A pulmonary rehabilitation program reduces levels of anxiety and depression inCOPD patients
© Tselebis et al.; licensee BioMed Central Ltd. 2013
Received: 7 January 2013
Accepted: 23 May 2013
Published: 22 June 2013
The presence of anxiety and depressive symptoms in COPD patients has beenacknowledged for many years. The preponderance of recent studies supportsthe utility of pulmonary rehabilitation programs to reduce the levels ofdepression and anxiety in these patients. The aim of this study is toinvestigate possible changes in levels of anxiety and depression amongpatients enrolled in a pulmonary rehabilitation program, along with the roleof disease severity in these changes.
In 101 COPD patients, who attended a pulmonary rehabilitation program, levelsof trait anxiety (STAI) and depressive symptoms (BDI) were assessed at thebeginning and at the end of the program. Age, sex, level of education inyears and stage of disease severity were recorded.
Our study included 80 male and 21 female patients. Mean age and meaneducation level were 64.1 ± 8.1 and11.3 ± 4.1 years, respectively. Regarding COPDstaging, 11 patients suffered from mild, 16 from moderate, 47 from severeand 27 from very severe COPD. Significant decreases in anxiety (from 39.7 to34.0, p < 0.001) and depression rates (from 10.7 to 6.3,p < 0.001) were observed. A statistically significantreduction in anxiety and depression was revealed (p < 0.05)atall stages of COPD.
Pulmonary rehabilitation programs should be offered to all COPD patientsirrespective of disease severity, since they all lead to improvement inanxiety and depressive symptoms.
Over the last decades, therapeutic evolution in healthcare,in conjunction with anincrease in average life expectancy, resulted in a significant and gradualdiminution in medical emergencies but simultaneously gave rise to chronicprogressive and debilitating diseases.
Gradual reintegration of the chronically suffering patients in family, social andprofessional environment is nowadays a challenge for the therapeutic team. Socialintegration is continuously threatened by a constellation of factors concerning thenature of the disease and by the psychosocial parameters implicating the dynamictask of adjustment mechanisms that constitute the subjective experience of theillness.
It is well known that Chronic Obstructive Pulmonary Disease (COPD) is a disease withpsychological comorbidities. Several studies have suggested that the prevalence ofanxiety and depression among patients with COPD is substantially greater thanlifetime rates in the general population and higher than in patients with otherpulmonary diseases such as bronchial asthma and tuberculosis , or other chronic diseases such as chronic heart failure . International prevalence rates of clinical depression in COPD patientsrise above 30% and sometimes above 50% , whereas corresponding rates in the background population is around 6-8% . Studies in Greece also report high prevalence rates of depression inCOPD patients, often above 42% . Moreover, studies indicate rates of anxiety varying from 10% to 19% , which is higher than the prevalence rate of 15% mentioned in the generalpopulation . Additionally, one out of two patients with COPD disease appears tosuffer from general psychopathological symptoms .
Recent studies show a reduction in anxiety and depression symptoms among patientswith COPD that are enrolled in pulmonary rehabilitation programs [7–9]; nevertheless some authors believe that further studies are needed . Several studies have pointed out that the degree of psychologicalimprovement brought about by the program depends on disease severity stage. Thesestudies mostly deal with severe COPD (usually leaving out stage I disease) [11, 12].
The aim of this study is to investigate the change in anxiety and depressive symptomsamong patients with COPD disease who attended a pulmonary rehabilitation program,along with the effect of disease severity on this change. Specifically, we assessedwhether the rehabilitation program alters anxiety and depression in patients withCOPD, and if this change depends on disease stage, severity and gender.
The study lasted four years and involved all patients with COPD who attended apulmonary rehabilitation program and met the criteria for inclusion in thestudy. All interested patients with COPD (for whom there was no contraindicationsuch as angina pectoris, myocardial infarction, severe pulmonary hypertension,congestive heart failure, labile diabetes, inability to exercise due toorthopedic or other reasons, dementia or severe hypoxia caused by exercise andcorrected by O2 administration) were admitted to this rehabilitationprogram . The sample consisted of 101 COPD patients, 80 males and 21 females,who completed a three months program. Inclusion criteria were the following: ageless than 80 years, without other chronic comorbid medical conditions(cardiovascular diseases, major psychiatric disorders, etc.) and absence ofacute exacerbation of COPD during the last two months before starting theprogram. We excluded patients who did not meet the inclusion criteria(n = 12) as well as those who did not complete the rehabilitationprogram (n = 43).
In order to determine COPD severity of our sample, a spirometric evaluationbefore and after bronchodilation(200 μg salbutamol) was performed. Wefollowed the Global Initiative for Chronic Obstructive Lung Disease (GOLD)diagnostic criteria, which classifies COPD severity [in relation to forcedexpiratory volume in 1 second (FEV1)/forced vital capacity (FVC)ratio (FEV1%) - percentage of predicted] into four stages: stage I(mild COPD): FEV1 > 80% predicted; stage II (moderateCOPD): FEV1 50% to 80% of predicted; stage III (severe COPD):FEV1 30% to 50% of predicted; and stage IV (very severe COPD):FEV1 < 30% of predicted . The spirometric evaluation of each patient was performed a few daysbefore he/she started the rehabilitation program.
Depression was assessed with the Beck Depression Inventory (BDI) , which is widely used, and has been standardized  and used in the Greek population previously . The BDI includes 21 items graded from 0 to 3. The inner coherencereliability is high and the re-test reliability ranges from 0.48 to 0.86 forclinical groups and 0.60 to 0.90 for non-clinical population. Its validity inrelation to an external criterion for depression, such as clinical diagnosis, isconsidered to be satisfactory. Anxiety was assessed with the SpielbergerState-Trait Anxiety Inventory (SSTAI) , one of the well-known and broadly used anxiety rating scales. Theinventory consists of 40 items, each one graded from 1 to 4. The SSTAIdifferentiates anxiety to (a) anxiety caused by a specific condition (statesubscale), and (b) anxiety as a more permanent characteristic of the personality(trait subscale). This second (trait) subscale was used in our study protocol.The SSTAI is considered as having a high inner coherence reliability andvalidity compared to clinical diagnosis. Also it has been standardized  and widely used in studies in the Greek population previously . Participants replied to the questionnaires in two phases, atbaseline and at discharge from the pulmonary rehabilitation program.
Pulmonary rehabilitation program
Patients of our study followed a pulmonary rehabilitation program for a period ofthree months, with three sessions per week, each lasting 50 minutes. Theprogram included respiratory physiotherapy, respiratory muscle training, aerobicexercise on a bicycle ergometer and on a treadmill and strengthening of musclegroups. The exercise was performed with oxygen supplementation whilesimultaneously recording heart rate and hemoglobin saturation. The minimum andmaximum number of sessions per patient was 34 and 39, respectively, with anaverage of 37 per patient.
The statistical program used was SPSS 16. The statistical analysis was performedusing x2 test, paired t-test, ANOVA, sample t-test,Pearson correlation and stepwise multiple regression. For regression models, anempirical approach was used after correlation analysis. Statistical significancewas set at p < 0.05.
The hospital ethics committee approved the study and all participants providedwritten informed consent. No financial support was necessary.
Demographics and baseline characteristics
(% of predicted)
Severity according to Global Initiative for ChronicObstructive Lung Disease (GOLD) diagnostic criteria:
mild/moderate/severe/very severe: 11 (10.9%)/16(15.8%)/47 (46.5%)/27 (26.7%).
Changes in anxiety and depression
Means (SD) and differences in BDI and STAI at baseline and after PRPin COPD severity subgroups
COPD Severity (as per GOLD)
N = 11
N = 16
N = 47
N = 27
N = 101
Severity of COPD and depressive symptoms severity
Depressive symptoms severity
BDI > 29
COPD Severity (GOLD criteria)
Changes in anxiety and depression per gender
Regarding anxiety scores our observations indicated that mean scores at baselinewere higher than the corresponding scores in the general population.Specifically, female patients of our sample had a mean STAI score of 42.62(versus 37.47  in the general female population, sample t-testp < 0.01), while men had an average of 38.87 (versus 34.54  in the general male population, sample t -test p <0.01). Atdischarge our study indicated reduced mean STAI scores for both female (36.29)and male patients (33.4). These scores were not statistically different from thecorresponding mean scores in the general population (sample t-testp > 0.05). The rate of female patients who had clinicallysignificant anxiety symptoms (STAI > 45) at baseline was 47.6%and was reduced to 19% at discharge (x2 p < 0.05). Regarding male patients of our sample,25% of them had clinically significant anxiety symptoms(STAI > 43) at baseline and the percentage was reduced to 12.5%at discharge (x2 p < 0.05).
N = 101
Education level (in years)
Depression (BDI 1) Time 1
Depression (BDI 2) Time 2
Anxiety (STAI 1) Time 1
Anxiety (STAI 2) Time 2
A significant positive correlation was also observed between first and lastmeasuring for both anxiety and depression (Pearson correlationp < 0.01, Table 3), but no correlationwas found between FEV1% of predicted and anxiety – depressionscores (Pearson correlation p > 0.05, Table 4).
More in detail, we implemented stepwise multiple regression analysis usingvariation in depression as the dependent variable and controlling for gender,age, FEV1%, years of education and variation in anxiety (independentvariables). Gender, age, years of education and FEV1% were notinvolved in the variance of the dependent variable whereas variation in anxietyinterpreted 34.3% of variation in depression (f 1.97 = 50.62, p<0.01). Considering anxiety variation as the dependent variable and gender,age, years of education, FEV1% as independent variables the resultswere not different, since variation in anxiety scores was independent of gender,age and FEV1%, whereas variation in depression interpreted 34.3% ofvariation in anxiety (f 1.97 = 50.62, p <0. 01).
Summarizing the results of this study, we have shown that a rehabilitation programcan reduce the high levels of anxiety and depression in patients with COPD.Improvement occurs for patients in all disease stages (with no statisticallysignificant differences among them), irrespective of gender. This improvement is notdependent on disease stage, gender, age or years of education. Spirometry showed nocorrelation with either anxiety or depression in the course of the program andanxiety and depression were not correlated with the severity of COPD”.
Drug treatment encounters serious problems. Benzodiazepines may cause respiratorydepression and should be avoided . In addition, beta-blockers are contraindicated in these patients,despite their anxiolytic action, because of the potential risk ofbronchoconstriction . Atypical antipsychotics in very small doses can alleviate anxietysymptoms in these patients, but they should be used cautiously because of possibleneurological and cardiovascular side effects . In other studies SSRIs have been used (first-line drugs for themanagement of depression) [26–30]. Sertraline [28, 29], fluoxetine [26, 31] citalopram  and paroxetine  may improve quality of life, however it is noted that patients with COPDand psychiatric comorbidity are reluctant to take additional medications [26, 33].
Both individual and group therapy are useful for the treatment of patients with COPD . The comparison of individual and group intervention usually favors thelatter [35–41]. Group therapy is a financially attractive treatment approach thatrequires few therapists to treat more patients. Furthermore it seems that grouptherapy offers valuable treatment opportunities, which may be due to recognition ofshared experiences and emotions among its members in a situation resembling the realworld more accurately .
It is very likely that improvement of psychological symptoms in rehabilitationprograms is associated with both psychological, and biological parameters (which areclosely coupled with the effects of exercise and respiratory physiotherapy).
Biological mechanisms associated with exercise activity, including changes in centralmonoamine function [36–40], enhanced hypothalamic- pituitary- adrenal axis regulation, increasedrelease of endogenous opioids [42–49] and reduced systemic inflammation [49, 50], may affect depression and anxiety among patients undergoing PR. Inaddition, behavioral mechanisms [51–56] associated with exercise activity as active distraction from worryingthought patterns (rumination), increase in self- efficacy by providing patients witha meaningful mastery experience, provision of daily pleasant events and regularsocial contact and support, operate synergistically to produce reductions ofsymptoms.
The fact that patients participate in a pulmonary rehabilitation program, which, withthe necessary modifications, works in a way that refers to the functioning of groupsformed by people sharing common characteristics , acts therapeutically. Moreover, it is well knownthat the sense ofbelonging to a group is often beneficial, as it provides the opportunity forparticipants to trigger interactions and through this process to identify elementsof personal experience among others, and to process them in a healthier way .
The results of this study are consistent with reports of strong evidence ofpsychological/psychiatric benefits of pulmonary rehabilitation [58–61], (such as improved mood and anxiety) in patients with COPD [62, 63]. This study is in accordance with previous findings indicating thatpatients with less favorable psychological conditions may also benefit from arehabilitation program .
An additional finding is that the effectiveness of a pulmonary rehabilitation programin reducing stress and depressive symptoms experienced by patients with COPD, isundeniable, regardless of disease stage, patients’ gender, age or educationlevel.
Furthermore, this study is in agreement with findings of other related works [29, 30] that reported anxiety and depression as being the major comorbidityproblem in patients with COPD. However, the prevalence of comorbidity seems to varywidely among different researchers [25, 65–67]. The acceptance of common assessment tools for stress and depression inpatients with COPD could mitigate the problem.
The fact that the predicted FEV1% and severity of COPD showed nocorrelation with anxiety or depression has been observed in other studies [6, 68]. These observations are consistent with the hypothesis that the predictedFEV1% does not reflect all aspects of the disease . It is likely that patients interpret disease seriousness subjectively,which contributes to the development of the levels of anxiety and depressivesymptoms.
Limitations of the study
The purpose of this study was to assess whether a brief three monthrehabilitation program can improve levels of anxiety and depression in patientswith COPD without being able to answerbut only to speculate on the reasons forthis improvement. Subsequent studies should focus on exploring the causes of theimprovement.
This was a short-term before-and-after design study (which is most useful indelineating immediate effects of short-term programs). Although it might be moreuseful in COPD patients to assess longer-term repercussions of therehabilitation program this was beyond the scope of this study (after all over alonger time period of time conditions may change and obscure any intervention'seffects by threatening the study's internal validity). The fact that the numberof men was unequal to that of women may actually underestimate baseline anxietyand depression scores, since women tend to have higher levels of both, but sucha choice would have eliminated the representativeness of the sample (women withCOPD, despite a steady increase in number, still remain fewer than men). Animportant problem in the study is that a substantial number of patients havechosen to discontinue the rehabilitation program and a subsequent study shouldexamine whether psychological factors are involved in patients attrition.Understanding the problem should not aim at excluding patients with COPD fromrehabilitation programs, but to create individualized interventions both beforeand during rehabilitation.
Our study supports that pulmonary rehabilitation programs should be offered to allCOPD patients regardless of disease severity, since they all get improvements inanxiety and depressive symptoms. Further research would be useful to confirm thesefindings and to focus on the possibilities of intervention and rehabilitation inpatients with mild COPD.
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