
To assess the prevalence and associated factors of psychological distress among patients with chronic hepatitis B receiving oral antiviral therapy and explore the association between psychological distress and self‐management behaviours among this population.
Design
A cross‐sectional study.
Methods
A convenience sample of 188 patients with chronic hepatitis B receiving oral antiviral therapy was recruited from March‐October 2018 to complete a self‐report questionnaire including the Chinese version of Depression Anxiety Stress Scale‐21 and Chronic Hepatitis B Self‐Management Scale. Logistic regression analysis and hierarchical multiple regression analysis were used to determine the factors associated with psychological distress and the association between psychological distress and self‐management behaviours respectively.
Results
The prevalence of depression, anxiety, and stress symptoms were 33.0%, 38.3% and 17.6% respectively. Depression was associated with older age, female gender, lower education level and longer treatment duration; anxiety was associated with female gender and longer treatment duration; and stress was associated with age of 31–40 years, female gender and unmarried status. There were significant associations between depression and anxiety symptoms and self‐management behaviours.
Conclusion
Psychological distress was prevalent among patients with chronic hepatitis B receiving oral antiviral therapy and had a negative impact on self‐management. Interventions targeting depression and anxiety symptoms may be beneficial to improve self‐management behaviours for this population.
Impact
This study explored the factors associated with psychological distress in patients with chronic hepatitis B receiving oral antiviral therapy. The findings showed psychological distress was more common in patients who were with older age, female, less educated, unmarried and receiving longer duration of treatment and psychological distress was significantly associated with self‐management behaviours. Nurses and other healthcare providers should provide interventions to reduce the risk of psychological distress and improve self‐management behaviours for this population.
... Depressive symptoms are more frequent among patients with COPD [3]. Depressive patients with COPD have an increased frequency of exacerbations [4,5], less effective pulmonary rehabilitation, impaired quality of life, aggravated dyspnea [6] and increased mortality [7,8]. Separately, both smoking and COPD are associated with increased risk of depressive symptoms [2,[9][10][11]. ...
Introduction
Depressive symptoms appear more often among patients with chronic obstructive pulmonary disease (COPD) and are associated with reduced disease control and increased mortality. Both smoking and COPD increase the risk of depressive symptoms. Whether smoking cessation among COPD patients affects the occurrence of depressive symptoms is unknown. We hypothesised that smoking cessation in patients with COPD leads to reduced use of antidepressants and fewer admissions to psychiatric hospitals with depression, anxiety or bipolar disorder.
Methods
We conducted a nationwide retrospective case-control study, in patients from The Danish Register for Chronic Obstructive Pulmonary Disease (DrCOPD) with spirometry verified COPD, age ≥40 years, a history of smoking and absence of cancer. Consistent smokers were matched 1:1 with ex-smokers using a propensity score model. Prescription fillings of antidepressants and risk of admissions to psychiatric hospitals with either depression, anxiety or bipolar disorder both descriptively was assessed by Cox proportional hazard models.
Results
We included 21 184 patients. A total of n=2011 consistent smokers collected antidepressant prescriptions compared with 1821 ex-smokers. Consistent smoking was associated with increased risk of filling prescription on antidepressants (HR 1.4, 95% CI 1.3–1.5, p<0.0001). and with increased risk of psychiatric hospital admission with either depression, anxiety or bipolar disorder (HR 2.0, 95% CI 1.6–2.5). The associations persisted after adjustment for former use of antidepressants.
Conclusion
Consistent smoking among COPD patients was associated with increased use of antidepressants and admissions to psychiatric hospitals with either depression, anxiety or bipolar disorder, compared to smoking cessation.
Introduction:
Chronic obstructive pulmonary disease (COPD) is frequently accompanied by a variety of comorbidities, complicating management and rehabilitation efforts. Understanding this interplay is crucial for optimizing patient outcomes.
Areas covered:
This review, based on the MEDLINE, Embase and Cochrane Library databases, summarizes the main research on the rehabilitation of patients with COPD, with an emphasis on relevant comorbidities, such as cardiovascular diseases, pulmonary hypertension, lung cancer, metabolic, musculoskeletal, and gastrointestinal disorders. anxiety/depression and cognitive disorders. The study highlights the importance of pre-participation assessments, ongoing monitoring and personalized rehabilitation programs. A review includes a comprehensive literature search to assess the scientific evidence on these interventions and their impact.
Expert opinion:
The integration of cardiorespiratory rehabilitation program is essential for improving physical capacity and quality of life in COPD patients with comorbidities. While existing studies highlight positive outcomes, challenges such as interdisciplinary collaboration and access to rehabilitation services remain. Future strategies must prioritize personalized and integrated approaches programs combining pharmacological optimization and a close monitoring during cardiopulmonary rehabilitation to significantly reduce hospital readmissions and mortality, even in patients with complex multimorbidities. Continued research is necessary to refine rehabilitation protocols and better understand the complexities of managing COPD alongside cardiac conditions.
In this chapter, we will consider the relationship between physical health and interoceptive processing. We will focus on the specific physiological conditions of cardiorespiratory disease, chronic pain, and metabolic disease, as well as the potential role of both nutrition and physical activity in interoception. In general, it appears that many chronic physiological diseases are related to disruptions in interoceptive processing. However, the notable comorbidity with psychiatric conditions (such as anxiety, depression, and panic disorder) means that care must be taken when interpreting interoceptive findings in physiological diseases, with a future focus on understanding the unique and combined contributions of physiological and psychological influences on interoception. Furthermore, the relationship between interoception and some physical health indices needs to be examined in more detail, including longitudinally to identify causality.
Aim of the book is to discuss the controversial items in GOLD about diagnosis and managenment of COPD
Dyspnea is defined as “a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity”. In patients especially with pulmonary diseases, dyspnea reduces daily activity, which worsens the physical condition, and thereby further increases dyspnea, forming a vicious cycle. In clinical practice, reduction of dyspnea in patients with diseases is crucial. One of the goals in pulmonary rehabilitation is reduction of dyspnea to break the above-mentioned vicious cycle. However, the mechanism of dyspnea perception has not been fully elucidated because it is complex and is not explained by a single factor such as changes in blood gas. Not all patients with chronic respiratory failure with hypercapnia are dyspneic, or not all patients with COPD with severe hypoxemia perceive dyspnea. To date, sufficiently effective methods to relieve dyspnea have not been established. We integrated the theories which explain the mechanisms of dyspnea perception with our considerations from the viewpoint of respiratory neurophysiology, and propose a model of dyspnea perception mechanism. In our model, dyspnea results from disassociation or mismatch between the neural respiratory motor output from the respiratory neural network in the lower brainstem and the actually accomplished ventilation. The projection modality of neural information on dyspnea to the higher sensory center of the brain, and the brain regions for comparison of the intended respiratory neural output from the brainstem respiratory center and the monitored actual ventilatory output remain unknown. Further clarification of these issues will enlighten understanding of the pathophysiology of dyspnea and contribute to more effective practice of pulmonary rehabilitation.
COPD is a chronic respiratory disease that commonly coexists with other chronic conditions. These comorbidities have been shown to influence overall disease burden and mortality in COPD, and these comorbidities have an important impact on functional status and other psychosocial factors. Mental health disorders, especially anxiety and depression are common comorbidities in COPD. However, the mechanisms and interactions of anxiety and depression in COPD are poorly understood and these conditions are often underdiagnosed. The interplay between anxiety and depression and COPD is likely multifactorial and complex. An obvious mechanism is the expected psychological consequences of having a chronic illness. However, there is increasing interest in other potential biological processes, such as systemic inflammation, smoking, hypoxia, and oxidative stress. Recognition and diagnosis of comorbid anxiety and depression in patients with COPD is often challenging because there is no consensus on the appropriate screening tools or rating scales to use in this patient population. Despite the challenges in accurate assessment of anxiety and depression, there is growing evidence to support that these comorbid mental health conditions in COPD result in worse outcomes, including poor health-related quality of life, increased exacerbations with associated health-care utilization and cost, increased functional disability, and increased mortality. There are limited data of variable quality on effective treatment and management strategies, both pharmacologic and non-pharmacologic, for anxiety and depression in COPD. However, cumulative evidence demonstrates that complex psychological and lifestyle interventions, which include a pulmonary rehabilitation component, may offer the greatest benefit. The high prevalence and negative impact of depression and anxiety highlights the need for comprehensive, innovative, and standardized chronic disease management programs for individuals with COPD.
Purpose: Dysfunctional breathing behaviors are prevalent in chronic obstructive pulmonary disease (COPD). Although these behaviors contribute to dyspnea, abnormal carbon dioxide (CO2) levels, and COPD exacerbations, they are modifiable. Current dyspnea treatments for COPD are suboptimal, because they do not adequately address dysfunctional breathing behaviors and anxiety together. We developed a complementary mind-body breathlessness therapy, called capnography-assisted respiratory therapy (CART), that uses real-time CO2 biofeedback at the end of exhalation (end-tidal CO2 or ETCO2), to target dysfunctional breathing habits and improve dyspnea treatment and pulmonary rehabilitation (PR) adherence in COPD. The study aim was to test the feasibility of integrating CART with a traditional, clinic-based PR program in an urban setting. Methods: We used a feasibility pre- and post-test design, with 2:1 randomization to CART+PR or control (PR-alone) groups, to test and refine CART. Multi-component CART consisted of six, 1-h weekly sessions of slow breathing and mindfulness exercises, ETCO2 biofeedback, motivational counseling, and a home program. All participants were offered twice weekly, 1-h sessions of PR over 10 weeks (up to 20 sessions). Results: Thirty-one participants with COPD were enrolled in the study. Approximately a third of participants had symptoms of psychological distress. Results showed that CART was feasible and acceptable based on 74% session completion and 91.7% homework exercise completion (n = 22). Within-group effect sizes for CART+PR were moderate to large (Cohen's d = 0.51-1.22) for reduction in resting Borg dyspnea (anticipatory anxiety) and respiratory rate, St. George's Respiratory Questionnaire (SGRQ) respiratory symptoms; and increase in Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and physical activity; all p < 0.05. Conclusions: CART is a new mind-body breathing therapy that targets eucapnic breathing, interoceptive function, and self-regulated breathing to relieve dyspnea and anxiety symptoms in COPD. Study findings supported the feasibility of CART and showed preliminary signals that CART may improve exercise tolerance, reduce dyspnea, and enhance PR completion by targeting reduced dysfunctional breathing patterns (CTR No. NCT03457103).
For many people suffering breathlessness, its severity is not fully explained by objective measures of disease. This conundrum has puzzled doctors for many years, and has led research efforts towards understanding whether brain perceptual processes may be involved. This chapter explains current theories of perception as applied to the understanding of breathlessness. Emerging evidence in relation to proprioception, pain and somatosensation suggests that perceptions arise from the integration of sensory signals from the periphery with a set of predictions, or expectations held in the brain. Neuroimaging and behavioural studies suggest that this model also applies in the perception of breathlessness. It therefore follows that any process that can influence the brain's set of predictions, such as mood, affective state and aberrant learning, may also influence the severity of breathlessness, independently of underlying pathology. This new theory of perception may help explain some of the benefits of pulmonary rehabilitation, and could help us develop new ways to treat breathlessness. Novel treatments might include drugs that target expectation mechanisms or more focused non-pharmacological interventions, or a combination of the two.
Background
Anxiety and depression are common among patients with chronic obstructive pulmonary disease (COPD), but the associations between psychiatric symptoms and specific COPD outcomes are uncertain.
Methods
Associations of psychiatric symptoms (anxiety and depression) and COPD outcomes (COPD Assessment Test (CAT), modified Medical Research Council dyspnea scale (mMRC), number of acute exacerbations and percentage predicted forced expiratory volume in 1 s (FEV1% predicted)) sets were performed by canonical correlation analysis in 876 patients with COPD.
Results
In primary analysis, we discovered a statistically significant relationship between symptoms of anxiety/depression and COPD outcomes sets (1 - Λ = 0.11; P < .001). Symptoms of anxiety/depression and four COPD outcomes sets shared 11 % of variance. CAT was the main driver of the relationship (rs = −0.930; rs² = 0.8649) followed by mMRC (rs = −0.632; rs² = 0.3994) and exacerbation history (rs = −0.478; rs² = 0.2285); FEV1% predicted did't make a significant contribution to the relationship (rs = 0.134; rs² = 0.018). In secondary analysis, women were associated with a stronger correlation based on the shared variance between psychiatric symptoms and COPD outcomes sets (17.4 %) than men (9.8 %).
Limitations
Some confounding factors such as education level, income, didn't be included. There were considerably fewer women enrolled in this study than men.
Conclusion
Psychiatric symptoms were associated with COPD subjective outcomes, and more related to COPD outcomes in women.
Pulmonary rehabilitation (PR) improves health-related quality of life (HRQoL) and exercise capacity. Little is known about the impact of depression symptoms and exercise self-efficacy on improvements in these key PR outcomes. This study examined the impact of baseline depression status and change in depression symptoms (Beck Depression Inventory-II [BDI-II] score) over the course of PR on change in HRQoL assessed by the Chronic Respiratory Disease Questionnaire-Self Reported (CRQ-SR) and exercise capacity as measured by the 6-Minute Walk Test (6MWT). We also examined whether baseline exercise self-efficacy moderated the association between baseline depression symptoms and change in these key PR outcomes. We studied 112 US veterans (aged 70.38 ± 8.49 years) with chronic obstructive pulmonary disease (COPD) who completed PR consisting of twice-weekly 2-hour classes for 18 sessions. Depressed (BDI-II >13) and nondepressed (BDI-II ≤13) patients at baseline demonstrated comparable and significant improvement in CRQ-SR total score, subscales, and 6MWT. Greater reduction in depression over the course of treatment was significantly associated with greater improvement in CRQ-SR total score and the following subscales: fatigue, mastery, and emotional function. Change in depression did not predict change in 6MWT distance. Baseline exercise self-efficacy moderated the association between baseline depression symptoms and change in CRQ-SR fatigue. Specifically, when baseline exercise self-efficacy was <30.4, greater baseline depression was associated with less improvement in CRQ-SR fatigue. When baseline self-efficacy was >152.0, greater baseline depression was associated with greater improvement in CRQ-SR fatigue. PR programs should address mood and confidence to exercise given their impact on key PR outcomes.
While Coronavirus disease-2019 (COVID-19) affects the whole world, most affected group is geriatric individuals. There is a need for strategies for geriatric individuals returning to society and their social life. The aim of this study is to investigate the effect of an 8-week home-based Pulmonary Rehabilitation program on quality of life, depression, anxiety and functional capacity in geriatric individuals with COVID-19. Twenty-five patients were included in this prospective study. Patients over 65 years of age with COVID-19 were evaluated. Physical capacity with the 6-minute walking test (6MWT), dyspnea status with the Medical Research Council Dyspnea Scale, quality of life with the Short Form-36 (SF-36), depression and anxiety with the Hospital Anxiety and Depression Scale were evaluated. The mean age of the patients included in the study was 68.9 ± 6.4 years. 56% of the patients were men and 44% were women. When pre-treatment and post-treatment values were compared, a significant improvement was found in the 6MWT, dyspnea scores, SF-36 and all subgroups, anxiety and depression scores (p <0.05). This study shows that the home-based Pulmonary Rehabilitation program is an effective method on parameters such as quality of life, depression and physical capacity in geriatric individuals with COVID-19. Prospective large-scale studies are needed to validate our current results.
Background:
The magnitude of response to pulmonary rehabilitation (PR) is influenced by the selection of outcomes and measures.
Objectives:
This systematic review aimed to review all outcomes and measures used in clinical trials of PR for individuals with chronic obstructive pulmonary disease (COPD).
Methods:
The review involved a search of Scopus, Web of Knowledge, Cochrane Library, EBSCO, Science Direct and PubMed databases for studies of stable individuals with COPD undergoing PR. Frequency of reporting for each domain, outcome and measure was synthesized by using Microsoft Excel.
Results:
We included 267 studies (43153 individuals with COPD). A broad range of domains (n=22), outcomes (n=163) and measures (n=217) were reported. Several measures were used for the same outcome. The most reported outcomes were exercise capacity (n=218) assessed with the 6-min walk test (n=140), health-related quality of life (n=204) assessed with the Saint George's respiratory questionnaire (n=99), and symptoms (n=158) assessed with the modified Medical Research Council dyspnea scale (n=56). The least reported outcomes were comorbidities, adverse events and knowledge.
Conclusions:
This systematic review reinforces the need for a core outcome set for PR in individuals with COPD because of high heterogeneity in reported outcomes and measures. Future studies should assess the importance of each outcome for PR involving different stakeholders.
Prospero id:
CRD42017079935.
Background
: Psychiatric symptoms are common in multiple sclerosis. The relationship of emotional state with respiratory function is unclear in these patients. We aimed to evaluate the relationship between the clinical characteristics, anxiety and depression status, and respiratory functions of patients with relapsing-remitting multiple sclerosis (RRMS).
Method
: The research was planned as a prospective case-control study. Ninety RRMS patients and 50 healthy controls were included in the study. The MS diagnosis was confirmed according to the revised 2017 McDonald's criteria. Disability was divided into two subgroups according to the Expanded Disability Status Scale (EDSS) (under 3.5 and 3.5-5.5). Beck anxiety and Beck depression inventories evaluated. A pulmonary function test was performed with a computerized spirometry device. Forced expiratory volume-1st second (FEV1), forced vital capacity (FVC), FEV/FVC, peak expiratory flow (PEF), maximal expiratory flow (MEF), peak inspiratory flow (PIF), and maximal inspiratory flow (MIF) values were obtained.
Results
: There were 90 RRMS patients with a mean age of 38.68±10.95 years, and 58 (64.40%) were female in the study. The anxiety and depression scores of the patients were significantly higher than the control group (p=0.02, 0.002). FVC and FEV1 values were lower in patients with higher Beck depression scores (p=0.012, 0.007). FVC, FEV1, MEF50, and PIF values were lower in patients with higher Beck anxiety scores (p=0.002, 0.002, 0.030, 0.027). When EDSS and number of attacks were fixed, there was a low to moderate correlation between anxiety and FEV1-FVC (p=0.001, r=-367, -0.360 respectively), and a low negative correlation between depression and FEV1 (p=0.045, r=-0.214).
Conclusion
: Anxiety and depression scores are higher in patients with RRMS. Depression and anxiety are particularly associated with low FVC and FEV1 in patients.
Dyspnea is a debilitating and threatening symptom in various diseases. Affected patients often report the unpredictability of dyspnea episodes being particularly anxiety‐provoking and amplifying the perception of dyspnea. Experimental studies testing dyspnea unpredictability together with related neural processes, physiological fear responses, and dyspnea‐related personality traits are sparse. Therefore, we investigated the impact of unpredictability of dyspnea offset on dyspnea perception and fear ratings, respiratory neural gating and physiological fear indices, as well as the influence of interindividual differences in fear of suffocation (FoS). Forty healthy participants underwent a task manipulating the offset predictability of resistive load‐induced dyspnea including one unloaded safety condition. Respiratory variables, self‐reports of dyspnea intensity, dyspnea unpleasantness, and fear were recorded. Moreover, respiratory neural gating was measured in a paired inspiratory occlusion paradigm using electroencephalography, while electrodermal activity, startle eyeblink, and startle probe N100 were assessed as physiological fear indices. Participants reported higher dyspnea unpleasantness and fear when dyspnea offset was unpredictable compared to being predictable. Individuals with high levels of FoS showed the greatest increase in fear and overall higher levels of fear and physiological arousal across all conditions. Respiratory neural gating, startle eyeblink, and startle probe N100 showed general reductions during dyspnea conditions but no difference between unpredictable and predictable dyspnea conditions. Together, the current results suggest that the unpredictable offset of dyspnea amplifies dyspnea perception and fear, especially in individuals with high levels of FoS. These effects were unrelated to respiratory neural gating or physiological fear responses, requiring future studies on underlying mechanisms.
Objective
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Depression and anxiety worsen COPD and lead to greater respiratory symptom severity and health care utilization. Fear of physical sensations of anxiety (AS-P) is known to exacerbate respiratory symptoms. The current study investigated the unique contribution of AS-P in respiratory symptom exacerbations, emergency department visits, hospitalizations, and COPD-related functional health status, controlling for medical characteristics, depression, and anxiety.
Method
The sample included 535 adults with COPD (Mage = 56.57; 58.1% male). Participants were recruited from a web-based panel of adults with chronic respiratory disease and completed an online battery of self-report measures.
Results
Consistent with hypotheses, AS-P significantly increased the likelihood of acute symptom exacerbations by 12% and respiratory-related emergency department visits and hospitalizations by 7% during the prior 12 month period. Additionally, AS-P demonstrated a unique, large effect (f² = 0.37) on COPD-related functional health status.
Conclusion
Fear of physical sensations contributed to worse respiratory outcomes and health care utilization among adults with COPD. Screening for AS-P may effectively identify at-risk COPD patients, while reducing AS-P through targeted interventions may result in decreased symptom severity, functional limitations, and burden on the health care system.
A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.
Examined 16 adult patients with severe chronic obstructive pulmonary disease (COPD), as indicated by spirometry testing. Ss reported the degree of difficulty in performing 10 tasks of daily living and completed the SCL-90-R to assess affective and somatic states. Results indicate that while restriction of 3 activities was correlated with severity of lung impairment, difficulty in performing daily activities appeared more consistently correlated with emotional functioning. In particular, SCL-90-R subscales of somatization, anxiety, and depression were correlated with behavioral impairment of multiple daily activities. Implications for psychosocial interventions in the rehabilitation of COPD patients are discussed, including the differential impact of stress management training and treatments for depression. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Approximately 60 million people in the United States live with one of four chronic conditions: heart disease, diabetes, chronic respiratory disease, and major depression. Anxiety and depression are very common comorbidities in COPD and have significant impact on patients, their families, society, and the course of the disease.
We report the proceedings of a multidisciplinary workshop on anxiety and depression in COPD that aimed to shed light on the current understanding of these comorbidities, and outline unanswered questions and areas of future research needs.
Estimates of prevalence of anxiety and depression in COPD vary widely but are generally higher than those reported in some other advanced chronic diseases. Untreated and undetected anxiety and depressive symptoms may increase physical disability, morbidity, and health-care utilization. Several patient, physician, and system barriers contribute to the underdiagnosis of these disorders in patients with COPD. While few published studies demonstrate that these disorders associated with COPD respond well to appropriate pharmacologic and nonpharmacologic therapy, only a small proportion of COPD patients with these disorders receive effective treatment.
Future research is needed to address the impact, early detection, and management of anxiety and depression in COPD.
Psychological functioning is an important determinant of health outcomes in chronic lung disease. To better define the role of anxiety in chronic obstructive pulmonary disease (COPD), a study was conducted of the inter-relations between anxiety and COPD in a large cohort of subjects with COPD and a matched control group.
Data were used from the FLOW (Function, Living, Outcomes, and Work) cohort of patients with COPD (n=1202) and matched controls without COPD (n=302). Anxiety was measured using the Anxiety subscale of the Hospital Anxiety and Depression Scale.
COPD was associated with a greater risk of anxiety in multivariable analysis (OR 1.85; 95% CI 1.072 to 3.18). Among patients with COPD, anxiety was related to poorer health outcomes including worse submaximal exercise performance (less distance walked during the 6-min walk test: -66.3 feet for anxious vs non-anxious groups; 95% CI -127.3 to -5.36) and a greater risk of self-reported functional limitations (OR 2.41; 95% CI 1.71 to 3.41). Subjects with COPD with anxiety had a higher longitudinal risk of COPD exacerbation in Cox proportional hazards analysis after controlling for covariates (HR 1.39; 95% CI 1.007 to 1.90).
COPD is associated with a higher risk of anxiety. Once anxiety develops among patients with COPD, it is related to poorer health outcomes. Further research is needed to determine whether systematic screening and treatment of anxiety in COPD will improve health outcomes and prevent functional decline and disability.
Anxiety in patients with chronic obstructive pulmonary disease (COPD) is associated with self-reported disability. The purpose of this study is to determine whether there is an association between anxiety and functional measures, quality of life and dyspnea.
Data from 1828 patients with moderate to severe emphysema enrolled in the National Emphysema Treatment Trial (NETT), collected prior to rehabilitation and randomization, were used in linear regression models to test the association between anxiety symptoms, measured by the Spielberger State Trait Anxiety Inventory (STAI) and: (a) six-minute walk distance test (6 MWD), (b) cycle ergometry peak workload, (c) St. Georges Respiratory Questionnaire (SRGQ), and (d) UCSD Shortness of Breath Questionnaire (SOBQ), after controlling for potential confounders including age, gender, FEV1 (% predicted), DLCO (% predicted), and the Beck Depression Inventory (BDI).
Anxiety was significantly associated with worse functional capacity [6 MWD (B = -0.944, p < .001), ergometry peak workload (B = -.087, p = .04)], quality of life (B = .172, p < .001) and shortness of breath (B = .180, p < .001). Regression coefficients show that a 10 point increase in anxiety score is associated with a mean decrease in 6 MWD of 9 meters, a 1 Watt decrease in peak exercise workload, and an increase of almost 2 points on both the SGRQ and SOBQ.
In clinically stable patients with moderate to severe emphysema, anxiety is associated with worse exercise performance, quality of life and shortness of breath, after accounting for the influence of demographic and physiologic factors known to affect these outcomes.
ClinicalTrials.gov NCT00000606.
Prognostic studies of mortality in patients with COPD have mostly focused on physiologic variables, with little attention to depressive symptoms. This stands in sharp contrast to the attention that depressive symptoms have been given in the outcomes of patients with other chronic health conditions. The present study investigated the independent association of depressive symptoms in stable patients with COPD with all-cause mortality.
The baseline characteristics of 121 COPD patients (78 men and 43 women; mean [+/- SD] age, 61.5 +/- 9.1 years; and mean FEV(1), 36.9 +/- 15.5% predicted) were collected on hospital admission to a pulmonary rehabilitation center. The data included demographic variables, body mass index (BMI), post-bronchodilator therapy FEV(1), and Wpeak (peak workload [Wpeak]). Depressive symptoms were assessed using the Beck depression inventory. The vital status was ascertained using municipal registrations. In 8.5 years of follow-up, 76 deaths occurred (mortality rate, 63%). Survival time ranged from 88 days to 8.5 years (median survival time, 5.3 years). The Cox proportional hazard model was used to quantify the association of the baseline characteristics (ie, age, sex, marital status, smoking behavior, FEV(1), BMI, Wpeak, and depressive symptoms) with mortality.
Depressive symptoms (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.12 to 3.33) were associated with mortality in patients with COPD, independent of other factors including male sex (OR, 1.73; 95% CI, 1.03 to 2.92), older age (OR, 1.05; 95% CI, 1.02 to 1.08), and lower Wpeak (OR, 0.98; 95% CI, 0.97 to 0.99).
This study provides evidence that depressive symptoms assessed in stable patients with COPD are associated with their subsequent all-cause mortality.
Patients with chronic obstructive pulmonary disease have perceptions of their illness and its management that determine their coping behaviors (e.g., adherence, self-management) and, consequently, their outcomes. This article reviews the empirical literature on illness perceptions in patients with COPD to provide clinicians with information regarding the potential utility of incorporating illness perceptions into clinical COPD care.
A literature search in PubMed identified 16 studies examining associations between illness perceptions and outcomes in patients with COPD.
Seven of the 16 papers were from US authors, followed by 3 each from the UK and The Netherlands, and one study each from Australia, Canada, and New Zealand. The first study was published in 1983, and the numbers of patients per study ranged fom 10 to 266. The illness perceptions were those delineated by two theoretical models (cognitive behavioral theory and the Common Sense Model), and they were assessed with open interviews and validated questionnaires. Outcomes were disability, quality of life, and psychological characteristics. The studies revealed clinically meaningful associations between illness perceptions and outcomes.
Our review supports the incorporation of illness perceptions into clinical care for patients with COPD. The assessment of illness perceptions should be routine, similar to routine assessments of pulmonary function. Discussing and changing illness perceptions will improve COPD patients' quality of life and reduce their levels of disability. COPD-specific assessments ("diagnosis") of illness perceptions and COPD-specific intervention methods ("therapy") that help change inadequate and maladaptive illness perceptions are research priorities.
Depression and anxiety are significant comorbid and potentially modifiable conditions in chronic obstructive pulmonary disease (COPD), but their effects on exacerbations are not clear.
To investigate the independent effect of depression and anxiety on the risk of COPD exacerbations and hospitalizations.
A multicenter prospective cohort study in 491 patients with stable COPD in China. Multivariate Poisson and linear regression analyses were used, respectively, to estimate adjusted incidence rate ratios (IRRs) and adjusted effects on duration of events.
Depression and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS) at baseline. Other measurements included sociodemographic, clinical, psychosocial, and treatment characteristics. Patients were then monitored monthly for 12 months to document the occurrence and characteristics of COPD exacerbations and hospitalizations. Exacerbation was determined using both symptom-based (worsening of > or =1 key symptom) and event-based definitions (> or =1 symptom worsening plus > or =1 change in regular medications). A total of 876 symptom-based and 450 event-based exacerbations were recorded, among which 183 led to hospitalization. Probable depression (HADS depression score > or = 11) was associated with an increased risk of symptom-based exacerbations (adjusted IRR, 1.51; 95% confidence interval [CI], 1.01-2.24), event-based exacerbations (adjusted IRR, 1.56; 95% CI, 1.02-2.40), and hospitalization (adjusted IRR, 1.72; 95% CI, 1.04-2.85) compared with nondepression (score < or = 7). The duration of event-based exacerbations was 1.92 (1.04-3.54) times longer for patients with probable anxiety (HADS anxiety score > or = 11) than those with no anxiety (score < or = 7).
This study suggests a possible causal effect of depression on COPD exacerbations and hospitalizations. Further studies are warranted to confirm this finding and to test the effectiveness of antidepressants and psychotherapies on reducing exacerbations and improving health resource utilizations.
A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.
Pulmonary rehabilitation seems to be an effective intervention in patients with chronic obstructive pulmonary disease. We undertook a randomised controlled trial to assess the effect of outpatient pulmonary rehabilitation on use of health care and patients' wellbeing over 1 year.
200 patients with disabling chronic lung disease (the majority with chronic obstructive pulmonary disease) were randomly assigned a 6-week multidisciplinary rehabilitation programme (18 visits) or standard medical management. Use of health services was assessed from hospital and general-practice records. Analysis was by intention to treat.
There was no difference between the rehabilitation (n=99) and control (n=101) groups in the number of patients admitted to hospital (40 vs 41) but the number of days these patients spent in hospital differed significantly (mean 10.4 [SD 9.7] vs 21.0 [20.7], p=0.022). The rehabilitation group had more primary-care consultations at the general-practitioner's premises than did the control group (8.6 [6.8] vs 7.3 [8.3], p=0.033) but fewer primary-care home visits (1.5 [2.8] vs 2.8 [4.6], p=0.037). Compared with control, the rehabilitation group also showed greater improvements in walking ability and in general and disease-specific health status.
For patients chronically disabled by obstructive pulmonary disease, an intensive, multidisciplinary, outpatient programme of rehabilitation is an effective intervention, in the short term and the long term, that decreases use of health services.
A review of the literature revealed high comorbidity of chronic obstructive pulmonary disease (COPD) and states of anxiety and depression, indicative of excess, psychiatric morbidity in COPD. The existing studies point to a prevalence of clinical significant symptoms of depression and anxiety amounting to around 50%. The prevalence of panic disorder and major depression in COPD patients is correspondingly markedly increased compared to the general population. Pathogenetic mechanisms remain unclear but both psychological and organic factors seem to play a role. The clinical and social implications are severe and the concurrent psychiatric disorders may lead to increased morbidity and impaired quality of life. Furthermore, the risk of missing the proper diagnosis and treatment of a concurrent psychiatric complication is evident when COPD patients are treated in medical clinics. Until now only few intervention studies have been conducted, but results suggest that treatment of concurrent psychiatric disorder leads to improvement in the physical as well as the psychological state of the patient. Panic anxiety as well as generalized anxiety in COPD patients is most safely treated with newer antidepressants. Depression is treated with antidepressants according to usual clinical guidelines. There is a need for further intervention studies to determine the overall effect of antidepressants in the treatment of anxiety and depression in this group of patients.
To characterize patients referred for pulmonary rehabilitation on a large number of psychologic and sociodemographic variables and to determine the contribution of these variables on the response to rehabilitation.
Cross-sectional, explorative.
University hospital and outpatient clinic.
Eighty-one consecutive patients with chronic obstructive pulmonary disease (forced expiratory volume in 1 second, 40%+/-16% of predicted) were included in outpatient pulmonary rehabilitation.
Multidisciplinary rehabilitation program.
Pulmonary function, exercise capacity (Wmax, 6-minute walk test [6MWT]), Chronic Respiratory Disease Questionnaire (CRDQ), Modified Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ-M), anxiety and depression (Hospital Anxiety and Depression Scale [HADS]) were assessed before and after 3 months rehabilitation. In addition, psychosocial adjustment, social support, marital status, mode of transportation, education, employment, and smoking status were assessed at the start of the rehabilitation.
Rehabilitation improved exercise performance (Wmax, 6+/-12W; P<.01; 6MWT, 41+/-72 m; P<.001), quality of life (CRDQ score, 12+/-13 points; P<.001), functional status (PFSDQ-M activity score, -8+/-11 points; PFSDQ-M dyspnea score, -6+/-12 points; PFSDQ-M fatigue score, -4+/-8 points; all P<.01), HADS anxiety score (-2+/-3 points, P<.01), and HADS depression score (-3+/-3 points, P<.001). In single regression analysis, only baseline depression was weakly negatively correlated with the change in maximal workload. No other relations of initial psychologic or sociodemographic variables with outcome were observed.
The effects of rehabilitation are not affected by baseline psychosocial factors. Patients with less favorable psychologic or sociodemographic conditions can also benefit from pulmonary rehabilitation. The multidisciplinary approach of the rehabilitation program might have contributed to this improvement.
The aim of this study was to evaluate the relationship between dyspnea and functional, psychosocial and quality of life parameters among persons with chronic obstructive pulmonary disease (COPD). We conducted a cross-sectional study of 90 stable COPD patients recruited from a specialized respiratory clinic. Dyspnea was measured using the ATS-DLD-78 questionnaire modified dyspnea scale (1-5 scale). Physical and functional evaluation included spirometry and six minute walking tests. Subjects then completed five psychological questionnaires: the Coping Inventory for Stressful Situations, the State/Trait Anxiety Inventory, the Beck Depression Index, the NEO-Five Factor Personality Inventory, and the Interpersonal Relationships Inventory. Patients also completed two disease-specific health-related quality of life (HRQL) questionnaires: St. George's Respiratory Questionnaire (SGRQ) and Chronic Respiratory Questionnaire (CRQ). Subjects were predominantly male (n = 65) with a mean age of 68 years (+/- standard deviation 7.6). Over half (54%) the patients reported severe dyspnea (grade 5), and a quarter (24%) reported moderate dyspnea (grade 3-4). Mean FEV1 was 37.8 +/- 14.8% predicted. The mean total SGRQ score was 49 +/- 16 and the CRQ total score was 4.2 +/- 0.9. Dyspnea severity was associated with poorer HRQL scores and decreased physical performance. Based on linear regression, dyspnea scores--but not spirometric values--also correlated with indices of anxiety, depression, and neuroticism. Dyspnea correlated more strongly with HRQL and with indices of anxiety and depression than spirometric values. Although spirometry is often used to evaluate disease severity, dyspnea which is a patient centered outcome better reflect overall disease impact among COPD patients.
To assess the effect of pulmonary rehabilitation (PR) on psychosocial morbidity, functional exercise capacity, and health-related quality of life (HRQL) in patients with severe COPD.
A prospective, randomized, controlled trial with blinding of outcome assessment and data analysis.
A tertiary-care respiratory service.
Forty patients (mean age, 65 +/- 8 years [+/- SD]) with severe chronic flow limitation (FEV(1), 35 +/- 13%) without respiratory failure (Pao(2), 72 +/- 9 mm Hg; Paco(2), 42 +/- 5 mm Hg) were randomized either to a control group or to a PR group (PRG).
Sixteen weeks of PR that included breathing retraining and exercise.
At baseline and 16 weeks, we evaluated psychosocial morbidity using two questionnaires (the Millon Behavior Health Inventory [MBHI] and the Revised Symptom Checklist [SCL-90-R]) and measured 6-min walk distance (6WMD) and HRQL using the Chronic Respiratory Questionnaire (CRQ).
We found differences in favor of the PRG in the following MBHI domains: introversive, forceful, and sensitive personality styles (all p </= 0.05) and chronic tension (p </= 0.01). Results of the depression, hostility, global severity, positive symptom distress index (all p </= 0.01), somatization, anxiety, psychoticism, and positive symptom (all p </= 0.05) domains of the SCL-90-R favored the PRG. We also found statistically and clinically significant differences between groups in 6MWD (85 m; p < 0.01) and in two domains of the CRQ: dyspnea (1.0; p < 0.01) and mastery (0.6; p < 0.05). The other two domains of CRQ showed strong trends in favor of PRG: 0.7 for both fatigue and emotional function (minimal important difference, 0.5).
PR may decrease psychosocial morbidity in COPD patients even when no specific psychological intervention is performed. Findings from this study also confirm the positive impact of PR on functional exercise capacity and HRQL.
The authors examined 179 veterans with chronic obstructive pulmonary disease (COPD) to determine the relative contribution of clinical depression and/or anxiety (Beck Depression and Beck Anxiety Inventories) to their quality of life (Chronic Respiratory Questionnaire and Medical Outcomes Survey Short Form). Multiple-regression procedures found that both depression and anxiety were significantly related to negative quality-of-life outcomes (anxiety with both mental and physical health quality-of-life outcomes, and depression primarily with mental health). When comorbid with COPD, mental health symptoms of depression and anxiety are some of the most salient factors associated with quality-of-life outcomes.
Pulmonary rehabilitation has become a standard of care for patients with chronic lung diseases. This document provides a systematic, evidence-based review of the pulmonary rehabilitation literature that updates the 1997 guidelines published by the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation.
The guideline panel reviewed evidence tables, which were prepared by the ACCP Clinical Research Analyst, that were based on a systematic review of published literature from 1996 to 2004. This guideline updates the previous recommendations and also examines new areas of research relevant to pulmonary rehabilitation. Recommendations were developed by consensus and rated according to the ACCP guideline grading system.
The new evidence strengthens the previous recommendations supporting the benefits of lower and upper extremity exercise training and improvements in dyspnea and health-related quality-of-life outcomes of pulmonary rehabilitation. Additional evidence supports improvements in health-care utilization and psychosocial outcomes. There are few additional data about survival. Some new evidence indicates that longer term rehabilitation, maintenance strategies following rehabilitation, and the incorporation of education and strength training in pulmonary rehabilitation are beneficial. Current evidence does not support the routine use of inspiratory muscle training, anabolic drugs, or nutritional supplementation in pulmonary rehabilitation. Evidence does support the use of supplemental oxygen therapy for patients with severe hypoxemia at rest or with exercise. Noninvasive ventilation may be helpful for selected patients with advanced COPD. Finally, pulmonary rehabilitation appears to benefit patients with chronic lung diseases other than COPD.
There is substantial new evidence that pulmonary rehabilitation is beneficial for patients with COPD and other chronic lung diseases. Several areas of research provide opportunities for future research that can advance the field and make rehabilitative treatment available to many more eligible patients in need.
Effective management of dyspnea in chronic obstructive pulmonary disease (COPD) requires a clearer understanding of its underlying mechanisms. This roundtable reviews what is currently known about the neurophysiology of dyspnea with the aim of applying this knowledge to the clinical setting. Dyspnea is not a single sensation, having multiple qualitative descriptors. Primary sources of dyspnea include: (1) inputs from multiple somatic proprioceptive and bronchopulmonary afferents, and (2) centrally generated signals related to inspiratory motor command output or effort. Respiratory disruption that causes a mismatch between medullary respiratory motor discharge and peripheral mechanosensor afferent feedback gives rise to a distressing urge to breathe which is independent of muscular effort. Recent brain imaging studies have shown increased limbic system activation in response to various dyspneogenic stimuli and emphasize the affective dimension of this symptom. All of these mechanisms are likely instrumental in exertional dyspnea causation in COPD. Increased central motor drive (and effort) is required to increase ventilation during activity because the inspiratory muscles become acutely overloaded and functionally weakened. Abnormal dynamic ventilatory mechanics and excessive chemostimulation during exercise also result in a widening disparity between escalating central neural drive and restricted thoracic volume displacement. This neuromechanical uncoupling may form the basis for the distressing sensation of unsatisfied inspiration. Interventions that alleviate dyspnea in COPD do so by improving ventilatory mechanics, reducing central neural drive, or both-thereby partially restoring neuromechanical coupling of the respiratory system. Self-management strategies address the affective aspect of dyspnea and are essential to successful treatment.
Study objective: To evaluate the short-form 36-item questionnaire (SF-36) as an instrument for measuring health-related quality of life (HRQL) in patients with symptomatic COPD.
Design: Observational data at a single point in time.
Setting: Outpatient pulmonary clinic.
Patients: Fifty male patients with COPD and no significant comorbidity.
Measurements and results: HRQL was assessed with the SF-36, which consists of 36 questions that cover nine health domains. Clinical ratings of dyspnea were measured by the multidimensional baseline dyspnea index (BDI). Pulmonary function tests included forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and maximal inspiratory mouth pressure (PImax). The mean (±SD) age of the patients was 72±8 years. The BDI focal score was 5.6±2.3, FEV1 was 1.32±0.60 L (48±22% pred), and PImax was 62±23 cm H2O. The BDI focal score was significantly correlated with seven of nine components of the SF-36 (range of r, 0.42 to 0.91; p<0.05). The FEV1, percent of predicted and PImax were significantly correlated with five of nine health components (range of r, 0.30 to 0.65 and 0.31 to 0.61, respectively). Using linear regression model analysis with the different SF-36 components as the dependent variable and BDI, FVC, FEV1, and PImax as independent variables, the BDI score was the only significant predictor of social and physical functioning, role-physical, vitality, pain, health perceptions, and health transition (p<0.05).
Conclusions: The SF-36 is a valid instrument to measure HRQL in patients with COPD. The severity of dyspnea but not respiratory function was a significant predictor of various components of HRQL.
Study objectives
To investigate whether psychological factors predict outcome after emergency treatment for obstructive pulmonary disease.
Setting
Emergency department at a university hospital.
Patients
Forty-three patients presenting with exacerbation of asthma or COPD.
Intervention
The patients received emergency treatment and were followed up for 4 weeks.
Measurement
Spirometry, blood sampling, pulse oximetry, breathing rate, pulse rate, and dyspnea score was measured before and during emergency treatment. The psychological status was assessed using the hospital anxiety and depression (HAD) scale questionnaire at the end of the follow-up period.
Results
Anxiety and/or depression was found in 17 patients (40%). Of these patients, nine patients (53%) were admitted to hospital or had a relapse within 1 month, compared with five patients (19%) in the group without anxiety and/or depression (p < 0.05). Among patients who relapsed within 1 month (n = 14), the HAD total score was 12.4 ŷ 5.9 compared with 8.6 ŷ 5.1 (mean ŷ SD) among the patients without a relapse (p < 0.05). After making adjustments for age, gender, atopic status, treatment, and pack-years, the significant association between treatment failure and anxiety and/or depression still remained.
Conclusion
Our study indicates that anxiety and depression are related to the outcome of emergency treatment in patients with obstructive pulmonary disease. Further studies should be conducted evaluating the effect of treatment of anxiety and depression in patients with recurrent exacerbations of asthma and COPD.
ABSTRACT– A self-assessment scale has been developed and found to be a reliable instrument for detecting states of depression and anxiety in the setting of an hospital medical outpatient clinic. The anxiety and depressive subscales are also valid measures of severity of the emotional disorder. It is suggested that the introduction of the scales into general hospital practice would facilitate the large task of detection and management of emotional disorder in patients under investigation and treatment in medical and surgical departments.
To review evidence regarding the prevalence, causation, clinical implications, aspects of healthcare utilisation and management of depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease.
A critical review of the literature (1994-2009).
The prevalence of depression and anxiety is high in both chronic obstructive pulmonary disease (8-80% depression; 6-74% anxiety) and chronic heart failure (10-60% depression; 11-45% anxiety). However, methodological weaknesses and the use of a wide range of diagnostic tools make it difficult to reach a consensus on rates of prevalence. Co-morbid depression and anxiety are associated with increased mortality and healthcare utilisation and impact upon functional disability and quality of life. Despite these negative consequences, the identification and management of co-morbid depression and anxiety in these two diseases is inadequate. There is some evidence for the positive role of pulmonary/cardiac rehabilitation and psychotherapy in the management of co-morbid depression and anxiety, however, this is insufficient to guide recommendations.
The high prevalence and associated increase in morbidity and mortality justifies future research regarding the management of anxiety and depression in both chronic heart failure and chronic obstructive pulmonary disease. Current evidence suggests that multi-faceted interventions such as pulmonary and cardiac rehabilitation may offer the best hope for improving outcomes for depression and anxiety.
The natural course of chronic obstructive pulmonary disease (COPD) is complicated by the development of systemic consequences and co-morbidities. These may be major features in the clinical presentation of COPD, prompting increasing interest. Systemic consequences may be defined as non-pulmonary manifestations of COPD with an immediate cause-and-effect relationship, whereas co-morbidities are diseases associated with COPD. The major systemic consequences/co-morbidities now recognized are: deconditioning, exercise intolerance, skeletal muscle dysfunction, osteoporosis, metabolic impact, anxiety and depression, cardiovascular disease, and mortality. The mechanisms by which these develop are unclear. Probably many factors are involved. Two appear of paramount importance: systemic inflammation, which presents in some patients with stable disease and virtually all patients during exacerbations, and inactivity, which may be a key link to most COPD-related co-morbidities. Further studies are required to determine the role of inflammatory cells/mediators involved in systemic inflammatory processes in causing co-morbidities; the link between activity and co-morbidities; and how COPD therapy may affect activity. Both key mechanisms appear to be influenced significantly by COPD exacerbations. Importantly, although the prevalence of systemic consequences increases with increasing severity of airflow obstruction, both systemic consequences and co-morbidities are already present in the Global Initiative for Chronic Obstructive Lung Disease Stage II. This supports the concept of early intervention in chronic obstructive pulmonary disease. Although at present early intervention studies in COPD are lacking, circumstantial evidence suggests that current treatments may influence events leading to the systemic consequences and co-morbidities, and thus may affect the clinical manifestations of the disease.
To improve the clinical measurement of dyspnea, we developed a baseline dyspnea index that rated the severity of dyspnea at a single state and a transition dyspnea index that denoted changes from that baseline. The scores in both indexes depend on ratings for three different categories: functional impairment; magnitude of task, and magnitude of effort. At the baseline state, dyspnea was rated in five grades from 0 (severe) to 4 (unimpaired) for each category. The ratings for each of the three categories were added to form a baseline focal score (range, 0 to 12). At the transition period, changes in dyspnea were rated by seven grades, ranging from -3 (major deterioration), to +3 (major improvement). The ratings for each of the three categories were added to form a transition focal score (range, -9 to +9). In 38 patients tested with respiratory disease, interobserver agreement was highly satisfactory for both indexes. The baseline focal score had the highest correlation (r = 0.60; P less than 0.001) with the 12-minute walking distance (12 MW), while significant, but lower, correlations existed for lung function. For the transition focal score, there was a significant correlation only with the 12 MW (r = 0.33; p = 0.04). These results indicate that dyspnea can receive a direct clinical rating that provides important information not disclosed by customary physiologic tests.
A self-assessment scale has been developed and found to be a reliable instrument for detecting states of depression and anxiety in the setting of an hospital medical outpatient clinic. The anxiety and depressive subscales are also valid measures of severity of the emotional disorder. It is suggested that the introduction of the scales into general hospital practice would facilitate the large task of detection and management of emotional disorder in patients under investigation and treatment in medical and surgical departments.
There is a great demand for perceptual effort ratings in order to better understand man at work. Such ratings are important complements to behavioral and physiological measurements of physical performance and work capacity. This is true for both theoretical analysis and application in medicine, human factors, and sports. Perceptual estimates, obtained by psychophysical ratio-scaling methods, are valid when describing general perceptual variation, but category methods are more useful in several applied situations when differences between individuals are described. A presentation is made of ratio-scaling methods, category methods, especially the Borg Scale for ratings of perceived exertion, and a new method that combines the category method with ratio properties. Some of the advantages and disadvantages of the different methods are discussed in both theoretical-psychophysical and psychophysiological frames of reference.
To evaluate the short-form 36-item questionnaire (SF-36) as an instrument for