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IIR 00-097 – HSR&D Study

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IIR 00-097
A Cognitive-Behavioral Intervention for Depression and Anxiety in COPD
Mark E. Kunik MD MPH
Michael E. DeBakey VA Medical Center, Houston, TX
Houston, TX
Funding Period: January 2002 - June 2006

BACKGROUND/RATIONALE:
The literature and our preliminary studies found that in COPD patients, psychosocial factors affect quality of life (QOL) and functioning more than would be expected given the severity of their disease. To improve QOL and functioning in the approximately 50% of COPD patients with significant anxiety and/or depressive symptoms, interventions are needed. Much research documents the utility of cognitive behavioral therapy (CBT) in treating depression and anxiety, showing it to have promise as a self-management intervention to improve QOL in COPD patients.

OBJECTIVE(S):
Objectives were to compare CBT for anxiety and depression with COPD education for COPD patients with moderate-to-severe anxiety and/or depressive symptoms.

METHODS:
Veterans were recruited from VAMC clinics and through press releases. Two hundred and thirty-eight COPD patients with comorbid anxiety and/or depressive symptoms were randomized to either 8 weeks of CBT/usual care or 8 weeks of COPD Education/usual care. We hypothesized that COPD patients receiving CBT/usual care would improve more than COPD patients receiving COPD Education/usual care. Improvement was defined as increased disease-specific QOL, generic QOL, and 6-minute walk distance; and decreased depression, anxiety, and health service use. Outcomes were examined pre-, mid- and post-treatment and at 4, 8 and 12 months.

FINDINGS/RESULTS:
Screening: Telephone administration of five depression/anxiety questions from the PrimeMD was highly sensitive (97.7%) in screening for depression/anxiety. Overall accuracy of the PRIME-MD was 80.7%.
Prevalence: Estimated prevalence of depression or anxiety in patients with breathing problems was 34-72%. Of these, 52% had severe levels, according to the Beck Anxiety Inventory and Beck Depression Inventory. In the subsample of patients with COPD, 65% received an anxiety and/or depressive disorder diagnosis using the Structured Clinical Interview for DSM-IV.
Quality of Care: Of 102 patients with anxiety and/or depressive disorders, only 50% were recognized by their primary care provider, 30% were receiving treatment, and almost none was receiving guideline-concordant diagnosis and treatment.
QOL: In a subsample of 179 veterans with COPD, both depression and anxiety were significantly related to negative QOL outcomes, over and beyond the effect of COPD severity. When co-morbid with COPD, mental health symptoms of depression and anxiety are some of the most salient factors associated with QOL outcomes.
Primary Outcomes of Randomized Controlled Trial: Both CBT and Education significantly improved QOL, anxiety and depression (p<.005) over 8 weeks; rate of change did not differ between groups. Improvements were maintained with no significant change during follow-up. Ratios of post- to pretreatment use of health services were equal to 1 for both groups.

IMPACT:
This study resulted in six published, two in press, and one submitted manuscripts that make the strongest contribution to date to the literature on the enormous unmet needs of depressed and/or anxious persons with COPD. Primary findings also indicate that nonpharmacologic interventions have value, but that CBT given in a group format has no advantage over Education in a group format. The findings were instrumental in development and funding of a recent National Institute of Health Conference on Management of Anxiety and Depression in COPD patients. Our study and this conference make it highly likely that future practice guidelines and funding priorities will aim to improve assessment and treatment of depression and anxiety in persons with COPD.

PUBLICATIONS:

Journal Articles

  1. Maurer J, Rebbapragada V, Borson S, Goldstein R, Kunik ME, Yohannes AM, Hanania NA, ACCP Workshop Panel on Anxiety and Depression in COPD. Anxiety and depression in COPD: current understanding, unanswered questions, and research needs. Chest. 2008 Oct 1; 134(4 Suppl):43S-56S.
  2. Kunik ME, Veazey C, Cully JA, Souchek J, Graham DP, Hopko D, Carter R, Sharafkhaneh A, Goepfert EJ, Wray N, Stanley MA. COPD education and cognitive behavioral therapy group treatment for clinically significant symptoms of depression and anxiety in COPD patients: a randomized controlled trial. Psychological medicine. 2008 Mar 1; 38(3):385-96.
  3. Kraus CA, Kunik ME, Stanley MA. Use of cognitive behavioral therapy in late-life psychiatric disorders. Geriatrics. 2007 Jun 1; 62(6):21-6.
  4. Cully JA, Graham DP, Stanley MA, Kunik ME. Depressed and Anxious COPD Patients: Predictors of Psychotherapy Engagement from a Clinical Trial. Journal of Clinical Psychology in Medical Settings. 2007 Jan 1; 14:160-164.
  5. Kunik ME, Azzam PN, Souchek J, Cully JA, Wray NP, Krishnan LL, Nelson HA, Stanley MA. A practical screening tool for anxiety and depression in patients with chronic breathing disorders. Psychosomatics. 2007 Jan 1; 48(1):16-21.
  6. Cully JA, Graham DP, Stanley MA, Ferguson CJ, Sharafkhaneh A, Souchek J, Kunik ME. Quality of life in patients with chronic obstructive pulmonary disease and comorbid anxiety or depression. Psychosomatics. 2006 Jul 1; 47(4):312-9.
  7. Ferguson CJ, Stanley M, Souchek J, Kunik ME. The utility of somatic symptoms as indicators of depression and anxiety in military veterans with chronic obstructive pulmonary disease. Depression and anxiety. 2006 Jun 1; 23(1):42-9.
  8. Burgess A, Kunik ME, Stanley MA. Chronic obstructive pulmonary disease: assessing and treating psychological issues in patients with COPD. Geriatrics. 2005 Dec 1; 60(12):18-21.
  9. Stanley MA, Veazey C, Hopko D, Diefenback G, Kunik ME. Anxiety and Depression in chronic obstructive pulmonary disease: a new intervention and case report. Cognitive and behavioral practice. 2005 Dec 1; 12(4):424-436.
  10. Kunik ME, Roundy K, Veazey C, Souchek J, Richardson P, Wray NP, Stanley MA. Surprisingly high prevalence of anxiety and depression in chronic breathing disorders. Chest. 2005 Apr 1; 127(4):1205-11.
  11. Roundy K, Cully JA, Stanley MA, Veazey C, Souchek J, Wray NP, Kunik ME. Are anxiety and depression addressed in primary care patients with chronic obstructive pulmonary disease? A chart review. Primary care companion to the Journal of clinical psychiatry. 2005 Jan 1; 7(5):213-8.
Conference Presentations

  1. Kunik ME. Screening for anxiety and depression in COPD. Paper presented at: American College of Chest Physicians on Depression and Anxiety Complicating Chronic Lung Disease Workshop; 2006 Sep 15; Northbrook, IL.
  2. Cully JA, Graham DP, Stanley MA, Ferguson CJ, Sharafkhaneh A, Souchek J, Kunik ME. Healthy IDEAS: Expanding the Boundaries of Treatment for Late-Life Depression. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2005 Nov 17; Washington, DC.
  3. Veazey C, Kunik ME, Stanley MA. Outcomes and future directions: Treating anxiety and depression in chronic obstructive pulmonary disease. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2005 Nov 17; Washington, DC.
  4. Kunik ME, Roundy K, Veazey C, Souchek J, Richardson P, Wray NP, Stanley MA. Surprisingly high prevalence of anxiety and depression in older adults with COPD. Paper presented at: American Association for Geriatric Psychiatry Annual Meeting; 2005 Mar 3; San Diego, CA.
  5. Veazey CH, Stanley MA, Hopko DR, Densmore D, Kunik ME. Randomized controlled trial of a cognitive behavioral intervention for anxiety and depression in chronic obstructive pulmonary disease. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2003 Nov 20; Boston, MA.


DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Observational
Keywords: Cardiovasc’r disease, Comorbidity, Self-care
MeSH Terms: none