ORIGINAL ARTICLES

The effect of psychotherapy provided as part of a pulmonary rehabilitation program for the treatment of patients with chronic obstructive pulmonary disease^*

Dagoberto Vanoni de Godoy^I; Rossane Frizzo de Godoy^II; Benno Becker Júnior^III; Paula Fernanda Vaccari^IV; Maurício Michelli^V; Paulo José Zimermann Teixeira^VI; Bruno Carlos Palombini^VI

^IPulmonologist at the University of Caxias do Sul (UCS), Caxias do Sul, Rio Grande do Sul, Brazil
^IIPsychologist at the University of Caxias do Sul (UCS), Caxias do Sul, Rio Grande do Sul, Brazil
^IIIPsychologist at the University of Cordoba - Spain
^IVPhysical Therapist at the University of Caxias do Sul (UCS), Caxias do Sul, Rio Grande do Sul, Brazil
^VEducator at the University of Caxias do Sul (UCS), Caxias do Sul, Rio Grande do Sul, Brazil
^VIPulmonologist at the Universidade Federal do Rio Grande do Sul (UFRGS, Federal University of Rio Grande do Sul), Porto Alegre, Rio Grande do Sul, Brazil

Correspondence to

ABSTRACT

OBJECTIVE: To assess the effect of psychotherapy on levels of anxiety and depression, as well as on quality of life and exercise capacity in patients with chronic obstructive pulmonary disease enrolled in a pulmonary rehabilitation program.
METHODS: A randomized, controlled, blind clinical trial was conducted involving 49 chronic obstructive pulmonary disease patients. Patients were randomized into three groups: those submitted to the complete pulmonary rehabilitation program, which included psychotherapy and an exercise regimen (group 1); those submitted to the program minus physical exercise (group 2); and those submitted to the program minus psychotherapy (group 3). The three groups underwent a 12-week treatment program. All patients were evaluated at baseline and at completion of the pulmonary rehabilitation program through four instruments: The Beck Anxiety Inventory, Beck Depression Inventory and St. George's Respiratory Questionnaire were applied. The distance walked-weight product was also calculated.
RESULTS: Statistically significant absolute improvements in exercise capacity were found for groups 1 and 2, although not for group 3 (p = 0.007, p = 0.008 and p = 0.06, respectively). In groups 1 and 2, levels of anxiety and depressions were also significantly reduced (group 1: p = 0.0000 and p < 0.0003; group 2: p = 0.0001 and p = 0.0014), and quality of life was significantly improved (p = 0.0007 and p = 0.002, respectively). Anxiety levels were also reduced in group 3 (p = 0.03), although levels of depression were not, and quality of life was unaffected.
CONCLUSION: Psychotherapy sessions provided as part of a pulmonary rehabilitation program assist patients with chronic obstructive pulmonary disease in coping with disease-related limitations by reducing behavioral symptoms, especially depression, thereby influencing exercise capacity and health-related quality of life.

Keywords: Pulmonary disease, chronic obstructive/rehabilitation; Pulmonary disease, chronic obstructive/psychology; Anxiety; Depression; Quality of Life; Exercise therapy

INTRODUCTION

Pulmonary rehabilitation may be defined as an art of medicalpractice focused on the stabilization or reversion of thephysiological and psychological effects of the pathogenesis ofpulmonary diseases. The aim is to restore the highest degree ofperformance capacity that is compatible with the pulmonaryfunction and general life situation of patients with lungdisease. Rather than a therapeutic approach restricted to medicalpractice, pulmonary rehabilitation should be considered aninterdisciplinary program that takes into account theestablishment of a precise diagnosis, pharmacological treatment,physical therapy, physical reconditioning, psychological supportand education. Pulmonary rehabilitation programs (PRPs) should beadapted to the needs of each individual patient. Some authorsconsider PRPs the standard therapeutic approach for many patientswith severe respiratory disease, particularly for those withchronic obstructive pulmonary disease (COPD).^(1-3)However, to date, the mechanism responsible for the clinicalimprovement of patients with lung disease submitted to PRPs hasnot been fully elucidated. The increased motivation, togetherwith desensitization to dyspnea, the learning of techniques thatmay facilitate daily life activities, and the training ofrespiratory and skeletal muscles, contribute, to varying degrees(as yet not well defined), to the well-being of thepatient.^(4-5)

The objective of this study was to analyze the effects of psychotherapy sessions on the severity of the behavioral symptoms anxiety and depression, on quality of life and on exercise tolerance in patients with COPD participating in a PRP.

METHODS

A prospective, controlled, randomized, blind (patients)clinical trial was conducted at the University of Caxias do SulCentral Outpatient Clinic and Vila Olímpica.

The study involved adults of both genders with COPD, staged asmoderate and severe, corresponding to stages and as defined bythe Global Initiative for Chronic Obstructive Lung DiseaseScientific Committee.⁽⁶⁾ The sample consisted ofconsecutive patients treated in the outpatient clinic of theUniversity of Caxias do Sul Pulmonology and Thoracic SurgeryDepartment. All patients were referred to the clinic bypulmonologists or thoracic surgeons. Initially, 58 patients werereferred to the PRP, but 6 of those patients declined toparticipate in the study. Of the remaining 52 patients, 3 wereexcluded during the first month of activities - 2 due to lesionsin the spinal column and 1 due to severe respiratory infectionthat required long-term hospitalization. Therefore, the finalstudy sample comprised 49 consecutive patients randomized intothree groups (G1, G2 and G3).

The medical evaluation consisted of anamnesis, physicalexamination and postbronchodilation spirometry (Spirodoc; MedicalInternational Research, Rome, Italy), as well as frontal andlateral view chest X-rays.

The measurement instruments described herein were applied by apsychologist blinded as to the group to which any given patientbelonged.

The Beck Anxiety Inventory (BAI) consists of a list of 21symptoms with four alternatives each. The alternatives are listedin ascending order by level of anxiety. In Brazil, the BAI wasvalidated with the following classification: 0 to 9 = minimal; 10to 16 = mild; 17 to 29 = moderate; and 30 to 63 = severe. Anxietyis considered clinically significant when classified as mild orhigher.^(7-8) The Beck Depression Inventory (BDI)consists of 21 categories of symptoms and activities, with fouralternatives each. The alternatives are listed in ascending orderby level of depression. The BDI was validated in Brazil with thefollowing classification: 0 to 11 = minimum; 12 to 19 = mild; 20to 35 = moderate; and 36 to 63 = severe. Depression is consideredclinically significant when classified as mild orhigher.^(7-8) The Saint George's RespiratoryQuestionnaire (SGRQ), also validated in Brazil, evaluates threedomains: symptoms; limitations in daily life activities; andimpact of the disease on the individual. Each domain has amaximum possible score, and differences of greater than 10%reflect a life quality alteration in that domain. Alterationsequal to or greater than 4% after an intervention indicate asignificant change in patient quality of life.⁽⁹⁾ Thedistance walked-weight product is obtained by multiplying thedistance walked by patient body weight. This parameter presentsgood correlation with the anaerobic threshold and with maximaloxygen uptake in patients with COPD.⁽¹⁰⁾ We used thedistance walked in six minutes.

The study protocol was approved by the Ethics in ResearchCommittee of the University of Caxias do Sul.

The G1 patients received the complete PRP. The participants inthis group performed various activities as listed below. Therewere two weekly sessions of physical exercises, includingupper-body, lower-body and flexibility exercises, as well asaerobic exercises using a treadmill. The intensity of theexercise was modulated based on patient signs and symptoms. Theprincipal objective was to exercise patients at 75% to 85% ofmaximum heart rate. The exercises were suspended when the heartrate exceeded the limits presented above or when the patientpresented any of the following: cardiac arrhythmia; arterialblood pressure above 180/110 mmHg; chest pain; blurred vision;pallor; cold sweats; hemoglobin oxygen saturation below 85%; anddeterioration of motor coordination or level of consciousness.This activity was supervised by the physical educationinstructor.

Individual psychotherapy sessions were held on a weekly basisand were conducted by a psychologist. The psychotherapy sessionsaddressed the psychological needs of the patients, includingdifficulties in social life, in marital life, at work and withtheir health. To that end, cognitive-behavioral therapy andlogotherapy techniques were used.^(11-13) Themaintenance of anxiety control was performed throughcognitive-behavioral techniques. For example, facing a situationthat is a dyspnea trigger, the patient was taught to apply thefollowing sequence of actions: "stop"; "calm down"; "breathe";"notice the reduction of anxiety"; and "take control of thesituation". In the logotherapy, also known as "therapy throughmeaning", patients were asked to reevaluate their quality oflife, seeking alternatives to cope with the painful situationscaused by the disease.

A monthly group educational session to discuss important COPDtopics was conducted by the pulmonologist. The objective of theeducational sessions was to enable patients to incorporate intotheir daily lives the knowledge imparted during the PRPactivities.

Meetings with the physical therapist to work on respiratoryrehabilitation were held twice weekly. During the physicaltherapy sessions, diaphragmatic breathing techniques were taught,as well as the use of an anchor point and pursed-lip breathing.Another goal was to remove excess respiratory secretions throughpostural drainage and coughing, as well as chest percussion andvibration.

The G2 patients received psychotherapy (identical to thatgiven to the G1 patients) but did not participate in the physicalexercise sessions.

The G3 patients participated in physical exercise sessions(identical to those attended by the G1 patients) but did notreceive psychotherapy.

The activities of the various groups were scheduled atdifferent times in order to ensure that the patients in eachgroup were blinded as to the activities of those in the othergroups.

At the end of the twelve weeks of PRP, as a post-test, thepatients went through the same phases used in the initialevaluation, being evaluated by the same professionals using thesame methodology.

The quantitative data are expressed as means and standard deviations. Data related to categorical variables are expressed as percentages. In the comparison of the groups by the type of variable analyzed, we used the following statistical tests: Student's t-test, ANOVA and chi-square test. The level of significance adopted in the study was = 0.05. The data were processed and analyzed using the programs SPSS for Windows, version 6.0, and Epi Info, version 6.04.

RESULTS

The 49 patients were studied from October 1999 to December2001 and were divided as follows: G1: 19 patients; G2: 16patients; and G3: 14 patients.

The comparisons among the groups regarding spirometric variables, COPD severity and body mass index are shown in Table 1. There was a predominance of males (73%) and Caucasians (93%). All of the patients were over 50 years old, 69% were married, 8% were illiterate, and 71% had completed elementary school. A total of 55% of the patients had an income of over three times the minimum wage. All were using medication, principally inhaled beta-2-agonists (90%), ipratropium (67%), oral or inhaled corticosteroids (57%) and xanthines (51%). Home oxygen therapy was used by 8% of the patients, antidepressants by 10% and anxiolytics by 6%. The most common concomitant diseases were: systemic arterial hypertension (20%), ischemic cardiopathy (18%) and diabetes mellitus (16%). At the beginning of the PRP, 5 (10%) of the patients were still smokers. None of the patients presented severe nutritional disturbances. Mean body mass index and mean serum electrolytes related to respiratory muscle function were normal. In the spirometric measurements, mean forced vital capacity was 66% of predicted, and mean forced expiratory volume in one second was 34% of predicted. On average, the patients were not polycythemic or hypercapnic, although most presented hypoxemia (hemoglobin oxygen saturation of 91%).

The groups were similar in the initial evaluation regardingBAI, BDI, SGRQ, distance walked-weight product and percentage ofmaximum heart rate attained.

The BAI and BDI scores indicated that the mean impact on thebehavioral symptoms anxiety and depression was from mild tomoderate. The SGRQ scores indicated that patient quality of lifewas seriously affected in all three domains: symptoms;limitations in daily life activities; and impact of the disease.The patients in all three groups exercised within a similar rangeof intensity, measured by the percentage of maximum heart rateattained (between 70% and 80%), with equal adherence to the PRPactivities.

At the end of the PRP, G1 and G2 patients demonstratedstatistically significant reductions in their levels of anxietyand depression, as well as statistically significant improvementin quality of life and exercise tolerance. The final mean BAI andBDI scores indicated that anxiety and depression were minimal.All of the SGRQ domains were at least 4% lower at the end of thePRP. Among G3 patients, the only statistically significantpost-PRP reduction was that seen in levels of anxiety. There wasno statistically significant improvement in quality of life or inthe distance walked-weight product.

The mean final BAI and BDI scores indicated that anxiety and depression were minimal. None of the SGRQ domains suffered a mean reduction of less than 4% by the end of the PRP. The data regarding BAI, BDI, SGRQ, distance walked-weight product and percentage of maximum heart rate attained are presented in Table 2.

In an ANOVA of the three groups, including the quantitativecovariables distance walked-weight product, BAI and BDI,increased exercise tolerance was not found to have any impact onlevels of anxiety and depression.

There were no statistical differences among the three groups regarding the confounding variables requiring hospitalization during the PRP (p = 0.8) and COPD exacerbation (p = 0.2).

DISCUSSION

The analysis of the evolution of the patients belonging to PRPgroups that were partially distinct demonstrated that theinclusion of psychotherapy sessions in the PRP was beneficial forthose patients. A reduction in the levels of the behavioralsymptoms anxiety and depression was obtained, as well as animprovement in the quality-of-life index.

Reviews of the literature have demonstrated a notableprevalence of anxiety and depression in individuals with moderateor severe COPD. Clinically significant levels of anxiety arefound in 40% to 96% of such patients,^(14-16) anddepression is seen in 51% to 74% of cases.^(17-18) Itis possible that depression and anxiety are being underdiagnosedand undertreated in the population of patients withCOPD.⁽¹⁹⁾

In the present study, a post-PRP reduction in anxiety wasobserved in all of the groups analyzed. However, this reductionwas significantly greater in patients receiving psychotherapy (G1and G2 patients) than in those not receiving such therapy (G3patients). After the PRP, depression was reduced in G1 and G2patients, whereas it was increased in G3 patients. These resultssuggest the need to include psychological support in PRPs inorder to better understand and motivate patients. In a study of55 individuals with COPD, it was reported that symptoms ofanxiety and depression were reduced after a single session ofcognitive intervention and relaxation techniquetraining.⁽²⁰⁾ The authors of another study showedincreased exercise tolerance, increased cognitive performance(greater verbal fluency) and reduced anxiety in a subgroup of PRPpatients who were trained using education, exercise and stressmanagement techniques.⁽²¹⁾ In a cases series studyinvolving 95 patients with COPD treated in a PRP that includedmeetings with a clinical psychologist, anxiety and depressionwere reduced by 81% and 82%, respectively, by the end of theprogram, and a control analysis carried out three months latershowed that these levels remained stable.⁽²²⁾

Patients with COPD are often segregated from society, mostreceiving fragmented and incomplete treatment, which results in alow quality of life for the patient and family. Those PRPs thatlast from six to ten weeks have been shown to have a favorableaffect on the quality of life of patients withCOPD.^(23-25) A marked increase in quality of life wasobserved in a ten-week PRP involving 30 patients withCOPD.⁽²⁴⁾ In the present study, baseline quality oflife was similar in all three groups. Statistically significantfavorable responses in the levels of quality of life, measuredthrough the use of the SGRQ, were obtained in all three groups,although the improvement in G3 was significantly inferior tothose seen in G1 and G2.

Patients with moderate to severe COPD typically experienceexercise intolerance, which may result in a severe reduction infunctional mobility. The mechanisms and the magnitude of post-PRPimprovement depend on the clinical profile, the degree ofincrease in aerobic capacity, the extent to which skeletal andrespiratory muscles recover, how advanced the exercise techniquesemployed are and the degree to which dyspnea is reduced, as wellon patient motivation. In the comparison between the baseline andpost-PRP values, the patients in all three groups presentedclinical improvement in exercise tolerance. The G3 patientspresented a clinically significant, albeit less thanstatistically significant, increase in exercise tolerance. Itshould be noted that the improved physical performance seen in G2patients might be attributable to the psychotherapy, in which wasdesigned to prepare patients to better cope with the pain imposedby the disease. Following this same line of thinking, the factthat the increase in exercise tolerance was found to be lesspronounced among G3 patients might have been related to thehigher levels of depression seen in those patients.

Physical activity may be an excellent alternative means ofunloading or releasing tensions, emotions and frustrationsaccumulated as a result of the pressures of modern life. However,the therapeutic impact of exercise on levels of anxiety anddepression has not been well defined.^(26-32) In thesample studied, no relation was found between improved physicalperformance and lower levels of anxiety and depression.

In conclusion, the inclusion of psychotherapy sessions in a PRP designed to treat patients with moderate to severe COPD reduced levels of the behavioral symptoms anxiety and depression, improved the quality-of-life indices and have a favorable effect on exercise tolerance. Further studies are needed in order to determine the duration of the beneficial effects that psychotherapy during a PRP has on anxiety and depression in this patient population.

REFERENCES

1. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines. AACP/AACVPR Pulmonary rehabilitation Guidelines Panel. American College of Chest Physicians. American Association of Cardiovascular and Pulmonary Rehabilitation. Chest. 1997;112(5):1363-96.         [ Links ]Comment in: Chest. 1998;114(1):343-5; Chest. 2000;117(4):929-31.

2. Celli BR. Pulmonary rehabilitation for patients with advanced lung disease. Clin Chest Med. 1997;18(3):521-34.        [ Links ]

3. Fahy B. Pulmonary rehabilitation: nuts and bolts. Clin Pulm Med. 2000;7:319-25.        [ Links ]

4. Lacasse Y, Brosseau L, Milne S, Martin S, Wong E, Guyatt GH, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2002;(3):CD003793.        [ Links ]

5. Sinn DD, McAllister FA, Man SF, Anthonisen NR. Contemporary management of chronic obstructive pulmonary disease: scientific review. JAMA. 2003;290 (17):2301-12.        [ Links ]

6. GOLD Global Initiative for Chronic Obstructive Lung Disease [home page on the Internet]. Global Initiative for Chronic Obstructive Lung Disease: 2000 [updated 2002 Aug 28; cited 2005 Jan 9]. Available from: www.goldcopd.com        [ Links ]

7. Cunha JA. Generalidades sobre a versão brasileira do BDI,BAI,BHS e BSI. In: 7º Encontro Nacional sobre testes psicológicos; 1º Congresso Ibero-Americano de Avaliação Psicológica. Anais. Porto Alegre, 1997. p.135-9.        [ Links ]

8. Cunha JA. Estudos dos pontos de corte do BDI e BAI na versão em português [pôster]. In: 8º Congresso Nacional de Avaliação Psicológica. Anais. Porto Alegre; 1999.        [ Links ]

9. Souza TC, Jardim JR, Jones P. Validação do questionário do Hospital Saint George na doença respiratória (SGRQ) em pacientes portadores de doença pulmonar obstrutiva crônica no Brasil. J Pneumol. 2000;26(2):119-28.        [ Links ]

10. Chuang ML, Lin IF, Wasserman K. The body-walking distance product as related to lung function, anaerobic threshold and peak VO₂ in COPD patients. Respir Med. 2001; 95(7):618-26.        [ Links ]

11. Beck AT, Rush AJ, Shaw BF, Emery GE. Cognitive therapy of depression. New York: Guilford Press; 1979.        [ Links ]

12. Beck AT, Emery GE, Greenberg RL. Anxiety disorders and phobias: a cognitive perspective. New York: Basic Book, 1985.        [ Links ]

13. Frankl VE. Psychotherapy and existentialism: selected papers on logotherapy New York: Simon & Schuster; 1985.        [ Links ]

14. White RJ, Rudkin ST, Ashley J, Stevens VA, Burrows S, Pounsford JC, et al. Outpatient pulmonary rehabilitation in severe chronic obstructive pulmonary disease. J R Coll Physicians Lond. 1997;31(5):541-5.        [ Links ]

15. Agle DP, Baum GL. Psychological aspects of chronic obstructive pulmonary disease. Med Clin North Am. 1977;61(4):749-58.        [ Links ]

16. Godoy RF, Becker Jr B, Godoy DV, Vaccari P, Michelli M. El efecto del ejercicio sobre los niveles de ansiedad, depression y autoconcepto de pacientes com dolencia pulmonar obstructiva crónica. Rev Psicol Deporte. 2001;10(2):267-78.        [ Links ]

17. Ries A, Kaplan RM, Limberg TM, Prewitt LM. Effects of pulmonary rehabilitation on physiologic and psychological outcomes in patients with chronic obstructive pulmonary disease. Ann Intern Med. 1995;122(11):823-32.        [ Links ]

18. Emery C, Leatherman N, Burker EJ, MacIntyre NR. Psychological outcomes of a pulmonary rehabilitation program. Chest. 1991;100(3):613-7.        [ Links ]

19. Kim HF, Kunik ME, Molinari VA, Hillman SL, Lalani S, Orengo CA, et al. Functional impairment in COPD patients: the impact of anxiety and depression. Psychosomatics. 2000;41(6):465-71.        [ Links ]

20. Kunik ME, Braun U, Stanley MA, Wristers K, Molinari V, Stoebner D, et al. One session cognitive and behavioural therapy for elderly patients with chronic obstructive pulmonary disease. Psychol Med. 2001;31(4):717-23.        [ Links ]

21. Emery CF, Schein RL, Hauck ER, MacIntyre NR. Psychological and cognitive outcomes of a randomized trial of exercise among patients with chronic obstructive pulmonary disease. Health Psychol. 1998;17(3):232-40.        [ Links ]

22. Whiters NJ, Rudkin SH, White RJ. Anxiety and depression in severe chronic obstructive pulmonary disease: the effects of pulmonary rehabilitation. J Cardiopulm Rehabil. 1999;19(6):362-5.        [ Links ]

23. Singh SJ, Smith DL, Hyland ME, Morgan MD. A short outpatient pulmonary rehabilitation programme: immediate and longer term effects on exercise performance and quality of life. Respir Med. 1998;92(9):1146-54.        [ Links ]

24. Lisboa C, Villafranca AC, Caiozzi AG, Berrocal C, Leiva A, Pinochet R, et al. [Quality of life in patients with chronic pulmonary obstructive disease and the impact of physical training]. Rev Med Chile. 2001;129(4):359-66. Spanish.        [ Links ]

25. Benzo R, Flume PA, Turner D, Tempest M. Effect of pulmonary rehabilitation on quality in patients with COPD: the use of SF-36 summary scores as outcomes measures. J Cardiopulm Rehabil. 2000;20(4):231-4.        [ Links ]

26. Lobstein DD, Mosbacher BJ, Ismail AH. Depression as a powerful discriminator between physically active and sedentary middle-aged men. J Psychosom Res. 1983;27(1):69-76.        [ Links ]

27. Francis KT, Carter R. Psychological characteristics of joggers. J Sports Med Phys Fitness. 1982;22(3):386-91.        [ Links ]

28. McCann L, Holmes DS. Influence of aerobic exercise on depression. J Pers Soc Psychol. 1984;46(5):1142-7.        [ Links ]

29. Wykoff W. The psychological effects of exercise on non-clinical population of adult women. Occup Ther Ment Health. 1993;12(3):69-106.        [ Links ]

30. Bennett J, Carmack M, Gardner VJ. Effect of a program of physical exercise on depression in older adults. Physiol Educ. 1982;39(1):21-4.        [ Links ]

31. Steptoe A, Edwards S, Moses J, Mathews A. The effects of exercise training on mood and perceived coping ability in anxious adults from the general population. J Psychosom Res. 1989;33(5):537-47.        [ Links ]

32. Morgan WP, Roberts VA, Brand FR, Feinerman AD. Psychological effects of chronic physical activity. Med Sci Sports. 1970;2(4):213-7.        [ Links ]

Correspondence to:
Dagoberto Vanoni de Godoy
Rua Arcy da Rocha Nóbrega, 401/204
CEP: 95.040-000, Caxias do Sul - RS, Brazil
Fax: (54) 228-4882
E-mail: dvggodoy@terra.com.br

Submitted: 24 June 2004. Accepted, after review: 6 May 2005

Sponsor: Grant of Scientific Productivity, President's Office of Graduate Studies and Research of the University of Caxias do Sul, Brazil.
* Study carried out at the University of Caxias do Sul (UCS), Caxias do Sul, Rio Grande do Sul, Brazil