Nurse-Led Cognitive Behavioral Therapy Cost-Effective in COPD

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Cognitive behavioral therapy delivered by respiratory nurses can reduce anxiety and is cost-effective in patients with chronic obstructive pulmonary disease (COPD).

Anxiety, an important comorbidity in patients with chronic obstructive pulmonary disease (COPD) that can lead to breathlessness, is associated with high morbidity, disability, healthcare expenditure, and mortality. Mental health professionals have traditionally treated anxiety, but COPD patients often have complex physical health problems and interrelated mental health issues, which can result in barriers to accessing mental health support. A new study published in ERJ Open Research suggests that cognitive behavioral therapy (CBT), delivered by respiratory nurses, reduces anxiety and is cost-effective in patients with COPD.

For each patient who attended CBT sessions, there was an average savings of £1,089 (US$1395.89) for hospital admissions and £63 (U$S80.75) for emergency department (ED) visits, according to Karen Heslop-Marshall, PhD, a nurse consultant at Newcastle-upon-Tyne National Health Service (NHS) Foundation Trust and Newcastle University, UK, and lead researcher of the study. Patients who received CBT had fewer hospitalizations and fewer ED visits (0.6 vs 1.10 and 0.37 vs 1.01, respectively), and patients’ anxiety symptoms scores on the HADS-Anxiety Scale improved by 3.4 in the CBT group versus only 1.9 in the leaflet-only group. Heslop-Marshall explained that many healthcare professionals do not screen patients with COPD for anxiety symptoms, even though it can impact overall health, and she and her colleagues designed the study to test whether one-on-one CBT sessions delivered by respiratory nurses could reduce symptoms of anxiety while being cost-effective.

From June 2011 to October 2014, the researchers screened 1518 outpatients with COPD using the HADS-Anxiety Subscale, a questionnaire that asks patients about their feelings of anxiety and depression over the past week. A total of 898 (59%) patients had a HADS-Anxiety Subscale of 8 or more, suggesting anxiety is very common in this patient population. The trial randomized 279 patients diagnosed with mild to very severe COPD; ultimately, 269 received the 2 interventions to the primary end-point of 3 months. The mean HADS-Anxiety Subscale score was 12.3 for the CBT group and 12.0 for the self-help leaflet group at baseline, suggesting moderate anxiety symptoms; 64% reported moderate to severe symptoms of anxiety.


Over a 3-month period, patients were either given leaflets on anxiety management (n = 140) or leaflets as well as 30-minute CBT sessions (n = 129) conducted at home or in clinic, 2 to 6 times within 2 weeks. In the CBT sessions, patients were coached on how to develop coping strategies to deal with anxiety caused by breathlessness and to help to improve physical activity levels. All study subjects received standard medical care including lung function testing, appropriate medications, medical review, and pulmonary rehabilitation if appropriate.

After 3 months, patients completed the HADS-Anxiety questionnaire again to assess how the different treatment methods affected anxiety levels. An economic analysis was conducted alongside the trial to evaluate cost-effectiveness of the CBT intervention compared with self-help leaflets. NHS costs (including intervention costs and costs of respiratory-related hospital admissions and ED visits) were compared with Quality Adjusted Life Years (QALYs); all resource use was costed at 2015-2016 prices in Pound Sterling (GBP). Costs of the CBT intervention comprised staff time, including cost of training, delivering the intervention, and ongoing supervision. Both groups received the self-help leaflet so that cost was assumed to be equal.

The study authors conclude that CBT should be incorporated into routine clinical care pathways. “We found that one-to-one CBT sessions delivered by respiratory nurses could reduce symptoms of anxiety and that this could be a cost-effective intervention,” said Heslop-Marshall. Although the CBT intervention initially resulted in added costs, as respiratory nurses required training in CBT skills, this was balanced by the savings associated with fewer hospital and ED visits. Respiratory nurses with dual respiratory and CBT skills can address common comorbid symptoms of anxiety that were previously undertreated.

“Reducing the levels of anxiety patients experience has a significant impact on their quality of life as well as their ability to keep physically active and may improve survival in the long-term,” she said.


Heslop-Marshall K, Baker C, Carrick-Sen D, et al. Randomised controlled trial of cognitive behavioural therapy in COPD. ERJ Open Res. 2018;4:00094-2018. doi: 10.1183/23120541.00094-2018.