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Changing practice

Using cognitive behavioural therapy to address the psychological needs of patients with COPD

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An outline of two studies investigating the benefits of using CBT to improve support for patients with COPD

Authors

Karen Heslop, MSc, PGDip, BSc, RGN, is respiratory nurse consultant, Newcastle upon Tyne Hospitals Foundation Trust; Thomas Foley, MPhil, BSc, is medical student, Newcastle University Medical School.

 

Abstract

Heslop, K., Foley, T. (2009) Using cognitive behavioural therapy to address the psychological needs of patients with COPD. Nursing Times; 105: 38, early online publication.

This article describes the psychological impact of chronic obstructive pulmonary disease and outlines how cognitive behavioural therapy can be used to manage these problems. It presents the results of research using CBT with this patient group.

Keywords: Respiratory care, COPD, CBT, Psychological impact

  • This article has been double-blind peer reviewed.

 

Practice points

  • Patients with COPD can experience physical, psychological and social difficulties as a result of their condition.
  • Some 25-50% of all those presenting for treatment for COPD have anxiety and depression, but treatment of these difficulties is often overlooked.
  • Interventions that reduce anxiety and depressive symptoms may have an impact on patients’ overall wellbeing and potentially affect COPD outcomes.
  • CBT is an approach that shows promising results in long term physical conditions.

Introduction

Chronic obstructive pulmonary disease (COPD) is a term commonly used to describe conditions such as chronic bronchitis and emphysema, and the major cause is cigarette smoking.

The true incidence of COPD is unknown. The prevalence is around 10% in the general population worldwide and it is described as “a growing but neglected global epidemic” (Barnes, 2007).

It is estimated that 3.7 million people in the UK have COPD but studies suggest that as few as one in four of these are diagnosed with the condition. The remaining 2.8 million are unaware they have a disease which is a progressive illness, and   if left untreated, could severely restrict their lives and shorten their life expectancy (British Lung Foundation, 2007).

Patients experience exacerbations of their condition as their disease progresses. Unfortunately, exacerbations frequently require hospital management. Long term oxygen therapy, poor quality of life and reduced physical activity are all associated with an increased risk of both admission and readmission to hospital (Bahadori and FitzGerald, 2007).

Smoking cessation is the most important intervention to prevent COPD or slow its progression. The management of this condition has traditionally focused on preventing deterioration and reversing impairment by drug therapy. Other important interventions include airway and secretion management, nutritional advice, exercise and pulmonary rehabilitation. 

Pulmonary rehabilitation

Pulmonary rehabilitation is a cost-effective, multidisciplinary, evidence-based intervention which includes physical training, disease education and nutritional and psychological intervention. It is designed to reduce symptoms, optimise functional status and reduce healthcare costs and is recommended by NICE (2004a).

Unfortunately, the provision of pulmonary rehabilitation is poor in many areas of the country. In addition, some patients decline to participate for a number of reasons including lack of transport and psychological reasons such as lack of motivation, lack of confidence or anxiety.

Psychological morbidity

The distressing nature of COPD has a significant impact on patients’ psychological wellbeing. They focus on feeling unwell, their ability to perform everyday activities and on the emotional consequences of the condition (British Lung Foundation, 2006). Physical variables thought to influence functional status include length of illness, age, pulmonary functioning, exercise capacity and breathlessness. Important psychological variables include depression, anxiety and self-esteem.

Anxiety and depression are extremely prevalent in patients with COPD and are associated with lower levels of self-efficacy, impaired health status, poorer treatment outcomes and reduced survival (Ng et al, 2007). The prevalence of depression in patients with COPD is estimated to be 40% (NICE, 2004a). 

Psychological morbidity has adverse effects on the outcome of medical illnesses. It has been associated with excessive use of medication (Royal College of Physicians and Royal College of Psychiatrists, 2003) and more frequent and longer hospital admissions (Osman et al, 1997).Patients who are depressed and admitted to hospital with a COPD exacerbation have an increased risk of mortality despite controlling for COPD duration, severity, smoking, length of stay and socioeconomic variables (Ng et al, 2007). While several studies acknowledge that psychological consequences of respiratory illness exist, they rarely discuss appropriate treatment.

International guidelines for managing COPD (Global Initiative for Chronic Obstructive Lung Disease, 2008; NICE, 2004a) recommend screening for anxiety and depression but do not offer appropriate advice on treating these problems.

Cognitive behavioural therapy

CBT is a psychological treatment and is concerned with understanding how events and experiences are interpreted. It addresses the interaction between thoughts, mood, behaviour and physical sensations, which are intricately linked with each other (Fig 1).   

NICE (2004a) published guidelines on COPD and also recommended CBT as the first-line treatment for anxiety and depression (NICE, 2004b; 2004c).

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