Are psychological therapies effective in treating depression in patients with COPD?

Chronic obstructive pulmonary disease (COPD) comprises two conditions: emphysema and chronic bronchitis. It has been recognised as a serious health problem and one of the main causes of death around the world. The World Health Organization (WHO) informs that the number of people with COPD continues to grow, and by 2030, COPD will become the world's third cause of death. Most of the people who have COPD also experience depression. Studies show that up to 80% of patients with more severe COPD can have symptoms of depression. Other findings show that patients with COPD are four times more likely to have depression than those without COPD.

Why is this review important?

The number of people living with COPD is increasing, rather than decreasing, around the world. Depression in this population is commonly unrecognised, and patients rarely receive appropriate treatment. Untreated depression increases the risk of death, hospitalisation, readmissions, and healthcare costs. Currently, there is no strong evidence showing which psychological therapy is most effective for patients with COPD and depression.

Who will be interested in this review?

People who have COPD and depression, respiratory physicians, mental health specialists, respiratory nurses, other healthcare professionals, and policy makers.

What questions does this review aim to answer?

Which psychological therapy (if any) is effective in reducing symptoms of depression in patients with COPD?

Which studies were included in the review?

This review included experimental studies, called randomised controlled trials (RCTs), with participants who had diagnosed COPD.

What does the evidence from the review tell us?

This review included 13 experimental studies (RCTs) with 1500 participants. Our main result shows that psychological therapies using cognitive-behavioural therapy (CBT) approach may, potentially, be effective in reducing depressive symptoms in patients with COPD. However, the quality of this evidence is very low because of many limitations related to the way the studies were conducted.

What should happen next?

More experimental studies with larger numbers of participants are needed, to confirm beneficial effects of CBT for patients with COPD-related depression. Future studies need to produce higher quality evidence and measure adverse events and other important outcomes, such as quality of life or cost-effectiveness.

Authors' conclusions: 

The findings from this review indicate that psychological therapies (using a CBT-based approach) may be effective for treating COPD-related depression, but the evidence is limited. Depressive symptoms improved more in the intervention groups compared to: 1) no intervention (attention placebo or standard care), 2) educational interventions, and 3) a co-intervention (pulmonary rehabilitation). However, the effect sizes were small and quality of the evidence very low due to clinical heterogeneity and risk of bias. This means that more experimental studies with larger numbers of participants are needed, to confirm the potential beneficial effects of therapies with a CBT approach for COPD-related depression.

New trials should also address the gap in knowledge related to limited data on adverse effects, and the secondary outcomes of quality of life, dyspnoea, forced expiratory volume in one second (FEV1), exercise tolerance, hospital length of stay and frequency of readmissions, and cost-effectiveness. Also, new research studies need to adhere to robust methodology to produce higher quality evidence.

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Background: 

Chronic obstructive pulmonary disease (COPD) has been recognised as a global health concern, and one of the leading causes of morbidity and mortality worldwide. Projections of the World Health Organization (WHO) indicate that prevalence rates of COPD continue to increase, and by 2030, it will become the world's third leading cause of death. Depression is a major comorbidity amongst patients with COPD, with an estimate prevalence of up to 80% in severe stages of COPD. Prevalence studies show that patients who have COPD are four times as likely to develop depression compared to those without COPD. Regrettably, they rarely receive appropriate treatment for COPD-related depression. Available findings from trials indicate that untreated depression is associated with worse compliance with medical treatment, poor quality of life, increased mortality rates, increased hospital admissions and readmissions, prolonged length of hospital stay, and subsequently, increased costs to the healthcare system. Given the burden and high prevalence of untreated depression, it is important to evaluate and update existing experimental evidence using rigorous methodology, and to identify effective psychological therapies for patients with COPD-related depression.

Objectives: 

To assess the effectiveness of psychological therapies for the treatment of depression in patients with chronic obstructive pulmonary disease.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2018, Issue 11), and Ovid MEDLINE, Embase and PsycINFO from June 2016 to 26 November 2018. Previously these databases were searched via the Cochrane Airways and Common Mental Disorders Groups' Specialised Trials Registers (all years to June 2016). We searched ClinicalTrials.gov, the ISRCTN registry, and the World Health Organization International Clinical Trials Registry Platform (ICTRP) to 26 November 2018 to identify unpublished or ongoing trials. Additionally, the grey literature databases and the reference lists of studies initially identified for full-text screening were also searched.

Selection criteria: 

Eligible for inclusion were randomised controlled trials that compared the use of psychological therapies with either no intervention, education, or combined with a co-intervention and compared with the same co-intervention in a population of patients with COPD whose depressive symptoms were measured before or at baseline assessment.

Data collection and analysis: 

Two review authors independently assessed the titles and abstracts identified by the search to determine which studies satisfied the inclusion criteria. We assessed two primary outcomes: depressive symptoms and adverse events; and the following secondary outcomes: quality of life, dyspnoea, forced expiratory volume in one second (FEV1), exercise tolerance, hospital length of stay or readmission rate, and cost-effectiveness. Potentially eligible full-text articles were also independently assessed by two review authors. A PRISMA flow diagram was prepared to demonstrate the decision process in detail. We used the Cochrane 'Risk of bias' evaluation tool to examine the risk of bias, and assessed the quality of evidence using the GRADE framework. All outcomes were continuous, therefore, we calculated the pooled standardised mean difference (SMD) or mean difference (MD) with a corresponding 95% confidence interval (CI). We used a random-effects model to calculate treatment effects.

Main results: 

The findings are based on 13 randomised controlled trials (RCTs), with a total of 1500 participants. In some of the included studies, the investigators did not recruit participants with clinically confirmed depression but applied screening criteria after randomisation. Hence, across the studies, baseline scores for depressive symptoms varied from no symptoms to severe depression. The severity of COPD across the studies was moderate to severe.

Primary outcomes

There was a small effect showing the effectiveness of psychological therapies in improving depressive symptoms when compared to no intervention (SMD 0.19, 95% CI 0.05 to 0.33; P = 0.009; 6 studies, 764 participants), or to education (SMD 0.23, 95% CI 0.06 to 0.41; P = 0.010; 3 studies, 507 participants).

Two studies compared psychological therapies plus a co-intervention versus the co-intervention alone (i.e. pulmonary rehabilitation (PR)). The results suggest that a psychological therapy combined with a PR programme can reduce depressive symptoms more than a PR programme alone (SMD 0.37, 95% CI -0.00 to 0.74; P = 0.05; 2 studies, 112 participants).

We rated the quality of evidence as very low. Owing to the nature of psychological therapies, blinding of participants, personnel, and outcome assessment was a concern.

None of the included studies measured adverse events.

Secondary outcomes

Quality of life was measured in four studies in the comparison with no intervention, and in three studies in the comparison with education. We found inconclusive results for improving quality of life. However, when we pooled data from two studies using the same measure, the result suggested that psychological therapy improved quality of life better than no intervention. One study measured hospital admission rates and cost-effectiveness and showed significant reductions in the intervention group compared to the education group. We rated the quality of evidence as very low for the secondary outcomes.

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