Psychological therapies for the treatment of anxiety disorders in chronic obstructive pulmonary disease.
BACKGROUND
Chronic obstructive pulmonary disease (COPD) (commonly referred to as chronic bronchitis and emphysema) is a chronic lung condition characterised by the inflammation of airways and irreversible destruction of pulmonary tissue leading to progressively worsening dyspnoea. It is a leading international cause of disability and death in adults. Evidence suggests that there is an increased prevalence of anxiety disorders in people with COPD. The severity of anxiety has been shown to correlate with the severity of COPD, however anxiety can occur with all stages of COPD severity. Coexisting anxiety and COPD contribute to poor health outcomes in terms of exercise tolerance, quality of life and COPD exacerbations. The evidence for treatment of anxiety disorders in this population is limited, with a paucity of evidence to support the efficacy of medication-only treatments. It is therefore important to evaluate psychological therapies for the alleviation of these symptoms in people with COPD.


OBJECTIVE
To assess the effects of psychological therapies for the treatment of anxiety disorders in people with chronic obstructive pulmonary disease.


METHODS
We searched the specialised registers of two Cochrane Review Groups: Cochrane Common Mental Disorders (CCMD) and Cochrane Airways (CAG) (to 14 August 2015). The specialised registers include reports of relevant randomised controlled trials from The Cochrane Library, MEDLINE, Embase, and PsycINFO. We carried out complementary searches on PsycINFO and CENTRAL to ensure no studies had been missed. We applied no date or language restrictions.


METHODS
We considered all randomised controlled trials (RCTs), cluster-randomised trials and cross-over trials of psychological therapies for people (aged over 40 years) with COPD and coexisting anxiety disorders (as confirmed by recognised diagnostic criteria or a validated measurement scale), where this was compared with either no intervention or education only. We included studies in which the psychological therapy was delivered in combination with another intervention (co-intervention) only if there was a comparison group that received the co-intervention alone.


METHODS
Two review authors independently screened citations to identify studies for inclusion and extracted data into a pilot-tested standardised template. We resolved any conflicts that arose through discussion. We contacted authors of included studies to obtain missing or raw data. We performed meta-analyses using the fixed-effect model and, if we found substantial heterogeneity, we reanalysed the data using the random-effects model.


RESULTS
We identified three prospective RCTs for inclusion in this review (319 participants available to assess the primary outcome of anxiety). The studies included people from the outpatient setting, with the majority of participants being male. All three studies assessed psychological therapy (cognitive behavioural therapy) plus co-intervention versus co-intervention alone. We assessed the quality of evidence contributing to all outcomes as low due to small sample sizes and substantial heterogeneity in the analyses. Two of the three studies had prespecified protocols available for comparison between prespecified methodology and outcomes reported within the final publications.We observed some evidence of improvement in anxiety over 3 to 12 months, as measured by the Beck Anxiety Inventory (range from 0 to 63 points), with psychological therapies performing better than the co-intervention comparator arm (mean difference (MD) -4.41 points, 95% confidence interval (CI) -8.28 to -0.53; P = 0.03). There was however, substantial heterogeneity between the studies (I2= 62%), which limited the ability to draw reliable conclusions. No adverse events were reported.


CONCLUSIONS
We found only low-quality evidence for the efficacy of psychological therapies among people with COPD with anxiety. Based on the small number of included studies identified and the low quality of the evidence, it is difficult to draw any meaningful and reliable conclusions. No adverse events or harms of psychotherapy intervention were reported.A limitation of this review is that all three included studies recruited participants with both anxiety and depression, not just anxiety, which may confound the results. We downgraded the quality of evidence in the 'Summary of findings' table primarily due to the small sample size of included trials. Larger RCTs evaluating psychological interventions with a minimum 12-month follow-up period are needed to assess long-term efficacy.
Department of Respiratory Medicine, The Queen Elizabeth Hospital, 4A, Main Building, 28 Woodville Road, Woodville South, Adelaide, Australia, SA 5011.|School of Medicine, The University of Adelaide, Adelaide, Australia.
Zafar A
ZA
Usmani
School of Medicine, The University of Adelaide, Adelaide, Australia.
Kristin V
KV
Carson
Chest Clinic, Newcastle upon Tyne NHS Hospitals Foundation Trust, RVI Hospital, Queen Victoria Road, Newcastle upon Tyne, Tyne & Wear, UK, NE1 4LP.
Karen
K
Heslop
Division of Health Sciences, University of South Australia, Adelaide, Australia.
Adrian J
AJ
Esterman
Institute of Cellular Medicine, Newcastle University, Newcastle, UK.
Anthony
A
De Soyza
School of Medicine, The University of Adelaide, Adelaide, Australia.
Brian J
BJ
Smith
D001008:Anxiety Disorders / Q000628:therapy*; D029481:Bronchitis, Chronic / Q000523:psychology; D004646:Emphysema / Q000523:psychology; D017079:Exercise Tolerance; D005260:Female; D006801:Humans; D008297:Male; D011613:Psychotherapy / Q000379:methods*; D029424:Pulmonary Disease, Chronic Obstructive / Q000523:psychology*; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic