Outcomes of Depressed Patients Undergoing Inpatient Pulmonary Rehabilitation

doi:10.1097/01.JGP.0000199381.98971.d1

The American Journal of Geriatric Psychiatry

Volume 14, Issue 5, May 2006, Pages 466-475

https://doi.org/10.1097/01.JGP.0000199381.98971.d1 Get rights and content

Objective

Approximately 30% of patients with chronic obstructive pulmonary disease (COPD) experience depression. Pulmonary rehabilitation for COPD focuses on physical conditioning, but includes behavioral interventions that may address depressive symptoms. This study tested the hypothesis that brief inpatient pulmonary rehabilitation is followed by improvement in both depressive symptoms and function in patients with COPD with major depression.

Methods

The subjects, who were recruited from the pulmonary rehabilitation unit of the Burke Rehabilitation Hospital in White Plains, NY, who had COPD and major depression were consecutively admitted patients to a pulmonary rehabilitation unit. Symptoms of depression, disability, medical burden, the experience of support, and satisfaction with treatment were systematically ascertained on admission and before discharge.

Results

Three hundred sixty-one patients were screened and 63 met criteria for COPD and major depression. Depressive symptoms improved by discharge (z = −6.785, p <0.0001); median length of stay was 16 days. Approximately 51% of subjects met criteria for response (50% or greater reduction in depressive symptoms scores from baseline), and 39% met criteria for remission (final Hamilton Depression scale score equal to or less than 10). History of treatment for depression was associated with limited change in depressive symptoms, whereas social support and satisfaction with treatment were predictors of improvement. All disability domains were lower at discharge compared to baseline (z = −3.928, p <0.0001). Subjects with pronounced disability at baseline had the greatest improvement if their depression improved by discharge.

Conclusions

Acute inpatient rehabilitation is followed by improvement of depressive symptoms and disability in older patients with COPD and major depression. Improvement of depression may be the result of behavioral interventions rather than the use of antidepressant drugs.

Section snippets

Subjects

The participants were consecutively admitted patients to the acute pulmonary rehabilitation unit of the Burke Rehabilitation Hospital, a university-affiliated hospital, and were recruited between April 2002 and June 2004. Approval was obtained from the Weill Cornell Medical College and Burke Rehabilitation Hospital Institutional Review Boards. All participants received a complete description of the study and signed informed consent. The Burke pulmonary rehabilitation unit accepts patients with

RESULTS

A total of 469 consecutively admitted patients to the rehabilitation unit were available for screening. Of these, 66 patients were excluded from screening as a result of severe medical illness, and another 42 patients who were approached refused to be screened. The remaining 361 patients were screened, and of these, 88 (24.4ü received the diagnosis of major depression. Of the 88 patients with major depression and COPD, 63 entered the study and 25 were excluded. The reasons for exclusion

DISCUSSION

The principal finding of this study is that brief inpatient pulmonary rehabilitation is followed by improvement of depressive symptoms and disability in older patients with COPD with MDD. Improvement occurred in a broad range of depressive symptoms and on all domains of disability. These favorable outcomes were noted regardless of the use of antidepressant drugs. To our knowledge, this is the first study documenting improvement in depressive symptoms and disability in older patients with COPD

CONCLUSIONS

Brief inpatient pulmonary rehabilitation is followed by improvement of depressive symptoms and disability in older patients with COPD with MDD. Improvement of depression may be the result of behavioral interventions of the rehabilitation program rather than use of antidepressant drugs. Satisfaction with treatment and the experience of support were predictors of favorable outcomes of MDD, whereas advanced age and history of treatment for depression were associated with limited improvement of

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Cited by (51)

Two Interventions for PatientsWith Major Depression and Severe Chronic Obstructive Pulmonary Disease: Impact on Quality of Life
2019, American Journal of Geriatric Psychiatry
Clinically significant depression occurs in approximately 40% of chronic obstructive pulmonary disease (COPD) patients, and both illnesses severely impair quality of life. This study tests the hypothesis that problem-solving integrated with a treatment adherence intervention, the Problem Solving-Adherence (PSA), is superior to a personalized treatment adherence intervention, the Personalized Intervention for Depressed Patients with COPD (PID-C), alone in improving quality of life in depressed COPD patients.
After screening 633 admissions for acute rehabilitation, we studied quality of life in 87 participants with major depression (by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) and severe COPD randomly assigned to 14 sessions of PID-C or PSA over 26 weeks. Quality of life was assessed using the Word Health Organization Quality of Life-BREF at baseline and weeks 10, 14, and 26.
The hypothesis was not supported. Exploratory latent class growth modeling identified two quality of life trajectories. In 80.5% of participants, quality of life remained unchanged and improved in the remaining 19.5% during the first 14 weeks. Patients with a stable quality trajectory had higher qualityof life at baseline and a stronger sense of personal agency.
Maintaining quality of life is a favorable outcome in depressed patients with COPD whose course is one of deterioration. These findings highlight the usefulness of PID-C, an easy to learn, personalized adherence enhancement intervention that, after further testing, may be integrated into the rehabilitation and care of depressed COPD patients.
A systematic review of the content and delivery of education in pulmonary rehabilitation programmes
2018, Respiratory Medicine
Pulmonary rehabilitation (PR) is a core component of Chronic Obstructive Pulmonary Disease (COPD) management with well recognized benefits. While suggestions for educational content within pulmonary rehabilitation have been detailed in clinical guidance, it is unclear what educational content is delivered as part of pulmonary rehabilitation, who delivers it, and how it is delivered.
A systematic review was conducted to identify what educational content is delivered as part of pulmonary rehabilitation, how is this delivered and who delivers it. Databases were searched from 1981 to 2017 using multiple search terms related to “pulmonary rehabilitation” and “education”.
Fourteen studies were identified. This included 6 survey studies, 5 quasi-experimental studies and 3 RCTs. Five key topics that were consistently included within PR programmes were identified as:
1) Anxiety/depression and stress management.
2) Early recognition of signs of infection.
3) Dyspnea and symptom management.
4) Nutrition.
5) Techniques using inhalers and nebulizers.
Broader topics such as welfare/benefits, sexuality, and advance care directives did not frequently feature. Only four studies used tools to measure knowledge or learning pre and post rehabilitation in an attempt to evaluate the effectiveness of the education delivered as part of PR.
The delivery of education in PR programmes is variable and does not follow suggested educational topics. Education needs to take a patient centered motivational approach to ensure effective delivery. Further research into appropriate educational outcome measures are needed, in order to evaluate the changes in behaviour associated with education.
Two Interventions for Patients with Major Depression and Severe Chronic Obstructive Pulmonary Disease: Impact on Dyspnea-Related Disability
2018, American Journal of Geriatric Psychiatry
The Personalized Intervention for Depressed Patients with Chronic Obstructive Pulmonary Disease (PID-C) is an intervention aiming to help patients adhere to their rehabilitation and care. This study tested the hypothesis that the Problem-Solving Adherence (PSA) intervention, which integrates problem-solving into adherence enhancement procedures, reduces dyspnea-related disability more than PID-C. Exploratory analyses sought to identify patients with distinct dyspnea-related disability trajectories and to compare their clinical profiles.
In this randomized controlled trial in an acute inpatient rehabilitation and community, 101 participants diagnosed with chronic obstructive pulmonary disease (COPD) and major depression were included after screening 633 consecutive admissions for acute inpatient rehabilitation. Participants underwent 14 sessions of PID-C versus PSA over 26 weeks using the Pulmonary Functional Status and Dyspnea Questionnaire.
The study hypothesis was not supported. Exploratory latent class growth modeling identified two distinct disability trajectories. Dyspnea-related disability improved in 39% of patients and remained unchanged in the rest. Patients whose dyspnea-related disability improved had more severe disability and less sense of control over their condition at baseline.
Improvement or no worsening of disability was noted in both treatment groups. This is a favorable course for depressed patients with a severe, deteriorating medical illness. PID-C is compatible with the expertise of clinicians working in community-based rehabilitation programs, and after further testing in the community, it can be integrated in the care of depressed COPD patients.
Two Behavioral Interventions for Patients with Major Depression and Severe COPD
2016, American Journal of Geriatric Psychiatry
Citation Excerpt :
Personalized treatment adherence procedures with and without problem-solving techniques led to a sustained, clinically significant improvement of depression in more than 70% of patients with major depression and severe COPD. These outcomes are quite favorable for depressed patients with severe medical burden, evidenced by a mortality rate of 14% over 26 weeks and considering that depressed COPD patients both resist taking antidepressants and have a rather low response rate when they receive them.6,7 The study hypotheses were not supported.
Personalized Intervention for Depressed Patients with COPD (PID-C), a treatment mobilizing patients to participate in their care, was found more effective than usual care. To further improve its efficacy, we developed a Problem Solving-Adherence (PSA) intervention integrating problem solving into adherence enhancement procedures. We tested the hypothesis that PSA is more effective than PID-C in reducing depressive symptoms. Exploratory analyses sought to identify patients with distinct depressive symptom trajectories and compare their clinical profiles.
Randomized controlled trial.
Acute inpatient rehabilitation and community.
A total of 101 diagnosed with chronic obstructive pulmonary disease (COPD) and major depression after screening 633 consecutive admissions for acute inpatient rehabilitation.
Fourteen sessions of PID-C versus PSA over 26 weeks.
24-item Hamilton Depression Rating Scale.
PSA was not more efficacious than PID-C in reducing depressive symptoms. Exploratory latent class growth modeling identified two distinct depressive symptoms trajectories. Unlike patients with unfavorable course (28%) who remained symptomatic, patients with favorable course (72%) had a decline of symptoms during the hospitalization followed by a milder decline after discharge. Patients with unfavorable course were younger and had greater scores in disability, anxiety, neuroticism, and dyspnea related limitation in activities and lower self-efficacy scores.
Both interventions led to sustained improvement depressive symptoms. PID-C matches the skills of clinicians employed by community rehabilitation programs and can be integrated in the care of depressed COPD patients. Patients with severe disability, anxiety, neuroticism, and low self-efficacy are at risk for poor outcomes and in need of close follow-up and targeted interventions.
The impact of depression in older patients with chronic obstructive pulmonary disease and asthma
2016, Maturitas
Citation Excerpt :
Further work is required on the efficacy of ‘maintenance’ therapy to alleviate symptoms and achieve ‘full remission’ (if this is possible). Cognitive behavioural therapy (CBT) is regarded as a first line of therapy for older patients with depression, especially mild to moderate with depression, depending on availability and patients’ preference [30]. CBT focuses on identifying and reframing negative, dysfunctional thoughts while participating in pleasurable and social activities.
Respiratory diseases are common in older people. However, the impact of comorbid depression in older patients with chronic obstructive pulmonary disease (COPD) and asthma has not been fully explored. This narrative review examines the impact of comorbid depression and its management in COPD and asthma in older adults. The causes of depression in patients with COPD and asthma are multifactorial and include physical, physiological and behavioural factors. Depression is associated with hospital readmission in older adults with asthma and COPD. We focus on the most current literature that has examined the efficacy of pulmonary rehabilitation (PR), cognitive behavioural therapy (CBT) and antidepressant drug therapy for patients with depression in the context of COPD and asthma. Our findings indicate that PR and CBT are beneficial in improving depressive symptoms and quality of life in short-term intervention studies. However, the long-term efficacy of CBT and PR is unknown. To date, the efficacy of antidepressant drug therapy for depression in patients with COPD and asthma is inconclusive. In addition, there has been no clear evidence that antidepressants can induce remission of depression or ameliorate dyspnoea or physiological indices of COPD. Factors that contribute to ‘inadequate’ assessment and treatment of depression in patients with COPD and asthma may include misconception of the disease by patients and their caregivers and stigma attached to depression. Thus, well-controlled randomized controlled trials are needed.
Association of psychological disorders with 30-day readmission rates in patients with COPD
2016, Chest
There is a growing understanding of the prevalence and impact of psychological disorders on COPD. However, the role of these disorders in early readmission is unclear.
We analyzed data from 5% fee-for-service Medicare beneficiaries diagnosed with COPD (International Classification of Diseases, Ninth Revision code, 491.xx, 492.xx, 493.xx, and 496.xx) between 2001 and 2011 who were hospitalized with a primary discharge diagnosis of COPD or a primary discharge diagnosis of respiratory failure (518.xx and 799.1) with secondary diagnosis of COPD. We hypothesized that such psychological disorders as depression, anxiety, psychosis, alcohol abuse, and drug abuse are independently associated with an increased risk of 30-day readmission in patients hospitalized for COPD.
Between 2001 and 2011, 135,498 hospitalizations occurred for COPD in 80,088 fee-for-service Medicare beneficiaries. Of these, 30,218 (22.30%) patients had one or more psychological disorders. In multivariate analyses, odds of 30-day readmission were higher in patients with COPD who had depression (OR, 1.34; 95% CI, 1.29-1.39), anxiety (OR, 1.43; 95% CI, 1.37-1.50), psychosis (OR, 1.18; 95% CI, 1.10-1.27), alcohol abuse (OR, 1.30; 95% CI, 1.15-1.47), and drug abuse (OR, 1.29; 95% CI, 1.11-1.50) compared with those who did not have these disorders. These psychological disorders increased amount of variation in 30-day readmission attributed to patient characteristics by 37%.
Psychological disorders like depression, anxiety, psychosis, alcohol abuse, and drug abuse are independently associated with higher all-cause 30-day readmission rates for Medicare beneficiaries with COPD.

View all citing articles on Scopus

The National Heart, Lung, and Blood Institute (RO1 HLB71992), the National Institute of Mental Health (P30 MH68638), the Sanchez Foundation, and Forest Pharmaceuticals, Inc., supported this research.

The authors thank the study Health Specialists Allison Rieger, C.S.W., and Susan Friedman, C.S.W.

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Regular Research ArticlesOutcomes of Depressed Patients Undergoing Inpatient Pulmonary Rehabilitation

Objective

Methods

Results

Conclusions

Section snippets

Subjects

RESULTS

DISCUSSION

CONCLUSIONS

Chest

Chest

J Psychiatr Res

J Chronic Dis

Psychosomatics

Lancet

Chest

Arch Phys Med Rehabil

Chest

Am J Geriatr Psychiatry

Biol Psychiatry

Am J Geriatr Psychiatry

Am J Geriatr Psychiatry

Biol Psychiatry

Psychosomatics

Pulmonary rehabilitation: Joint ACCP/AACVPR evidence-based guidelines

J Cardiopulmonary Rehabil

Seven chronic conditions: their impact on US adults' activity levels and use of medical services

Am J Public Health

Depression and chronic obstructive pulmonary disease: treatment trials

Semin Clin Neuropsychiatry

Anxiety and depression in patients with chronic obstructive pulmonary disease (COPD): a review

Nord J Psychiatry

Correlates of daily impairment in COPD

Rehabil Psychol

Influence of symptoms, lung function, and social support on level of functioning of patients with COPD

Res Nurs Health

Regular Research Articles
Outcomes of Depressed Patients Undergoing Inpatient Pulmonary Rehabilitation