Dr Colleen Doylea,b
Professor David Dunta
Professor David Amesb
Dr Suganya Selvarajahb
a Centre for Health Policy, Programs and Economics, The University of Melbourne
b National Ageing Research Institute
beyondblue Victorian Centre of Excellence
Project completion year
The authors investigated depression and anxiety in a sample of clients with chronic obstructive pulmonary disease (COPD) attending pulmonary rehabilitation clinics and patient support groups in Victoria. The research focused on:
- the prevalence of depression
- whether people who drop out of rehabilitation and support groups have higher depression scores than those who do not
- how depression in people with COPD is recognised and managed by health practitioners associated with pulmonary rehabilitation clinics and patient support groups in Victoria.
Of the 61 clinics in Victoria, 22 were recruited into the study and patient responses were received from 18 sites. From the 294 patients invited to participate, 105 questionnaires were returned (36 per cent response rate). The mean age was 70.9 (SD 8.3, range 52–90 years). They rated their COPD symptoms as mild (20.2 per cent), moderate (67.7 per cent) or severe (12.1 per cent). Most (71.6 per cent) were previous smokers, and these people had a mean depression score of 5.0 (SD 3.0) and mean anxiety score of 5.5 (SD 3.4).
Of the sample of 105 clients who agreed to participate in the study, 43% were male and 57% were female. The mean age was 70.9 (SD 8.3) and clients ranged in age from 52 to 90 years of age. 31% lived alone. The mean Duke Social Support Index score was 8.0 (SD 1.6).
When clients were asked to rate their COPD symptoms, 20.2 percent rated them as mild, 67.7% rated them as moderate and 12.1% rated their symptoms as severe. Therefore the majority of these clients were experiencing moderate to severe COPD symptoms. Most clients (71.6%) were previous smokers.
When depression and anxiety scores were analysed from the Hospital Anxiety and Depression Scale, we found that the mean depression score was 5.0 (SD 3.0). The minimum depression score was zero and maximum score was thirteen. The mean anxiety score was 5.5 (SD 3.4). The range of scores for anxiety was zero to eighteen. A low score for both subscales is considered to be less than 7, while scores of between 8 and 10 are suggestive of case level disorder, and a score of over 11 indicates significant disorder. Therefore the mean depression and anxiety scores were within the low normal range. However the range of scores indicated that a number of clients were experiencing concerning symptoms of depression and/or anxiety. When we analysed scores that were suggestive or case level depression, we found that overall 20.4 percent of clients reported depression. For anxiety, 27.2 percent of clients reported suggestive or case level anxiety.
Correlating social network scores with depression and anxiety, there was a negative, non-significant, correlation – people with lower social network scores tended to have higher depression scores although the relationship was not significant.
There was no evidence of a link between depression or anxiety scores and compliance with programs. We found only three clients did not complete the program of pulmonary rehabilitation (one client with high depression/anxiety, two without). Therefore the second hypothesis of the study was rejected, and there was no link between compliance and depression.
Implications for policy, practice and further research
There is good compliance with pulmonary rehabilitation, but this study had insufficient data to examine any link between high depression/anxiety and low compliance with rehabilitation. This remains a question for further research.
Qualitative responses from pulmonary rehabilitation coordinators indicated that there was not uniformly high awareness of COPD-X and HARP guidelines for treating depression and anxiety. Clinics should be provided with more information about screening tools for depression/anxiety and management guidelines for these conditions in people with COPD.
Also, more psychological and psychosocial support should be provided to people with COPD in order to maximise the effects of rehabilitation on quality of life. Consequently, future research needs to investigate alternative models of support that would supplement the exercise and education currently offered by the pulmonary rehabilitation clinics studied here.
Given the importance of providing psychological and psychosocial support for COPD patients in order to maximise the effect of rehabilitation on quality of life, future research needs to investigate alternative models of support to supplement the exercise and education that is currently offered routinely by all pulmonary rehabilitation clinics studied here. Some studies have reported that cognitive behaviour therapy (CBT) can be helpful in treating anxiety and depression in COPD patients. Two early case series (Lisansky & Clough, 1996; Eiser et al, 1997) reported that CBT did not change anxiety symptoms but did increase exercise tolerance. Heslop et al (2009) reported on the effects of a CBT program which was administered to 10 patients with COPD. Patients were exposed to an average of four sessions delivered by a respiratory nurse. The sessions resulted in reductions in depression and reductions in number of admissions. Coventry and Gellatly (2008) conducted a systematic review of CBT for COPD patients and found good evidence for the effectiveness of CBT with these clients, but further refinement of the mode of delivery needed investigating. Future research is needed therefore to investigate efficient ways to provide psychological and psychosocial support, perhaps through telephone or internet delivery to avoid transport issues.