Pulmonary rehabilitation can offer many of the same ideas to patients that cognitive behavioral therapy (CBT) can, even inadvertently, the study authors said.
Cognitive behavioral therapy (CBT) produced small but significant reductions in chronic obstructive pulmonary disease (COPD) symptom burden as well as improved exercise capacity and quality of life, according to a paper published in the International Journal of Chronic Obstructive Pulmonary Disease.
Investigators from the University of South Australia in Adelaide conducted a literature review in order to describe both the nature of CBT interventions and comparators in controlled trials as well as the factors which influence intervention effects on health outcomes. CBT interventions are often thought to be useful to this population based on the “vicious cycle” of exertional breathlessness, to breathing discomfort, to anxiety, and finally, to inactivity.
For patients with COPD in particular, anxiety and depression are comorbidities associated with poorer prognosis, the study authors wrote. In the studies they examined, CBT was either the sole intervention or was used in combination with pulmonary rehabilitation. Comparators were usual care or other active high resource interventions, the study authors said.
After searching the Medline and Scopus databases for studies published between 1996 and 2019, the study authors determined 33 studies met inclusion criteria. Those papers totaled 3215 participants, of which nearly two-thirds were male, who had a mean age of 67 years.
The investigators categorized the studies based on 2 definitions. Low intensity meant minimal or no involvement from a health professional and were styled as self-help interventions from written or electronic self-help materials or psychoeducational groups. High intensity meant that a majority of the individual or group sessions were facilitated by a health care professional from a psychological discipline (or another trained in CBT) with a direct intent to target and facilitate change in an individual’s related behaviors. These were conducted most often in a face-to-face setting, though occasionally over the phone or telemedicine.
They were typically weekly rather than less frequently, the study authors added, and often lasted 60-plus minutes rather than shorter durations.
Pulmonary rehabilitation addresses anxiety and fear associated with physical exertion in people with COPD. While it continues to be “best or recommended practice” or “not quite usual practice,” the study authors said, it can reframe an individual’s expectations around their activity-derived anxiety. It can often be a blurred line between pulmonary rehabilitation and CBT, the study authors said.
“Given the risk that pulmonary rehabilitation (with its capacity to deliver aspects of CBT) may not be accessible to all with COPD in low-resource environments, further investment in targeting, development, delivery of low-intensity CBT is indicated,” they wrote.
The authors determined that across all the studies, there was a small but significant improvement in anxiety in patients who received the CBT interventions. This observation was similar across all health outcomes, notably depression, breathlessness, quality of life (mental wellbeing and physical wellbeing), and exercise capacity. However, the investigators noted, when CBT interventions and comparators were of equally high resource intensity, the evidence for the benefit of CBT became less compelling.
“Overall, there was negligible evidence that the specific focus of the CBT intervention, number of intervention sessions, facilitator profession, delivery mode, presence of co-morbid clinical anxiety/depression or sample size/study quality were associated with the effect sizes of health outcomes,” the study authors said.
These findings are not unique to CBT use among patients with COPD, the investigators said, as similar findings have been reported for CBT use in the older population both with and without generalized anxiety or depressive disorders.
“Given the dearth of specific studies (qualitative and experimental) of low-resource CBT identified within this review and the implications for health-care resources, especially for people with COPD without access to or participating in recommended care, exploration of low-intensity CBT against similar intensity interventions and/or usual care warrants further investment,” the authors concluded.
Williams MT, Johnston KN, Paquet C. Cognitive behavioral therapy for people with chronic obstructive pulmonary disease: Rapid review. Int J Chron Obstruct Pulmon Dis. Published online April 23, 2020. doi: 10.2147/COPD.S178049