Effects of cognitive behavioral therapy on anxiety and depression in patients with chronic obstructive pulmonary disease:A Meta-analysis and Systematic Review

DOI: https://doi.org/10.21203/rs.2.17078/v1

Abstract

Symptoms such as depression and anxiety are common psychiatric symptoms in patients with chronic obstructive pulmonary disease (COPD). Cognitive-behavioral therapy (CBT) is still controversial in the treatment of anxiety and depression in patients with COPD. We conducted a meta-analysis and systematic review to evaluate the effect of CBT on anxiety and depression in patients with COPD, with a view to providing some guidance for clinical application.Materials and Methods Computer search Web of Science, EMbase, PubMed, Cochrane Library, search time limit from the establishment of the library to August 2019.Collect the randomized controlled trial (RCT) for this topic. Two investigators independently screened the literature according to inclusion and exclusion criteria, extracted the data, and assessed the risk of bias in the included studies. Meta analysis using RevMan5.3 software.Results A total of 10 studies were included in a total of 1278 patients. Meta-analysis shows that cognitive behavioral therapy can improve depression and anxiety in patients with COPD. Subgroup analysis showed that intervention time ≥ 8 weeks had significant differences in improving anxiety, while intervention time <8weeks had significant differences in improving depression.Conclusion Cognitive-behavioral therapy can improve depression in COPD patients in a short period of time, and it takes longer to improve anxiety. Therefore, clinical practice can choose the appropriate intervention time according to the patient's psychological condition.

Background

Chronic Obstructive Pulmonary Disease (COPD) is a chronic disease of the respiratory system, which can reduce lung function and labor endurance year by year. In severe cases, life cannot take care of itself [1, 2]. In addition to causing organic damage, COPD can seriously affect the quality of life and prognosis of patients, and even lead to a variety of psychological disorders such as anxiety, depression, and fear [3]。People with COPD are 2 to 3 times more likely to have mental health problems than the general population [4, 5]. The prevalence of anxiety and depression in patients with COPD was 40% and 36%, respectively. The data show that the prevalence of COPD combined with depression in the acute exacerbation period is as high as 86%, and anxiety is as high as 55% in hospitalized patients [6]。Therefore, coped combined with mental illness is also considered to be a "grey disease, blue mood. The study found that patients with COPD often fall into a vicious circle of dyspnea, decreased exercise capacity, inconvenient movement and social isolation. Anxiety and depression are the cycle. important part [7]。COPD patients with anxiety and depression often lack self-confidence or self-efficacy, leading to poor disease-related coping skills and poor self-care ability [8]. This indicates poor compliance with COPD medications with anxiety and depression, decreased exercise capacity and health-related quality of life, loss of labor, increased consumption of health resources, functional disability, and increased risk of acute exacerbations and deaths [9, 10]. Therefore, it is extremely important to identify patients' bad emotions early and manage them effectively [6]. However, the management of COPD psychological problems is still very poor [11]. Cognitive Behaviour Therapy (CBT) is a general term for cognitive treatment and behavioral techniques to change the cognitive and behavioral psychology of patients. It is an effective treatment for anxiety, depressive symptoms and physical health. Methods of dysfunction, there is evidence that it is effective for patients with COPD combined with anxiety and depression [12, 13]. Relevant evidence suggests that CBT is as effective as medication and may be the first choice for patients with mental health problems [14, 15]. However, the anxiety and depression of CBT intervention in patients with COPD has not been well confirmed. Taking into account the effects of these inconsistencies, we conducted a systematic review and meta-analysis of the subject's RCT to assess the effectiveness of CBT in the intervention of anxiety and depression in patients with coddle.

Materials And Methods

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) [16] and the recommendations of the Cochrane Collaboration [17].

 

Literature screening and identification of relevant studies

Computer search Web of Science, EMbase, PubMed, Cochrane Library, search time limit from the establishment of the library to August 2019.The search term is Cognitive Behavioral Therapy, Chronic Obstructive Pulmonary Disease. The review of the retrieved articles by reading the titles and abstracts. Then, the full text of the likelihood relevant studies was examined for further. The following studies in the meta-analysis were firstly published in the primary literature with no reproduction in other studies.

 

Inclusion criteria

(1) Population: patients with COPD, all patients were treated with standard COPD medications, including bronchodilators, and oral corticosteroids and/or oxygenation when appropriate; (2) Intervention: cognitive behavioral therapy; (3) Comparison: usual care or health education intervention or blank control; (4) Study design: RCT, Language limited to English. (5) Outcome: anxiety and depression scale.

 

Exclusion criteria

(1) Incomplete data or misrepresentation of data reports; (2) repeated publication of documents; (3) case reports, reviews, etc.; (4) inability to obtain original documents.

 

Quality assessment and data extraction

Two researchers (Xuemei Zhang and Changchun Yi) independently screened the literature and extracted the data. In the event of a disagreement, the third investigator (Wuguo Tian) was asked to judge. The extracted content includes author, publication date, country, sample size, age, type of CBT, content and duration, type of anxiety and depression scale, measurement data, intervention time, intervention details, etc.

The Cochrane Systematic Review Manual 5.1.0 recommended bias risk assessment method for risk assessment for inclusion in RCT. The main items are: 1) randomization plan; 2) group concealment; 3) blind method; 4) incomplete data reporting; 5) selective outcome report; 6) other sources of bias. Each item is evaluated as "high", "low" and "unclear".

 

Data synthesis and statistical analysis

RevMan5.3 (The Cochrane Collaboration, Software Update, Oxford, UK)) software for meta-analysis. Statistical results of continuous data were expressed as standardized mean difference (SMD).The heterogeneity between the included studies was analyzed by the χ2 test (test level is α=0.1), and I2 was used to quantitatively determine the size of heterogeneity. When P < 0.1 and / or I2 > 50%, the random effects model is used for the combined analysis, and conversely, the fixed effect model is used for the combined analysis. Sensitivity analysis of heterogeneity sources. Subgroup analysis was performed based on the time of intervention. Draw a funnel plot to assess possible publication bias and small sample bias, including Egger's method and Begg's method.

Results

A detailed overview of the study flow is presented in Figure 1. Ten studies [12, 13, 18-25] comprising 1278 participants were included in the review. Characteristics of included studies are summarized in Tables 1 and 2. Part of the studies were deemed to be of moderate risk of bias (Figure2-3) because of inadequate blinding of participants and intervenors (an inherent challenge in CBT studies), allocation concealment and random sequence generation. The most commonly reported outcome measure for assessing anxiety and depression symptoms was the HADS, BAI and BDI.A detailed summary of outcome data is provided in Table 3.

 

Symptoms of Anxiety

1 item [12] The study did not report anxiety scores after intervention, the rest [13, 18-25] The results of the pooled study were SMD = -0.28, 95% CI [-0.51, 0.05], P = 0.02, and the difference was statistically significant (Figure 4).Subgroup analysis revealed no significant difference in the magnitude of difference between shorter and longer programs (P = 0.53).However, the effect in longer programs was statistically significant, while that of shorter programs was not data for this outcome were

statistically heterogeneous (I2 =70%). Exploratory sensitivity analysis revealed the study of Lamers et al [25]. To be the likely source of this heterogeneity, with its exclusion from meta-analysis resulting in a revised I2= 34%. The reason may be: in this study, the number of interventions per patient with CBT intervention resulted in different of 2 items [12, 20].

 

Symptoms of Depression

The study did not report anxiety scores after intervention, the rest [13, 18, 19, 21-25]. The results of the combined analysis were SMD=-0.54, 95% CI [-1.06,-0.02], P=0.04, and the difference was statistically significant (Fig. 5). Subgroup analysis revealed no significant difference in the magnitude of difference between shorter and longer programs (P=0.55). However, the effect in shorter programs was statistically significant, while that of longer programs was not. Data for this outcome were statistically heterogeneous (I2 =92%). Exploratory sensitivity analysis revealed the study of Lamers et al [25]. To be the likely source of this heterogeneity, with its exclusion from meta-analysis resulting in a revised I2 = 55%. The reason may be: in this study, the number of interventions per patient with CBT intervention resulted in different of.

.

Publication bias

Publication bias assessment was performed using Egger's method and Begg's method. (Figure) suggests that there are no publication bias, anxiety (Egger's, P=0.532; Begg's, P=0.823), depression (Egger's, P=0.322; Begg's, P=0.960). Figure 6~7.

Discussion

The incidence of anxiety, depression and panic in patients with COPD is significantly higher than that of normal people, which can increase the mortality rate of patients, reduce the quality of life and prognosis of patients, and increase the risk of acute exacerbation [6, 26-28]。The efficacy of psychopharmacological treatment in COPD is limited and patients are often reluctant to take additional medication [29, 30]. Psychosocial intervention has been suggested as an alternative or complementary treatment strategy for reducing psychological distress and physical impairment [31, 32]. National Institute for Health and Care Excellence(NICE) [33] CBT is recommended as a treatment option for mental health problems in patients with chronic diseases and as an adjunct to other treatments. However, the effect of CBT intervention on anxiety and depression in patients with COPD is controversial. Our meta-analysis shows that CBT can effectively improve anxiety and depression in COPD patients. This with Smith at el [34] The results of the study are consistent. We conducted a subgroup analysis of the duration of the intervention and found that CBT short-term (<8weeks) intervention had no significant effect on improving patient anxiety, and depression showed significant differences. At the same time, Howard[21]A 5-week CBT intervention in patients with COPD improved the patient's depression in the short term, and there was no significant difference in anxiety.Farver-Vestergaard [35]. The meta-analysis showed that CBT seems to be effective in improving the psychological status of patients with COPD, but the study was a combined analysis of Psychological (anxiety + depression) without a separate analysis of anxiety or depression, providing limited evidence. Our meta-analysis shows that CBT not only improves anxiety and depression in patients with COPD, but depression can be improved in a short period of time.

Coventry [36] Inclusion of 3 RCT and 1 non-RCT for meta-analysis, when CBT is combined with exercise and education, can reduce anxiety and depression in patients with COPD; but the evidence provided is valid. Small medium-quality RCT [18].The results show that CBT combined with exercise training and health education, anxiety and depression have significant therapeutic effects. Our meta-analytic inclusion of RCT, cbt interventions in a variety of forms, can be tailored to the actual situation of patients to develop a personalized cognitive behavioral intervention program. Traditional CBT has a long duration, operation

Frequent, high economic costs [37, 38] and there is not enough evidence to show which specific form of CBT treatment is best. Currently, telephone-administered CBT intervention, Mindfulness-based CBT and Nurse-led CBT, etc. [13, 19, 20]. The new CBT intervention model came into being, and different new, cost-effective CBTs should be further developed in the future.

 

Limitations

Our meta-analysis has certain limitations. First of all, our analysis is based on 10 rct, with 4 items [12, 18, 22, 23].The RCT sample size is small. Compared with the larger sample, it is more likely to overestimate the treatment effect in the smaller experiment. Our study is heterogeneous, although the sensitivity is found by using the culling method to find the source of heterogeneity. , remove Lamers et al [25] After the study, the heterogeneity has decreased, but there is still some heterogeneity; the generation of the randomized scheme of RCT, the allocation of concealment, the implementation of blind method, etc. may have certain methodological heterogeneity, different cbt The frequency of treatment, the degree of anxiety and depressive symptoms before intervention, age, different outcome assessment tools, and fev1% lead to possible risk of bias.

Conclusion

CBT can improve the depression of patients with COPD in a short period of time, and it takes longer to improve anxiety.

Abbreviations

COPD: Chronic obstructive pulmonary disease; CBT: Cognitive-behavioral therapy; RCT: Randomized controlled trial; SMD: standardized mean difference; NICE: National Insti-tute for Health and Care Excellence.

Declarations

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. 

Authors’ contributions

ZXM and YXM contributed to the conception and design of the study, or acquisition of data, or analysis and interpretation of data; ZXM and YCC drafted the article or revising it critically for important intellectual content; TWG and LDB gave the final approval of the version to be submitted. 

Ethics approval and consent to participate

This study did not involve human subjects, so informed consent was not required. In addition, no approval was required from an institutional review board. 

Consent for publication

Not applicable. 

Competing interests

The authors declare that they have no competing interests 

Acknowledgements

Not applicable. 

Funding

None.

References

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Tables

Table 1. Baseline Characteristics of Included Studies

 

Study

Year

State

No. of Patients (Start)

No. of Patients (End)

Cognitive therapy group

Control group

Anxiety Measure

Depression
Measure

Age (years)

FEV1(% Predicted)

Age (years)

FEV1(% Predicted)

Kunik

2008

USA

238

238

66.1±10.1

45.3±16.8

66.5±10.4

46.8±17.5

BAI

BDI

Lamers

2010

Netherlands

187

187

70.5±6.5

NA

71.5±7.1

NA

SCL

BDI

Hynninen

2010

Norway

51

51

59.3±7.6

59.8±21.1

62.6±9.9

57.8±25.8

BAI

BDI

Howard

2014

UK

222

222

71.2±10.4

55.9±15.7

73.2±11.4

59.6±15.9

HADS

HADS

Livermore

2015

Australia

31

31

72 ± 6

NA

72 ± 6

NA

HADS

HADS

Doyle

2017

Denmark

110

110

68.5±9.4

NA

 67.0±9.1

NA

BAI

PHQ-9

Farver-Vestergaard

2018

Denmark

82

67

66.67±8.03

37.50±12.09

67.67±7.54

37.94±11.62

HADS

HADS

Heslop-Marshall

2018

UK

279

236

66±10.2

NA

67±9.6

NA

HADS

HADS

de Godoy

2003

Brazil

30

30

62.1±14.9

NA

58.8±11.8

NA

BAI

BDI

Kunik

2001

USA

48

48

≥60

NA

≥60

NA

BAI

GDS

Abbreviations: NA, data Not Available; BAI, beck anxiety Inventory; BDI, beck depression rating scale; SCL, anxiety subscale of the symptom checklist-90; HADS, hospital anxiety and depression scale; PHQ-9, patient health questionnaire-9; GDS, geriatric depression scale.



Table 2.Description of Interventions

Study

Year

Cognitive therapy group

Control group

Duration

Methods

Frequency

Methods

Frequency

Kunik

2008

group CBT

eight 1-h sessions

Health education

45-minute lectures/15-minute discussions

8,w

Lamers

2010

Individual CBT

1 to10 times at  12 weeks, 60-min sessions

usual care

NA

12,w

Hynninen

2010

group CBT

120-min sessions, 3 times/week

usual care

2 times /week

4,w

Howard

2014

group CBT

60-min sessions,1
times/day

usual care

NA

5,w

Livermore

2015

Individual CBT

60-min sessions, 4 times/week

usual care

NA

8,w

Doyle

2017

telephone-administered CBT intervention

8 times/week

usual care

8 times/week

8,w

Farver-Vestergaard

2018

Mindfulness-based CBT

105-min sessions, 8 times/week

blank control

NA

8,w

Heslop-Marshall

2018

Nurse-led CBT

30-min sessions, once every 4 to 6 weeks

usual care

NA

3,mo

de Godoy

2003

group CBT

1
times/week

blank control

NA

12,w

Kunik

2001

group CBT

2 hour session

Health education

2 hour education session

2,h

Abbreviations:NA,data Not Available;w,week;mo,month;h,hour.



Table 3. Outcome Data Summary

 

Outcome

Instrument

Study

Year

Cognitive therapy group

Control group

No. of
Patients

 Baseline

No. of
Patients

Post-treatment

No. of
Patients

Baseline

No. of
Patients

Post-treatment

Anxiety

BAI

Kunik

2008

118

22.67±14.22

118

 15.89±14.87

120

22.67±13.84

120

17.46±14.54

 

SCL

Lamers

2010

96

20.6±6.2

61

20.76±0.73

91

20.4±7.3

66

21.43±0.69

 

BAI

Hynninen

2010

25

17.5±7.3

25

 12.7±6.8

26

17.5±9.5

26

18.7±10

 

HADS

Howard

2014

112

8.4±4.5

112

6.8±3.7

110

7.8±4.2

110

6.8±3.8

 

HADS

Livermore

2015

18

5.3 ± 3.0

18

NA

13

 5.8 ± 2.7

14

NA

 

BAI

Doyle

2017

54

20.0±11.2

54

 18.4 ±11.8

56

20.9±10.4

56

 17.2 ±10

 

HADS

Farver-Vestergaard

2018

37

7.72±4.72

30

6.80±3.86

45

7.57±4.12

37

7.92±4.16

 

HADS

Heslop-Marshall

2018

130

12.3±3.19

115

8.8±4.49

140

12.0±2.94

121

10.0±4.42

 

BAI

de Godoy

2003

14

12.9±6.9

14

4.2±3.8

16

10.9±9.8

16

9.2±8.6

 

BAI

Kunik

2001

21

15.3±9.2

21

12.6±8.7

27

10±6.8

27

11.9±7.6

Depression

BDI

Kunik

2008

118

23.44±12.49

118

 14.19 ±13.69

120

21.12±12.09

120

 14.54±13.47

 

BDI

Lamers

2010

96

17.1±6.5

64

15.45±0.8

91

18.3±7.2

68

17.31±0.77

 

BDI

Hynninen

2010

25

 20.7 ±8.6

25

14.8 ±7.8

26

20.5 ±9.7

26

19.5 ±9.4

 

HADS

Howard

2014

112

8.8±3.7

112

6.0±3.5

110

8.6±3.5

110

7.8±3.3

 

HADS

Livermore

2015

18

 3.8 ± 2.0

18

NA

13

4.6 ± 2.7

13

NA

 

PHQ-9

Doyle

2017

54

12.6 ±6

54

 9.6 ±6

56

 11.2 ±6.8

56

9.5 ±7.6

 

HADS

Farver-Vestergaard

2018

37

6.32±3.67

30

5.33±3.77

45

5.90±4.10

37

6.26±4.60

 

HADS

Heslop-Marshall

2018

130

NA

NA

NA

140

NA

NA

NA

 

BDI

de Godoy

2003

14

13.7±8.9

14

5±4.5

16

14.9±11.5

16

12.3±11.8

 

GDS

Kunik

2001

21

11.5±7.3

21

9.4±6.5

27

7.7±5.4

27

8.8±7.6

Abbreviations:NA,data Not Available;BAI,beck anxiety Inventory;BDI,beck depression rating scale;SCL,anxiety subscale of the symptom checklist-90;HADS,hospital anxiety and depression scale;PHQ-9 ,patient health questionnaire-9;GDS,geriatric depression scale.