Association of change in depression and anxiety symptoms with functional outcomes in pulmonary rehabilitation patients

The Impact of Depression and Exercise Self-Efficacy on Benefits of Pulmonary Rehabilitation in Veterans with COPD

Pulmonary rehabilitation (PR) improves health-related quality of life (HRQoL) and exercise capacity. Little is known about the impact of depression symptoms and exercise self-efficacy on improvements in these key PR outcomes. This study examined the impact of baseline depression status and change in depression symptoms (Beck Depression Inventory-II [BDI-II] score) over the course of PR on change in HRQoL assessed by the Chronic Respiratory Disease Questionnaire-Self Reported (CRQ-SR) and exercise capacity as measured by the 6-Minute Walk Test (6MWT). We also examined whether baseline exercise self-efficacy moderated the association between baseline depression symptoms and change in these key PR outcomes. We studied 112 US veterans (aged 70.38 ± 8.49 years) with chronic obstructive pulmonary disease (COPD) who completed PR consisting of twice-weekly 2-hour classes for 18 sessions. Depressed (BDI-II >13) and nondepressed (BDI-II ≤13) patients at baseline demonstrated comparable and significant improvement in CRQ-SR total score, subscales, and 6MWT. Greater reduction in depression over the course of treatment was significantly associated with greater improvement in CRQ-SR total score and the following subscales: fatigue, mastery, and emotional function. Change in depression did not predict change in 6MWT distance. Baseline exercise self-efficacy moderated the association between baseline depression symptoms and change in CRQ-SR fatigue. Specifically, when baseline exercise self-efficacy was <30.4, greater baseline depression was associated with less improvement in CRQ-SR fatigue. When baseline self-efficacy was >152.0, greater baseline depression was associated with greater improvement in CRQ-SR fatigue. PR programs should address mood and confidence to exercise given their impact on key PR outcomes.

Improving Physiological, Physical, and Psychological Health Outcomes: A Narrative Review in US Veterans with COPD

The Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States (US) providing healthcare to an increasing number of middle-aged and older adults who remain at greater risk for chronic obstructive pulmonary disease (COPD) compared to their civilian counterparts. The VHA has obligated research funds, drafted clinical guidelines, and built programmatic infrastructure to support the diagnosis, treatment, and care management of Veterans with COPD. Despite these efforts, COPD remains a leading cause of morbidity and mortality in Veterans. This paper provides a narrative review of research conducted with US Veteran samples targeting improvement in COPD outcomes. We review key physiological, physical, and psychological health outcomes and intervention research that included US Veteran samples. We conclude with a discussion of directions for future research to continue advancing the treatment of COPD in Veterans and inform advancements in COPD research within and outside the VHA.

Predictors of Outpatient Pulmonary Rehabilitation Uptake, Adherence, Completion, and Treatment Response Among Male U.S. Veterans With Chronic Obstructive Pulmonary Disease

OBJECTIVE

To examine predictors of uptake (never start), adherence (drop out), and completion of pulmonary rehabilitation (PR), as well as PR treatment response based on minimal clinically important difference (MCID) on the 6-minute walk test (6MWT) distance and Chronic Respiratory Questionnaire-Self-Report (CRQ-SR).

DESIGN

Retrospective, cohort study.

SETTING

Veterans Health Administration.

PARTICIPANTS

U.S. veterans with chronic obstructive pulmonary disease (COPD) (N=253) referred to PR between 2010 and 2018.

INTERVENTIONS

Outpatient PR program.

MAIN OUTCOME MEASURES

Participants completed baseline (time 1) measures of depression (Beck Depression Inventory-II), health-related quality of life (CRQ-SR), self-efficacy (Exercise Self-Regulatory Efficacy Scale [Ex-SRES]), and COPD knowledge. Exercise capacity was assessed with the 6MWT. Participants who completed all 18 sessions of PR repeated assessments (time 2). Logistic regression models examined predictors of uptake, adherence, and completion of PR as well as treatment response based on MCID.

RESULTS

Participants were referred to PR with 24.90% never starting, 28.90% dropping out, and 46.20% completing. No differences emerged between never starters and dropouts. Having a history of any cancer increased the likelihood of completing PR (vs never starting; odds ratio [OR], 3.18; P=.003). Greater CRQ-SR dyspnea score, indicating less dyspnea, was associated with increased likelihood of completing PR (OR, 1.12; P=.006). Past smoking compared with current smoking was associated with increased likelihood of completion (OR, 3.89; P≤.002). Those without a history of alcohol use disorder had increased likelihood of completing PR (OR, 2.23; P=.048). Greater baseline 6MWT distance was associated with lower likelihood of achieving MCID in 6MWT (OR, 0.99; P<.001). Greater Ex-SRES was associated with decreased likelihood of achieving 6MWT MCID (OR, 0.98; P=.023).

CONCLUSIONS

Findings suggest that early psychoeducation on dyspnea management and smoking and alcohol cessation may increase completion of PR.

Effectiveness of Cognitive Behavioral Therapy on Health Outcomes in Patients with Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

"The incidence of psychological distress (such as anxiety and depression) is high in COPD patients. CBT has been proved to reduce depression and anxiety and enhance quality of life. This meta-analysis evaluated the effectiveness of cognitive behavioral therapy(CBT) on patients with chronic obstructive pulmonary disease(COPD). The following electronic databases were searched from inception to March 2020: PubMed, EMBase, Cochrane Library, Web of Science, Medline, OVID, CINAHL, Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), Wangfang Database (WF), PsycARTICLES, VIP database. The Scopus and Google scholar database that we did not use. Randomized controlled trials (RCTs) that compared CBT with routine methods of care in COPD were retrieved in electronic databases. The Cochrane Risk of Bias Tool and Review Manager version 5.3 were used for risk of bias assessment and meta-analysis, respectively. Both data synthesis and descriptive analysis were used for outcome assessment. A total of 10 RCTs involving 1173 patients were included. Data synthesis showed that CBT was statistically significant in improving short- and medium-term depression and treatment compliance. Mediumterm anxiety and quality of life were improved among COPD patients receiving CBT, although no significant effect was found for short-term quality of life and anxiety. Descriptive analysis showed that CBT could reduce dyspnea. No clear evidence supports the effectiveness on improving self-efficacy in COPD patients with the use of CBT (P > 0.05). CBT can be a useful strategy to improve the symptoms of depression, dyspnea and treatment compliance in patients with COPD. It can also improve patients’ quality of life and anxiety to some extent, but there is still lack of strong evidence in improving patients’ self-efficacy."

Participation in Pulmonary Rehabilitation by Veterans Health Administration and Medicare Beneficiaries After Hospitalization for Chronic Obstructive Pulmonary Disease

BACKGROUND

Hospitalization with acute exacerbation of chronic obstructive pulmonary disease (COPD) is common and costly to the health care system. Pulmonary rehabilitation (PR) can improve symptom burden and morbidity associated with COPD. The use of PR among Medicare beneficiaries is poor, and the use by Veterans Health Administration (VHA) beneficiaries is unknown. We sought to determine whether participation in PR was similarly poor among eligible veterans compared with Medicare beneficiaries.

METHODS

We performed a retrospective study using national VHA and Medicare data to determine the proportion of eligible patients who participated in PR after hospitalization for an acute exacerbation of COPD between January 2007 and December 2011. We also evaluated patient characteristics including demographic factors and comorbid medical history associated with participation.

RESULTS

Over the 5-year study period, 485 (1.5%) of 32 856 VHA and 3199 (2.0%) of 158 137 Medicare beneficiaries hospitalized for COPD attended at least 1 session of PR. Among both VHA and Medicare beneficiaries, participation was higher in those who had had comorbid pneumonia or pulmonary hypertension and was lower in older patients. Although participation increased in both groups over time, it remained exceedingly low overall.

CONCLUSION

Pulmonary rehabilitation is significantly underused in both the VHA and Medicare populations. Although comorbid pulmonary disease is associated with higher use, the proportion of eligible patients who participate remains extremely low.

Pulmonary Rehabilitation Reduces Subjective Fatigue in COPD: A Responder Analysis

To date, it remains unknown which patients report a clinically-relevant improvement in fatigue following pulmonary rehabilitation (PR). The purpose of this study was to identify and characterize these responders. Demographics, lung function, anxiety (anxiety subscale of the 90-item symptom checklist (SCL-90-A)), depression (Beck depression inventory for primary care (BDI-PC)), exercise tolerance (six-minute walking distance test (6MWD)), and health status (Nijmegen clinical screening instrument (NCSI)) were assessed before and after a 12-week PR programme. Fatigue was assessed using the checklist individual strength (CIS)-Fatigue. Patients with a decline ≥ 10 points (minimally clinically important difference, MCID) on the CIS-Fatigue were defined as responders. Chronic obstructive pulmonary disease (COPD) patients (n = 446, 61 ± 9 years, 53% male, forced expiratory volume in 1 s (FEV1) 43% ± 18% predicted, 75% severe fatigue) were included. Mean change in fatigue after PR was 10 ± 12 points (p < 0.01) and exceeded the MCID. In total, 56% were identified as fatigue responders. Baseline CIS-Fatigue (45 ± 7 vs. 38 ± 9 points, respectively, p < 0.001) and health-related quality-of-life (HRQoL; p < 0.001) were different between responders and non-responders. No differences were found in demographics, baseline anxiety, depression, lung function, 6MWD, and dyspnoea (p-values > 0.01). Responders on fatigue reported a greater improvement in anxiety, depression, 6MWD, dyspnoea (all p-values < 0.001), and most health status parameters. PR reduces fatigue in COPD. Responders on fatigue have worse fatigue and HRQoL scores at baseline, and are also likely to be responders on other outcomes of PR.

High Symptom Burden and Low Functional Status in the Setting of Multimorbidity

OBJECTIVES

To enhance understanding of the relationship between multimorbidity, symptom burden, and functional status in individuals with life-limiting illness.

DESIGN

Secondary analysis of baseline data from a randomized clinical trial conducted in the Palliative Care Research Cooperative Group. Group differences were tested using a t-test; multivariate regression analysis was used to determine the effect of multiple variables on functional status and symptom burden.

SETTING

Fifteen Palliative Care Research Cooperation sites.

PARTICIPANTS

Adults who participated in a parent statin-discontinuation clinical trial were included in the analysis (N = 381). Inclusion criteria were diagnosis of a life-limiting illness, statin use for 3 months or longer, life expectancy longer than 1 month, and declining functional status.

MEASUREMENTS

Cancer diagnosis (solid organ and hematologic malignancies), multimorbidity (Charlson Comorbidity Index (CCI) score), symptom burden (Edmonton Symptom Assessment Scale (ESAS) score, number of symptoms with ESAS severity score >4), functional status (Australia-modified Karnofsky Performance Scale (AKPS)).

RESULTS

Fifty-one percent had a primary diagnosis of cancer; mean age 74.1 ± 11.6. Participants had multiple comorbid illnesses (CCI score 4.9 ± 2.8), multiple symptoms (ESAS score 27.2 ± 15.9), and poor functional status (AKPS = 53 ± 13). In univariate and multivariate analyses, multimorbidity was associated with greater symptom burden (4.2 vs 3.1 moderate or severe symptoms (t = -3.2, P = .002), 12% vs 6% with severe symptoms (t = -3.7, P < .001)), but cancer diagnosis was not. In univariate and multivariate analyses, higher symptom burden was associated with poorer functional status (F = 11.6, P < .001), but multimorbidity was not.

CONCLUSION

Symptoms cannot be attributed solely to a diagnosis of cancer. The association between symptom burden and functional status underscores the importance of clinical attention to symptoms in individuals with multimorbidity.

Development of a Conceptual Model of Disease Progression for Use in Economic Modeling of Chronic Obstructive Pulmonary Disease

BACKGROUND

To develop and validate a new conceptual model (CM) of chronic obstructive pulmonary disease (COPD) for use in disease progression and economic modeling. The CM identifies and describes qualitative associations between disease attributes, progression and outcomes.

METHODS

A literature review was performed to identify any published CMs or literature reporting the impact and association of COPD disease attributes with outcomes. After critical analysis of the literature, a Steering Group of experts from the disciplines of health economics, epidemiology and clinical medicine was convened to develop a draft CM, which was refined using a Delphi process. The refined CM was validated by testing for associations between attributes using data from the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE).

RESULTS

Disease progression attributes included in the final CM were history and occurrence of exacerbations, lung function, exercise capacity, signs and symptoms (cough, sputum, dyspnea), cardiovascular disease comorbidities, 'other' comorbidities (including depression), body composition (body mass index), fibrinogen as a biomarker, smoking and demographic characteristics (age, gender). Mortality and health-related quality of life were determined to be the most relevant final outcome measures for this model, intended to be the foundation of an economic model of COPD.

CONCLUSION

The CM is being used as the foundation for developing a new COPD model of disease progression and to provide a framework for the analysis of patient-level data. The CM is available as a reference for the implementation of further disease progression and economic models.

Balance Training in Pulmonary Rehabilitation: EFFECTS ON PSYCHOSOCIAL OUTCOMES

PURPOSE

Balance impairment in chronic obstructive pulmonary disease (COPD) is associated with a worsening of quality of life (QOL) as related with fatigue perception, depression, and anxiety. The aim of this study was to examine the effect of balance training included in pulmonary rehabilitation (PR) on QOL, fatigue perception, depression, and anxiety in patients with COPD.

METHODS

Patients were assigned randomly to an intervention or PR-only group. The intervention group underwent balance training 3 times a week for 6 months concurrently with PR. The PR-only group received 6 months of the standard PR program. Quality of life was assessed at the beginning and at the end of the program using the St. George's Respiratory Questionnaire, fatigue using the Multidimensional Fatigue Inventory, and anxiety and depression using the Hospital Anxiety and Depression Scale. Exercise tolerance was determined from the 6-minute walk test.

RESULTS

After the 6 months of the intervention or PR-only, both the intervention (n = 32) and PR-only (n = 30) groups improved their QOL (activity, impact, and total) with a significant intergroup difference (P < .05) after PR. General fatigue, physical fatigue, and reduced activity decreased in both groups with an intergroup difference (P < .05). Anxiety decreased significantly in both groups with a greater change in the intervention group (P < .01). Only the intervention group had an improved depression score at the end of 6 months.

CONCLUSIONS

Balance training added to PR improved health-related QOL, fatigue, and mental health in patients with COPD.

The Responsiveness of the Anxiety Inventory for Respiratory Disease Scale Following Pulmonary Rehabilitation

BACKGROUND

To date, there are no studies that have examined the responsiveness of the Anxiety Inventory for Respiratory disease (AIR) scale to any intervention in patients with COPD. We examined the responsiveness of the AIR scale in an 8-week pulmonary rehabilitation (PR) program.

METHODS

A total of 192 patients with COPD who were clinically stable and had a percent predicted FEV1 < 70% completed 8-week outpatient multidisciplinary PR. The duration of the program was 2 h per/week (1 h exercise and 1 h education). Pre- and postrehabilitation outcome measures were evaluated: exercise capacity by the incremental shuttle walk test, quality of life by the St Georges Respiratory Questionnaire (SGRQ), and severity of dyspnea by the Medical Research Council (nMRC) scale. Anxiety was measured using the self-administered AIR scale.

RESULTS

The mean (SD) age was 71 (8.4) years and 51% were women. The AIR scale was responsive to PR with (AIR ≥ 8, high anxiety load) a mean change pre- vs post scores (12.25 vs 6.70, t = 7.56, P < .001), in incremental shuttle walk test (183 vs 258, t = 9.49, P < .001), in total SGRQ score (62.54 vs 55.70, t = 4.77, P < .001) and in nMRC score (3.32 vs 3.04, t = 2.57, P = .03) following PR. Change in AIR was significantly correlated with change in total SGRQ (r = 0.16, P = .02) and in nMRC (r = 0.15, P = .03). The effect size for the AIR was 1.01 and minimal clinical important difference was 5.55. Anxiety is a predictor of noncompletion of PR.

CONCLUSIONS

The AIR scale is sensitive to change following PR in patients with COPD and can be used in future studies evaluating interventions that reduce anxiety in this disease.

Strategies to improve anxiety and depression in patients with COPD: a mental health perspective

Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease characterized by progressive and only partially reversible symptoms. Worldwide, the incidence of COPD presents a disturbing continuous increase. Anxiety and depression are remarkably common in COPD patients, but the evidence about optimal approaches for managing psychological comorbidities in COPD remains unclear and largely speculative. Pharmacological treatment based on selective serotonin reuptake inhibitors has almost replaced tricyclic antidepressants. The main psychological intervention is cognitive behavioral therapy. Of particular interest are pulmonary rehabilitation programs, which can reduce anxiety and depressive symptoms in these patients. Although the literature on treating anxiety and depression in patients with COPD is limited, we believe that it points to the implementation of personalized strategies to address their psychopathological comorbidities.

Testing of the Hospital Anxiety and Depression Scale in Patients With Chronic Obstructive Pulmonary Disease

PURPOSE

The aim of this study was to develop the Arabic version of the Hospital Anxiety and Depression Scale (A-HADS) and test its psychometric proprieties for the assessment of anxiety and depression in patients with chronic obstructive pulmonary disease (COPD).

METHOD

The A-HADS and Quality of Life Index Pulmonary version were completed by 67 Jordanian patients with COPD.

RESULTS

Cronbach's alpha coefficient has been found to be 0.75 for the A-HADS anxiety subscale and 0.82 for the A-HADS depression subscale. A-HADS scores correlated significantly with the Quality of Life Index Pulmonary version and demonstrated construct validity.

IMPLICATIONS

This preliminary validation study supports the A-HADS as a reliable and valid instrument for the assessment of anxiety and depression in Arabic speaking patients with COPD.

Is there an association between symptoms of anxiety and depression and quality of life in patients with chronic obstructive pulmonary disease?

BACKGROUND

In addition to symptoms, such as dyspnea and fatigue, patients with chronic obstructive pulmonary disease (COPD) also experience mood disturbances.

OBJECTIVE

To explore the relationships between health-related quality of life measures collected from patients with stable COPD and a commonly used measure of depression and anxiety.

METHODS

The present analysis was a retrospective study of patients with COPD enrolled in a pulmonary rehabilitation program. Hospital Anxiety and Depression Scale (HADS), Chronic Respiratory Disease Questionnaire (CRQ), Medical Research Council dyspnea scale and 6 min walk test data were collected. Statistical analyses were performed using Spearman's correlations, and categorical regression and categorical principal component analysis were interpreted using the biplot methodology.

RESULTS

HADS anxiety scores retrieved from 80 patients were grouped as 'no anxiety' (n=43 [54%]), 'probable anxiety' (n=21 [26%]) and 'presence of anxiety' (n=16 [20%]). HADS depression scores were similarly grouped. There was a moderate relationship between the anxiety subscale of the HADS and both the emotional function (r=-0.519; P<0.01) and mastery (r=-0.553; P<0.01) domains of the CRQ. Categorical regression showed that the CRQ-mastery domain explained 40% of the total variation in anxiety. A principal component analysis biplot showed that the highest distance between the groups was along the mastery domain, which separated patients without feelings of anxiety from those with anxiety. However, none of the CRQ domains were able to discriminate the three depression groups.

CONCLUSIONS

The CRQ-mastery domain may identify symptoms of anxiety in patients with COPD; however, the relationship is not strong enough to use the CRQ-mastery domain as a surrogate measure. None of the CRQ domains were able to discriminate the three depression groups (no depression, probable and presence); therefore, specific, validated tools to identify symptoms of depression should be used.

Anxiety and depression-Important psychological comorbidities of COPD

Anxiety and depression are common and important comorbidities in patients with chronic obstructive pulmonary disease (COPD). The pathophysiology of these psychological comorbidities in COPD is complex and possibly explained by common risk factors, response to symptomatology and biochemical alterations. The presence of anxiety and/or depression in COPD patients is associated with increased mortality, exacerbation rates, length of hospital stay, and decreased quality of life and functional status. There is currently no consensus on the most appropriate approach to screening for anxiety and depression in COPD. Treatment options include psychological [relaxation, cognitive behavioural therapy (CBT), self-management] and pharmacological interventions. Although there is some evidence to support these treatments in COPD, the data are limited and mainly comprised by small studies. Pulmonary rehabilitation improves anxiety and depression, and conversely these conditions impact rehabilitation completion rates. Additional high quality studies are urgently required to optimise screening and effective treatment of anxiety and depression in patients with COPD, to enhance complex chronic disease management for these patients.

Effect of a Pulmonary Rehabilitation Program on the levels of anxiety and depression and on the quality of life of patients with chronic obstructive pulmonary disease

OBJECTIVE

To analyze the effect of a Pulmonary Rehabilitation Program (PRP) on the levels of anxiety and depression and the quality of life of patients with chronic obstructive pulmonary disease.

METHOD

Patients with chronic obstructive pulmonary disease (COPD) who completed the PRP of 3 weekly sessions of 60 min duration for 12 weeks, a total of 36 sessions, were assessed using Beck Inventory (BAI and BDI) and Saint George's Respiratory Questionnaire (SGRQ).

RESULTS

A total of 125 individuals, with an average age of 63.7 ± 8.8 years, FEV1: 1.17 ± 0.57L (43.18 ± 18.79% predicted), 61.6% male and 38.4% female, were analyzed. The BAI and BDI before and after PRP were, respectively, 10.15 ± 6.32 vs. 7.67 ± 7.21; p=0.0041 and 12.60 ± 7.99 vs. 8.96 ± 7.29; p=0.00016. The results of the SGRQ domains were, respectively, Before and After symptoms (48.53 ± 20.41 vs. 32.58 ± 18.95), Activity (69.15 ± 20.79 vs. 52.42 ± 23.70), Impact (32.92 ± 18.29 vs. 20.27 ± 16.70), Total (46.69 ± 16.90 vs. 32.07 ± 16.96). When correlating the BDI to the domains of the SGRQ, weak correlations were observed (Symptoms r=0.22; p=0.01; Activity r=0.28; p=0.001; Impact r=0.52; p=2.72; Total r=0.44; p=0.17). In the same way, weak correlations were observed when correlating the BAI to the SGRQ (Symptoms r=0.28; p=0.0009; Activity r=0.32; p=0.0005; Impact r=0.42; p=7.33; Total r=0.43; p=0.74).

CONCLUSION

Although the PRP improves levels of depression and anxiety as well as the quality of life in patients with COPD, no significant correlation of these analyzed variables was observed.

Defining COPD-Related Comorbidities, 2004-2014

Chronic obstructive pulmonary disease (COPD) is a disease of aging in combination with genetic, environmental, and behavioral risk factors. Aging and many of these risk factors are shared with other diseases, and, as a result, it is not surprising that patients with COPD often have coexistent diseases. This review of COPD comorbidities uses a framework in which coexistent diseases are considered important comorbidities if they are more frequent, have more severe consequences, influence the progression and outcomes of COPD, or are clustered together into proposed phenotypes, supplemented by a framework in which certain comorbidities are expected to share specific pathogenic mechanisms. This review explores classic COPD comorbidities such as cardiovascular disease, cachexia and sleep apnea, but also looks at more recently described comorbidities, such as gastroesophageal reflux, osteoporosis and depression/anxiety.

Psychometric properties of the Hospital Anxiety and Depression Scale and The General Health Questionnaire-20 in COPD inpatients

AIM

To compare the psychometric properties between the Hospital Anxiety and Depression Scale (HADS) and General Health Questionnaire-version 20 (GHQ-20) in detecting psychological distress in COPD patients referred to pulmonary rehabilitation, and to examine the factor structure of GHQ-20.

METHODS

The study comprised 161 consecutive patients with mild to very severe COPD. For comparison of mean scores between the HADS and GHQ-20, one sample t-test was used. Potential differences in the detection of possible and normal cases were analysed using Pearson Chi square test. We report Pearson's correlations within and between the questionnaires, and internal consistency was assessed through Chronbach's alpha. The factor structure of the GHQ-20 was examined through principal axis factoring (PAF) with oblique rotation and eigenvalue >1.

RESULTS

There were no differences in mean scores of psychological distress between HADS and GHQ-20 (12.03 vs. 24.73, p = 0.000), as well as no differences in the prevalence of possible cases of psychological distress (34.6 vs. 36.9, p = 0.000) and normal cases (65.4 vs. 63.1, p = 0.000). The observed difference between HADS and GHQ-20 regarding internal consistency was marginal, with Chronbach's alpha coefficients of 0.91 and 0.94, respectively. The PAF analysis resulted in a three-factor solution for GHQ-20, notably with only two items loading on the third factor, giving an internal consistency <0.70. A two-factor solution, comprising anxiety/depression and coping, may therefore be more appropriate.

CONCLUSIONS

This study demonstrates no significant differences between the HADS and GHQ-20 in their ability to detect possible cases of psychological distress in a rehabilitation setting for COPD patients. Although the HADS and GHQ-20 are measuring different concepts of psychological distress, both questionnaires can be recommended as screening tools for detection of psychological distress in COPD inpatients. The GHQ-20 appears to be two-dimensional, comprising anxiety/depression as one dimension, and coping as the other dimension.

Shape shifters: biobehavioral determinants and phenomena in symptom research

Symptom assessment and management are critical to patient-centered care. Traditionally, the determinants of a symptom are viewed as separate from the phenomena associated with that symptom. By separating determinants and phenomena, however, the complexity and dynamism of the patient experience are ignored. Likewise, categorizing symptom determinants and phenomena as solely biological or behavioral minimizes their dimensionality and may hinder interdisciplinary dialogue. Here we propose that determinants and phenomena are not fixed but shift between each other depending on perspective. To illustrate this way of thinking the metaphor of the "shape shifter" from folklore is used. A shape shifter moves between states and may be seen differently by the same person at different times or by multiple individuals at one time. To guide discussion, we present 5 exemplars of increasing complexity, wherein a determinant becomes a phenomenon or vice versa, depending upon context. Suggestions for statistical testing of the model are included with each. We conclude by exploring how shifting between determinants and phenomena may affect symptom cluster assessment and management.

Sleep quality as a potential mediator between psychological distress and diabetes quality of life in veterans with type 2 diabetes

OBJECTIVE

The goal of this study was to explore sleep quality as a potential mediator between depression symptoms and diabetes quality of life (DQOL), and anxiety symptoms and DQOL.

METHOD

Participants were 83 male and 3 female veterans with type 2 diabetes (Mage = 62.4). Self-report measures were completed during the baseline assessment of a larger intervention study conducted at the VA Boston Healthcare System.

RESULTS

Depression symptoms, anxiety symptoms, and sleep quality were all associated with DQOL. Additionally, sleep quality had a partial indirect effect on the relationships between depression symptoms and DQOL, and between anxiety symptoms and DQOL.

CONCLUSIONS

These findings suggest that sleep quality may have an important role in the way that psychological distress affects diabetes quality of life.

Palliative care concepts in respiratory disease

Many respiratory diseases besides lung cancer are still not curable. There is an unmet need for palliative care, especially in non-malignant conditions. In this article we focus on symptomatic treatment of typical symptoms in respiratory disease beyond causal treatment.