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COPD education and cognitive behavioral therapy group treatment for clinically significant symptoms of depression and anxiety in COPD patients: a randomized controlled trial

  • M. E. Kunik (a1) (a2) (a3) (a4) (a5), C. Veazey (a6), J. A. Cully (a1) (a2) (a3) (a5), J. Souchek (a1) (a2) (a4), D. P. Graham (a1) (a2) (a3) (a5), D. Hopko (a7), R. Carter (a8), A. Sharafkhaneh (a2) (a4), E. J. Goepfert (a3), N. Wray (a1) (a2) (a4) and M. A. Stanley (a1) (a2) (a3) (a5)...



Chronic obstructive pulmonary disease (COPD) affects 14 to 20 million Americans and is associated with increased prevalence of affective disorders, contributing significantly to disability. This study compared cognitive behavioral therapy (CBT) group treatment for anxiety and depression with COPD education for COPD patients with moderate-to-severe anxiety and/or depressive symptoms.


A randomized controlled trial (RCT) was conducted between 11 July 2002 and 30 April 2005 at the Michael E. DeBakey VA Medical Center, Houston, TX. Participants were 238 patients treated for COPD the year before, with forced expiratory value in 1 second (FEV)1/forced vital capacity (FVC)<70% and FEV1<70% predicted, and symptoms of moderate anxiety and/or moderate depression, who were being treated by a primary care provider or pulmonologist. Participants attended eight sessions of CBT or COPD education. Assessments were at baseline, at 4 and 8 weeks, and 4, 8 and 12 months. Primary outcomes were disease-specific and generic quality of life (QoL) [Chronic Respiratory Questionnaire (CRQ) and Medical Outcomes Survey Short Form-36 (SF-36) respectively]. Secondary outcomes were anxiety [Beck Anxiety Inventory (BAI)], depressive symptoms [Beck Depression Inventory-II (BDI-II)], 6-minute walk distance (6MWD) and use of health services.


Both treatments significantly improved QoL, anxiety and depression (p<0.005) over 8 weeks; the 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.


CBT group treatment and COPD education can achieve sustainable improvements in QoL for COPD patients experiencing moderate-to-severe symptoms of depression or anxiety.


Corresponding author

*Address for correspondence: M. E. Kunik, M.D., M.P.H., Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey VAMC (152), 2002 Holcombe, Houston, TX 77030, USA. (Email:


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American Thoracic Society (1991). Official statement on lung function testing: selection of reference values for interpretative strategies. American Review of Respiratory Disease 1444, 12021218.
Arnau, RC, Meagher, MW, Norris, MP, Bramson, R (2001). Psychometric evaluation of the Beck Depression Inventory-II with primary care medical patients. Health Psychology 20, 112119.
Barlow, J, Wright, C, Sheasby, J, Turner, A, Hainsworth, J (2002). Self-management approaches for people with chronic conditions: a review. Patient Education and Counseling 48, 177187.
Beck, AT, Steer, RA (1993). Beck Anxiety Inventory: A Manual, 2nd edn. Psychological Corporation: San Antonio, TX.
Beck, AT, Steer, RA, Brown, G (1996). Manual for the Beck Depression Inventory-II. Psychological Corporation: San Antonio, TX.
Borson, S, McDonald, GJ, Gayle, T, Deffebach, M, Lakshminarayan, S, VanTuinen, C (1992). Improvement in mood, physical symptoms, and function with nortriptyline for depression in patients with chronic obstructive pulmonary disease. Psychosomatics 33, 190201.
Cambach, W, Chadwick-Straver, RV, Wagenaar, RC, van Keimpema, AR, Kemper, HC (1997). The effects of a community-based pulmonary rehabilitation programme on exercise tolerance and quality of life: a randomized controlled trial. European Respiratory Journal 10, 104113.
Carter, R, Holiday, DB, Nwasuruba, C, Stocks, J, Grothues, C, Tiep, B (2003). 6-minute walk work for assessment of functional capacity in patients with COPD. Chest 123, 14081415.
Carter, R, Nicotra, B, Tucker, JV (1999). Courage and Information for Life with Chronic Obstructive Pulmonary Disease. New Technology Publishing, Inc.: Onset, MA.
Cully, JA, Graham, DP, Stanley, MA, Ferguson, CJ, Sharafkhaneh, A, Souchek, J, Kunik, ME (2006). Quality of life in patients with chronic obstructive pulmonary disease and comorbid anxiety or depression. Psychosomatics 47, 312319.
Cully, JA, Graham, DP, Stanley, MA, Kunik, ME (2007). Depressed and anxious COPD patients: predictors of psychotherapy engagement from a clinical trial. Journal of Clinical Psychology in Medical Settings 14, 160164.
de Beurs, E, Beekman, ATF, van Balkom, AJLM, Deeg, DJH, van Dyck, R, van Tilburg, W (1999). Consequences of anxiety in older persons: its effect on disability, well-being and use of health services. Psychological Medicine 29, 583593.
de Godoy, D, de Godoy, RF (2003). A randomized controlled trial of the effect of psychotherapy on anxiety and depression in chronic obstructive pulmonary disease. Archives of Physical Medicine and Rehabilitation 84, 11541157.
den Boer, PC, Wiersma, D, Van den Bosch, RJ (2004). Why is self-help neglected in the treatment of emotional disorders? A meta-analysis. Psychological Medicine 34, 959971.
Druss, BG, Rohrbaugh, RM, Rosenheck, RA (1999). Depressive symptoms and health costs in older medical patients. American Journal of Psychiatry 156, 477479.
Eiser, N, West, C, Evans, S, Jeffers, A, Quirk, F (1997). Effects of psychotherapy in moderately severe COPD: a pilot study. European Respiratory Journal 10, 15811584.
Folstein, MF, Folstein, SE, McHugh, PR (1975). Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research 12, 189198.
Gallagher-Thompson, D, Steffen, AM (1994). Comparative effects of cognitive-behavioral and brief psychodynamic psychotherapist for depressed family caregivers. Journal of Consulting and Clinical Psychology 62, 543549.
Gallefoss, F (2004). The effects of patient education in COPD in a 1-year follow-up randomized, controlled trial. Patient Education and Counseling 52, 259266.
Gill, D, Hatcher, S (1999). A systematic review of the treatment of depression with antidepressant drugs in patients who also have a physical illness. Journal of Psychosomatic Research 47, 131143.
Gill, D, Hatcher, S (2007). withdrawn: antidepressants for depression in medical illness. The Cochrane Database of Systematic Reviews: Issue 3. Art. No.: CD001312. Accessed 24 September 2007.
Gillis, MM, Haaga, DAF, Ford, GT (1995). Normative values for the Beck Anxiety Inventory, Fear Questionnaire, Penn State Worry Questionnaire, and Social Phobia and Anxiety Inventory. Psychological Assessment 7, 450455.
Global Initiative for Chronic Obstructive Lung Disease (2001) (updated 2004). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. NHLBI/WHO workshop report. National Heart, Lung, and Blood Institute: Bethesda ( Accessed 10 October 2005.
Graydon, JE, Ross, E (1995). Influence of symptoms, lung function, mood, and social support on level of functioning of patients with COPD. Research in Nursing and Health 18, 525533.
Griffiths, TL, Burr, ML, Campbell, IA, Lewis-Jenkins, V, Mullins, J, Shiels, K, Turner-Lawlor, PJ, Payne, N, Newcombe, RG, Ionescu, AA, Thomas, J, Tunbridge, J (2000). Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet 355, 362368.
Guyatt, GH, Berman, LB, Townsend, M, Pugsley, SO, Chambers, LW (1987). A measure of quality of life for clinical trials in chronic lung disease. Thorax 42, 773778.
Jaeschke, R, Singer, J, Guyatt, GH (1989). Measurement of health status. Ascertaining the minimal clinically important difference. Controlled Clinical Trials 10, 407415.
Kabacoff, RI, Segal, DL, Hersen, M, VanHasselt, VB (1997). Psychometric properties and diagnostic utility of the Beck Anxiety Inventory and the State-Trait Anxiety Inventory with older adult psychiatric outpatients. Journal of Anxiety Disorders 11, 3347.
Karajgi, B, Rifkin, A, Doddi, S, Kolli, R (1990). The prevalence of anxiety disorders in patients with chronic obstructive pulmonary disease. American Journal of Psychiatry 147, 200201.
Kim, HFS, Kunik, ME, Molinari, VA, Hillman, SL, Lalani, S, Orengo, CA, Petersen, NJ, Nahas, Z, Goodnight-White, S (2000). Functional impairment in COPD patients: the impact of anxiety and depression. Psychosomatics 1, 465471.
Kunik, ME, Azzam, PN, Souchek, J, Cully, J, Wray, NP, Krishnan, LL (2006). A practical screening tool for anxiety and depression in patients with chronic breathing disorders. Psychosomatics 48, 1621.
Kunik, ME, Braun, U, Stanley, MA, Wristers, K, Molinari, V, Stoebner, D, Orengo, CA (2001). One session cognitive behavioural therapy for elderly patients with chronic obstructive pulmonary disease. Psychological Medicine 31, 717723.
Kunik, ME, Roundy, K, Veazey, C, Souchek, J, Richardson, P, Wray, NP, Stanley, MA (2005). Surprisingly high prevalence of anxiety and depression in chronic breathing disorders. Chest 127, 12051211.
Lejuez, CW, Hopko, DR, Lepage, JP, Hopko, SD, McNeil, DW (2001). A brief behavioral activation treatment for depression. Cognitive and Behavioral Practice 8, 164175.
Lisansky, DP, Clough, DH (1996). A cognitive-behavioral self-help educational program for patients with COPD: a pilot study. Psychotherapy and Psychosomatics 65, 97101.
Lorig, KR, Sobel, DS, Stewart, AL, Brown, Jr. BS, Bandura, A, Ritter, P, Gonzalez, VM, Laurent, DD, Holman, HR (1999). Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Medical Care 37, 514.
Oslin, DW, Streim, J, Katz, IR, Edell, IR, Edell, WS, TenHave, T (2000). Change in disability follows inpatient treatment for late life depression. Journal of the American Geriatrics Society 48, 357362.
Pincus, H (2003). The future of behavioral health and primary care: drowning in the mainstream or left on the bank? Psychosomatics 44, 111.
Ritter, PL, Stewart, AL, Kaymaz, H, Sobel, DS, Block, DA, Lorig, KR (2001). Self-reports of health care utilization compared to provider records. Journal of Clinical Epidemiology 54, 136141.
Roundy, K, Cully, JA, Stanley, MA, Veazey, C, Souchek, J, Wray, NP, Kunik, ME (2005). Are anxiety and depression addressed in primary care patients with COPD? Primary Care Companion to the Journal of Clinical Psychiatry 715, 213218.
Seggar, LB, Lambert, MJ, Hansen, NB (2002). Assessing clinical significance: application to the Beck Depression Inventory. Behavior Therapy 33, 253269.
Simon, GE, Fleck, M, Lucas, R, Bushnell, DM; LIDO Group (2004). Prevalence and predictors of depression treatment in an international primary care study. American Journal of Psychiatry 161, 16261634.
Spitzer, RL, Williams, JBW, Gibbon, M, First, MB (1992). The Structured Clinical Interview for DSM-III-R (SCID). 1. History, rationale, and description. Archives of General Psychiatry 49, 624629.
Stanley, MA, Beck, JG, Glassco, JD (1996). Treatment of generalized anxiety in older adults: a preliminary comparison of cognitive-behavioral and supportive approaches. Behavior Therapy 27, 565581.
Stanley, MA, Beck, JG, Novy, DM, Averill, PM, Swann, AC, Diefenbach, GJ, Hopko, DR (2003 b). Cognitive-behavioral treatment of late-life generalized anxiety disorder. Journal of Consulting and Clinical Psychology 71, 309319.
Stanley, MA, Hopko, DR, Diefenbach, GJ, Bourland, SL, Rodrigues, H, Wagener, P (2003 a). Cognitive-behavior therapy for late-life generalized anxiety disorder in primary care: preliminary findings. American Journal of Geriatric Psychiatry 11, 9296.
Stanley, MA, Roberts, RE, Bourland, SL, Novy, DM (2001). Anxiety disorders among older primary care patients. Journal of Clinical Geropsychology 7, 105116.
Stanley, MA, Veazey, C, Hopko, D, Diefenbach, G, Kunik, ME (2005). Anxiety and depression in chronic obstructive pulmonary disease: a new intervention and case report. Cognitive and Behavioral Practice 12, 424436.
Steer, R, Willman, M, Kay, P, Beck, AT (1994). Differentiating elderly medical and psychiatric outpatients with the Beck Anxiety Inventory. Assessment 4, 345351.
Tiep, BL (1997). Disease management of COPD with pulmonary rehabilitation. Chest 112, 16301656.
Van Ede, L, Yzermans, C, Brouwer, H (1999). Prevalence of depression in patients with chronic obstructive pulmonary disease: a systematic review. Thorax 54, 688692.
VA Office of Quality and Performance (2000). Health Status and Outcomes of Veterans: Physical and Mental Component Summary Scores, Veterans SF-36, 1999 Large Health Survey of Veteran Enrollees Executive Report. Office of Quality and Performance, Department of Veterans Affairs, Veterans Health Administration; and VHA Health Assessment Project, Center for Health Quality, Outcomes and Economic Research: Bedford, MA.
Ware, JE, Sherbourne, CD (1992). The MOS 36-item Short-Form Health Survey (SF-36). 1. Conceptual framework and item selection. Medical Care 30, 473483.
Wetherell, JL, Arean, PA (1997). Psychometric evaluation of the Beck Anxiety Inventory with older medical patients. Psychological Assessment 9, 136144.
Wetherell, JL, Gatz, M, Craske, MG (2003). Treatment of generalized anxiety disorder in older adults. Journal of Consulting and Clinical Psychology 71, 3140.
Wetherell, JL, Lenze, EJ, Stanley, MA (2005). Evidence-based treatment of geriatric anxiety disorders. Psychiatric Clinics of North America 28, 88718896.
Wilson, L, Devine, EB, So, K (2000). Direct medical costs of chronic obstructive pulmonary disease: chronic bronchitis and emphysema. Respiratory Medicine 94, 204213.
Worth, H, Dhein, Y (2004). Does patient education modify behaviour in the management of COPD? Patient Education and Counseling 2, 267270.
Wyrwich, KW, Bullinger, M, Aaronson, N, Hays, RD, Patrick, DL, Symonds, T (2005). Estimating clinically significant differences in quality of life outcomes. Quality of Life Research 14, 285295.
Yohannes, AM, Roomi, J, Waters, K, Connolly, MJ (1998). Quality of life in elderly patients with COPD: measurement and predictive factors. Respiratory Medicine 92, 12311236.
Yu, W, Ravelo, A, Wagner, TH, Phibbs, CS, Bhandari, A, Chen, S, Barnett, PG (2003). Prevalence and costs of chronic conditions in the VA health care system. Medical Care Research and Review 60, 146S167S.


COPD education and cognitive behavioral therapy group treatment for clinically significant symptoms of depression and anxiety in COPD patients: a randomized controlled trial

  • M. E. Kunik (a1) (a2) (a3) (a4) (a5), C. Veazey (a6), J. A. Cully (a1) (a2) (a3) (a5), J. Souchek (a1) (a2) (a4), D. P. Graham (a1) (a2) (a3) (a5), D. Hopko (a7), R. Carter (a8), A. Sharafkhaneh (a2) (a4), E. J. Goepfert (a3), N. Wray (a1) (a2) (a4) and M. A. Stanley (a1) (a2) (a3) (a5)...


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