Nurse respiratory specialist Karen Heslop-Marshall explains why patients with COPD are vulnerable to anxiety and depression, and how addressing these problems can help them manage their condition
Chronic obstructive pulmonary disease (COPD) is a common, largely preventable lung condition characterised by airflow obstruction and respiratory symptoms such as breathlessness, persistent cough and frequent chest infections.
It results from long-term exposure to harmful gases and particulates (including tobacco smoke, air pollution and occupational dusts and fumes) in combination with factors such as childhood lung development and genetics.
COPD is incurable and its trajectory is one of progressive decline punctuated by acute exacerbations (symptom ‘flare-ups’).1 However, early diagnosis and treatment can help slow progression and reduce the risk of exacerbations. People with COPD often have other conditions, with depression and anxiety being common comorbidities.2
Management centres on evidence-based medical therapy to control symptoms and slow lung-function decline. There are also a number of recommended self-management interventions that allow patients to monitor symptoms and optimise health-related quality of life.1 Research has found such interventions reduce respiratory-related A&E visits and admissions1,3,4, which is why it is important to get self-management right.
What are the important elements of self-management?
Self-management in COPD includes:1
- Treatment adherence and the ability to recognise deterioration.
- Maintaining physical activity.
- Attending to mental health.
Interventions that incorporate mental health are significantly more effective than those targeting physical symptoms alone.1 There is also increasing evidence that integrating mental and physical care for people with long-term conditions can reduce healthcare costs.5
Why are mental health issues a consideration in COPD?
Breathlessness is a common symptom for people with respiratory problems such as COPD.4 Even with optimal treatment, breathlessness can persist and is highly distressing for those affected.
Understandably, breathlessness can trigger anxiety. Indeed, panic attacks are common in COPD; the prevalence of panic disorder is at least 10 times higher than in the general population.6
A natural way of coping with breathlessness is to avoid doing activities that provoke it. While in the short term this may help alleviate the anxiety, in the longer term it can be counterproductive because it means patients become deconditioned and muscle strength declines, making them even more prone to breathlessness and less able to stay physically active.
Furthermore, as patients become less able to do things they used to do, they can develop symptoms of depression. Patients can experience dysthymia (persistent mild depression) or develop moderate-to-severe depression.7
How common are symptoms of anxiety and depression in COPD?
Estimated prevalence rates of anxiety and depression vary. One randomised controlled trial in north-east England screened 1,500 stable COPD outpatients at a secondary care clinic and found 59% had symptoms of anxiety based on a Hospital Anxiety and Depression scale (HADS) score of greater than 7.8
How do physical and mental health symptoms interact?
Research has demonstrated the impact of anxiety and depression on people with COPD, in terms of physical functioning, breathlessness, quality of life, exacerbation rates, use of healthcare resources, length of hospital stays, readmission rates and mortality.9
It has also been shown that people with COPD who have psychological symptoms are less able to manage physical symptoms and less likely to be physically active or attend pulmonary rehabilitation (an evidence-based intervention).10
Adherence to rehabilitation, psychological and antidepressant pharmacological treatments in depressed patients has been linked to a decreased risk of hospitalisation.7
What can nurses do to help?
The first step in addressing symptoms of anxiety or depression is to screen for them using a validated tool at the patient’s annual review – and more frequently if needed. The Patient Health Questionnaire-2 (PHQ-2) or General Anxiety Disease questionnaire (GAD-2) can be used as brief screening tools. If any symptoms are identified, questionnaires such as HADS can then be used to explore symptoms further.
It has been found that cognitive behavioural therapy (CBT) delivered by respiratory nurses can help alleviate symptoms of anxiety, and in turn improve patients’ self-management. Nurses can develop their skills in CBT, which can be used with all patients living with long-term conditions, but may not feel confident to do it without appropriate training.11
How does CBT work?
CBT is an evidence-based, patient-centred, individualised and structured form of psychological therapy that explores the links between a patient’s situation and their physical symptoms, thoughts, emotions and behaviours. Once unhelpful links are identified, this information can be used to explore and challenge negative thoughts or behaviours – such as the fear of becoming breathless, over-reliance on drug treatment or oxygen, and reluctance to engage in physical activity.
A starting point for patients with respiratory problems is to identify what triggers breathlessness – both physical factors such as exertion and psychological factors such as fear or panic. Skilled nurses can then work with the patient to develop a self-management plan to address these physical and psychological difficulties so they can reduce the impact of breathlessness.13 Alternatively, patients can be referred to a local CBT service or targeted resources such as pulmonary rehabilitation services if the nurse does not have the necessary skills.
Can CBT help to counter physical inactivity?
Reduced physical activity is common among people with COPD, and is a strong predictor for all-cause mortality in this group of patients.14
Barriers to physical activity include:14
- Older age.
- Being female.
- Reduced lung function.
- Having comorbidities.
- Increased COPD symptoms (fear of breathlessness and injury, severe fatigue, anxiety and depression).
- More advanced GOLD (Global Initiative for Chronic Obstructive Lung Disease) stage.
- More frequent exacerbations.
- Oxygen use.
- Lack of motivation.
- Environmental factors, such as the season and weather.
Behavioural activation interventions that form part of CBT can help address physical inactivity. For example, an approach comprising motivational interviews, monitoring and feedback using a pedometer and goal setting could be used to increase physical activity levels and reduce deconditioning.15
Why should nurses gain CBT skills?
Frontline clinicians know COPD patients experience symptoms of anxiety and depression. After all, breathlessness is a frightening symptom experienced by most respiratory patients. However, it is less well recognised that taking steps to address psychological distress will also help achieve important physical outcomes, such as reducing breathlessness and admissions.12,16
Even a basic knowledge of CBT will help nurses understand COPD patients’ experiences and develop more helpful ways of dealing with difficulties. Basic training in CBT skills can enhance practice nurses’ ability to recognise and explore areas that could be changed to manage or reduce symptoms of anxiety or depression. This training is available through the Pivotal training course.
Are there any digital programmes that can help?
Digital self-management programs are now available, such as BreathTec. This is a personalised, interactive programme to help patients with asthma, COPD, bronchiectasis and interstitial lung disease to manage their condition. Key components include managing breathlessness, staying active and maintaining good mental health. Such programs can enhance self-management interventions delivered by nurses in clinical practice.
Self-management is an important part of COPD care. The overall benefits are greater where a focus on mental health is included and CBT may be a valuable component in this respect. The challenge facing clinicians, managers and commissioners is to embed this model in routine clinical care while maintaining a clear pathway to refer more complex psychological problems to mental health teams.
Dr Karen Heslop-Marshall is a nurse consultant at Newcastle upon Tyne Hospitals NHS Foundation Trust
- Newham J, Presseau J, Heslop-Marshall K et al. Features of self-management interventions for people with COPD associated with improved health-related quality of life and reduced emergency department visits: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis 2017;12:1705-20
- Askey R. Exploring the benefits of a psychoeducation session for patients with chronic obstructive pulmonary disease (COPD) and co-morbid depression and/or anxiety. Mental health 2020. DOI:10.7748/mhp.2020.e1435
- Schrijver J, Lenferink A, Brusse-Keizer M et al. Self-management interventions for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2022;1:CD002990
- GOLD. Global Strategy for the Diagnosis, Management and Prevention of COPD. 2022. Link
- Foley T. Bridging the Gap: the financial case for a reasonable rebalancing of health and care resources. London, Royal College of Psychiatrists. 2013. Link
- Livermore N, Butler J, Sharpe L et al. Panic Attacks and Perception of Inspiratory Resistive Loads in Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2008;178(1):7–12
- Volpata E, Toniolo S, Pagnini F et al. The Relationship Between Anxiety, Depression and Treatment Adherence in Chronic Obstructive Pulmonary Disease: A Systematic Review. Int J Chron Obstruct Pulmon Dis 2021:16:2001-21
- Heslop-Marshall K, De Soyza A. Are we missing anxiety in people with chronic obstructive pulmonary disease (COPD)? Ann Depress Anxiety 2014;1(5):1023
- Yohannes A, Alexopoulos G. Depression and anxiety in patients with COPD. Eur Respir Rev 2014;23(133):345-9
- Bolton C, Bevan-Smith E, Blakey J et al. British Thoracic Society guideline on pulmonary rehabilitation in adults. Thorax 2013;68:2:1-30. Link
- Heslop-Marshall K, Pilkington M, Knighting K et al. Nurse-led cognitive behavioural therapy for respiratory patients. Nursing Times 2021;117(2)47-48
- 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
- Heslop-Marshall K. Using cognitive behavioural therapy techniques in COPD. Pract Nurs 2018;29(12):594-97
- Xiang X, Huang L, Fang Y et al. Physical activity and chronic obstructive pulmonary disease: a scoping review. BMC Pulm Med 2022;22(1):301
- Armstrong M, Hume E, McNeillie L et al. Behavioural modification interventions alongside pulmonary rehabilitation improve COPD patients’ experiences of physical activity. Respir Med 2021;180:106353
- Heslop-Marshall K, Burns G. The role of cognitive behavioural therapy in living well with COPD. Breathe 2019;15(2):95-97
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