Panic attacks and panic disorder in chronic obstructive pulmonary disease: a cognitive behavioral perspective

Obstructive respiratory disease in U.S. veterans: Prevalence, characteristics, and health burden

OBJECTIVE

To examine the psychiatric and physical health burden of obstructive respiratory disease in a nationally representative sample of U.S. Veterans.

METHODS

Secondary data analyses were conducted using data from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of U.S. Veterans. Participants self-reported health professional-diagnosed obstructive respiratory disease (i.e., asthma, chronic bronchitis or chronic obstructive pulmonary disease). Veterans who reported obstructive respiratory disease (n = 502) were compared to veterans without this disease but with at least one or more other medical conditions-controls (n = 3169) on measures of sociodemographic, trauma, psychiatric, and physical health characteristics. Multivariable regression analyses examined independent associations between obstructive respiratory disease and psychiatric conditions and physical characteristics.

RESULTS

A total 12.5% of the sample reported a diagnosis of obstructive respiratory disease. Compared to controls, veterans with obstructive respiratory disease were more likely to be female, unmarried/partnered, lower income, residing in the Midwest, receiving VA healthcare, and had greater lifetime and childhood trauma burden. In adjusted analyses, veterans with respiratory disease had 47-91% greater odds of screening positive for current posttraumatic stress, major depressive, and generalized anxiety disorders, and had 48% greater odds of current suicide ideation. They were also more likely to have lifetime nicotine use disorder and had more medical comorbidities and more severe somatic symptoms.

CONCLUSIONS

Obstructive respiratory disease is prevalent among U.S. veterans and associated with significant mental and physical health burden. Results highlight the need for timely screening and treatment for psychiatric and medical conditions that are highly comorbid with obstructive respiratory disease in this population.

Emotional Distress and Physical Activity Engagement in U.S. Veterans With Chronic Obstructive Pulmonary Disease: A Qualitative Study

BACKGROUND

Physical activity is recommended as part of guideline-based care for managing chronic obstructive pulmonary disease (COPD) at all stages of the disease. However, physical activity interventions are less effective in individuals with co-occurring emotional distress (i.e., depression and/or anxiety symptoms). Interventions that dually promote improved physical and mental health in COPD are needed. The first step for intervention development is understanding individuals' experience of these factors.

PURPOSE

To understand the experience of emotional distress in U.S. Veterans diagnosed with COPD and to explore how emotional distress impacts physical activity engagement.

METHODS

Structured interviews informed by the cognitive and behavioral models of psychopathology were conducted with 29 United States Veterans with COPD (89.66% male, age 67.72 ± 6.55 years, 93.10% White) at the VA Boston Healthcare System. Interviews were audio recorded, transcribed, and underwent thematic analysis.

RESULTS

Three major themes encapsulating 17 codes emerged through thematic analysis: (i) the experience of emotional distress in Veterans with COPD; (ii) the complex relationship between emotional distress, physical activity engagement, and COPD; (iii) contextual and personal factors.

CONCLUSIONS

Veterans' interpretation of their COPD symptoms as unpredictable and uncontrollable and COPD-related physical limitations influenced their experience of emotional distress, while the experience of emotional distress both promoted and deterred physical activity engagement. Veterans were motivated to engage in physical activity despite experiencing emotional distress when they faced a responsibility in daily life. They identified motivational strategies and self-regulation techniques to manage emotional distress and to foster physical activity.

Evaluation of effect of brief-intensive cognitive behavior therapy on symptoms severity in relation with catastrophic cognition in patients with panic disorder: a randomized controlled trial

INTRODUCTION

Due to a dearth of evidence, we examined the effectiveness of brief-intensive CBT on symptom severity and catastrophic cognition in patients with panic disorder (PD).

MATERIALS AND METHODS

In this randomized controlled trial, 155 patients were assigned to either the experimental group (2 successive days of brief-intensive CBT-3 h per day) or the control group (regular pharmacotherapy only). After excluding ineligible participants, 20 patients in the brief intensive CBT group and 18 patients in the control group completed the study and were included in the final analysis. The primary outcome was symptom severity, and the secondary outcome was catastrophic cognition, assessed by the Panic Disorder Severity Scale (PDSS) for symptoms severity and the Agoraphobic Cognition Scale (ACS) for cognitive assessment, respectively.

RESULTS

The study showed that after one month of treatment, the PDSS (1.70 vs. 4.78; p = 0.0172) in the brief-intensive CBT group was significantly lower compared to the control group in contrast with the ACS (5.10 vs. 5.44; p = 0.8533). The mean score of PDSS and ACS significantly decreased from 21.60 to 1.7 (p < 0.0001) and from 22.55 to 5.10 (p < 0.0001) in the brief CBT group and from 19.44 to 4.78 (p < 0.0001) and 20.00 to 5.44 (p < 0.0001) in the control group, respectively. After treatment, the mean scores of PDSS and ACS significantly decreased in the brief intensive CBT and control groups. Both higher ACS and lower education levels contributed to higher PDSS in the brief intensive CBT group. However, only the PDSS correlated to the ACS in the control group.

CONCLUSIONS

The study showed that brief-intensive CBT is an effective technique for reducing the severity of symptoms among PD patients. But, it was not effective to improve the cognitive level in PD patients at one month.

Prevalence and Predictive Factors of Panic Disorder among Adults in Saudi Arabia: A Cross-Sectional Study

Panic disorder (PD) is a severe anxiety disorder characterized by recurrent and unexpected panic attacks that cause intense distress. Despite the high prevalence of panic disorder and its significant impact on life, limited research has been conducted on its prevalence and their associated factors in Saudi Arabia. This study seeks to contribute to the understanding of PD among adults in Saudi Arabia by examining its prevalence and associated factors, using an online survey method. A validated questionnaire-based cross-sectional study was conducted targeting 1276 Saudi adults. Data were collected electronically via Google Forms from the eligible participants. The questionnaire comprised three sections: sociodemographic information, medical history, and a validated diagnostic tool for PD. The prevalence of PD among Saudi adults was 13.1%. Most individuals with PD experienced their first panic attack before the age of 18. Only 38.3% individuals with PD sought medical attention, and approximately one-third of those who sought help did not receive a diagnosis. Multiple logistic regression analysis revealed that significant risk factors for PD included being female; having chronic health problems, a comorbid psychiatric disorder, a high body mass index; and experiencing suicidal ideation (P < 0.05). The highest risk was associated with chronic diseases (adjusted odds ratio = 3.1, 95% confidence interval: 2.1-4.6). This study demonstrates that PD is a prevalent and debilitating mental health condition among Saudi Arabian adults. Non-mental health physicians should be aware of PD, as many cases remain undiagnosed.

Effects of emotional contexts on respiratory attention task performance

Negative emotions have been found associated with high prevalence of respiratory disease and increased subjective feelings of dyspnea, while positive emotional stimulus has been suggested to alleviate dyspneic feelings. However, the extent to which different emotional contexts affect individuals' respiratory interoceptive attention was not clear. Therefore, the purpose of this study was to investigate the influences of emotional contexts on respiratory interoceptive accuracy, and the relationships between respiratory interoceptive accuracy and negative emotions as well as respiratory symptoms. Fifty-six healthy participants completed the self-reported questionnaires of depression, anxiety, and respiratory symptoms. During the experiment, the participants were instructed to watch one neutral and one positive affective picture series and mentally count the number of perceived occlusions (reported at the end of the trials). The Wilcoxon Signed-Rank test and Spearman's correlations were used to examine the effect of the emotional pictures and to explore the relationships between the level of emotional status or respiratory symptoms and respiratory interoceptive task performance. The significance level was set at p < 0.05. Our results did not show a significant difference in participants' occlusion counting task performance between the neutral and positive emotional context. However, Spearman's Rho correlation analysis revealed that depression level was negatively correlated with accuracy of the task performance in the neutral emotional context, and this relationship diminished in the positive emotional context. In summary, our study demonstrated that negative emotional status, especially depression, may lead to decreased respiratory interoceptive accuracy. Future studies are recommended to test the effect of positive emotional context on respiratory interoceptive task performance in individuals with clinical depression and anxiety.

Respiratory psychophysiology and COVID-19: A research agenda

After multiple waves of the COVID-19 pandemic, it has become clear that the impact of SARS-CoV-2 will carry on for years to come. Acutely infected patients show a broad range of disease severity, depending on virus variant, vaccination status, age and the presence of underlying medical and physical conditions, including obesity. Additionally, a large number of patients who have been infected with the virus present with post-COVID syndrome. In September 2020, the International Society for the Advancement of Respiratory Psychophysiology organized a virtual interest meeting on 'Respiratory research in the age of COVID-19', which aimed to discuss how research in respiratory psychophysiology could contribute to a better understanding of psychophysiological interactions in COVID-19. In the resulting current paper, we propose an interdisciplinary research agenda discussing selected research questions on acute and long-term neurobiological, physiological and psychological outcomes and mechanisms related to respiration and the airways in COVID-19, as well as research questions on comorbidity and potential treatment options, such as physical rehabilitation.

Depressive and anxiety symptoms in patients with COPD: A network analysis

BACKGROUND

Individuals with Chronic Obstructive Pulmonary Disease (COPD) often develop anxiety and depression, which worsen illness management and prognosis. Physical and psychological symptoms, contextual and illness-related factors display complex reciprocal interactions, which give rise to heterogeneous presentations. Examining the patterns of association between specific physical and psychological symptoms in patients with COPD may help to focus on the precision of the patient-centred care.

RESEARCH QUESTION

We used network analyses to examine the links between symptoms of COPD, depression and anxiety.

METHODS

Data from 1587 individuals with COPD from the COPDGene study were included. We estimated a Bayesian Gaussian Graphical Model to highlight the unique associations between symptoms of COPD (assessed with the COPD Assessment Test), depression and anxiety (assessed with the Hospital Anxiety and Depression Scale (HADS), while examining the role of sociodemographic characteristics, lung function tests, and health status.

RESULTS

Unique Variable Analysis reduced 14 HADS items to Tension/worry (chronic anxiety), Fear/panic (acute anxiety), Restlessness, Anhedonia, Sadness and Slowing. In network analyses, chest-tightness was related to acute anxiety, while cough and weakness were connected with core depressive symptoms (sadness and lack of pleasure). Chronic anxiety was linked with acute anxiety and depressive symptoms. Findings were confirmed accounting for the role of confounders, including lung function, sex, ethnicity and lifestyle factors. A simulation based on our model yielded distinct predictions about anxiety and depression in two participants with similar COPD severity, but different symptom profiles.

CONCLUSION

Network analyses highlighted specific associations between symptoms of COPD, depression and anxiety. Accounting for symptom-level interactions may help to promote personalized treatment approaches.

Relationship between clinical anxiety and patient outcomes in patients with chronic obstructive lung disease exacerbation in the emergency department

Purpose

Anxiety is a comorbidity that is not routinely addressed in patients with chronic obstructive lung disease (COPD) exacerbation in the emergency department (ED). Anxiety in patients with COPD exacerbation can be related with negative outcomes. The Generalized Anxiety Disorder 7 (GAD-7) score is an easy-to-use tool to determine anxiety. This study aimed to investigate the relationship between GAD‑7 score and patient outcomes in patients with COPD exacerbation in the ED.

Methods

A prospective, cross-sectional study was conducted in a tertiary academic ED between July 2019 and January 2021. Patients admitted to the ED with COPD exacerbation were included. A GAD‑7 score of ≥ 10 was defined as clinically significant anxiety. Negative outcomes were defined as a composite outcome that included recurrent ED visits, intensive care unit admission, and mortality. The relationship between clinically significant anxiety and negative outcomes within 30 days was determined.

Results

A total of 92 patients were assessed for eligibility and 80 were included in the study. Thirty-seven patients (46.3%) experienced negative outcomes. Although no significant difference was detected in median GAD‑7 scores between patients with positive and negative outcomes, negative outcomes were significantly higher in patients who had a GAD‑7 score of ≥ 10 (n = 25, p = 0.03). A sensitivity of 43.2%, specificity of 79.1%, positive likelihood ratio of 2.1 and negative likelihood ratio of 0.7 were determined for GAD‑7 score in predicting negative outcome.

Conclusion

In patients with COPD exacerbation in the ED, a GAD‑7 score of ≥ 10 was associated with 30-day negative outcomes.

Pain, functional disability and mental disorders as potential mediators of the association between chronic physical conditions and suicidal ideation in community living older adults

OBJECTIVES

To examine the associations between chronic physical conditions and suicidal ideation and to assess whether associations are mediated by pain, anxiety, depression, post-traumatic stress syndrome (PTSS), and functional disability.

METHODS

The study sample includes 1533 older adults aged 65+ recruited in primary care clinics between 2011-2013 and participating in Quebec's Health Survey on Services "Étude sur la Santé des Aînés-Services" (ESA-S) study. Path analysis was used to assess the associations. The presence of suicidal behaviour was ascertained using 4 questions. PTSS was based on a validated scale for primary care older adults. Anxiety and depression were assessed according to DSM-IV criteria. Pain was self-reported on an ordinal scale and functional disability was based on the presence of disability in 8 dimensions of activities of daily living. The main predictors included a list of 13 physical disorders identified by diagnostic codes. Suicidal ideation was also controlled by a number of socio-demographic and psychosocial factors.

RESULTS

PTSS, depression, and functional disability mediate the association between various chronic conditions and suicidal ideation. Although pain and anxiety are associated with many physical disorders, they did not mediate the association with suicidal ideation.

CONCLUSIONS

Chronic physical disorders are associated with suicidal ideation, either directly or indirectly through PTSS, depression, and functional disability. The findings underscore the importance of early identification and management of older patients with specific chronic disorders in primary care as they may be most at risk for suicidal ideation.

Panic disorder in general medical practice- A narrative review

The under-or misdiagnosis, and symptomatic treatment of the panic disorder (PD), despite high prevalent medical illness, is common among non-psychiatric physicians. The non-psychiatrist physician’s role is vital in the care of PD as most patients initially approach general medical settings for medical help, including primary care. However, a significant proportion is undiagnosed and undergoes either unnecessary investigation, misdiagnosed, or mismanaged even among post-Coronary Artery Bypass Grafting patients, which profoundly affects the patients functioning and quality of life. This article aims to provide overviews of relevant epidemiological aspects, presenting features across medical specialties with respective diagnostic dilemmas, assessment, and management of the PD in their general medical settings, including emergency visits. Apart from psychiatrists, this will also assist non-psychiatrist physicians across all medical specialties, including general practitioners, to understand, identify, and provide the first line evidence-based pharmacotherapy and address the unmet need of patients with PD in their day-to-day busy clinical practice. This paper also provides a referral guide for non-psychiatrist physicians to refer to psychiatrists for further management after their first-line management.

Integration of mental health comorbidity in medical specialty programs in 20 countries

METHODS

A systematic analysis was performed of the medical specialization academic programs of 20 different countries to establish which medical specialties take into account mental health issues in the specialty curricular design and which mental health content these programs address. The criteria that were explored in the educational programs include: 1) name of the medical specialties that take into account mental health content in curriculum design, 2) name of the mental health issues addressed by these programs. After independent review and data extraction, paired investigators compared the findings and reached consensus on all discrepancies before the final presentation of the data. Descriptive statistics evaluated the frequency of the data presented.

RESULTS

Internal medicine, family medicine, neurology, pediatrics and geriatrics were the specialties that included mental health topics in their programs. In four countries: Bangladesh, Serbia, the Netherlands and France, 50%of all graduate specialty training programs include mental health content. In ten countries: Germany, Sweden, the United Kingdom, Mexico, Belgium, India, Russia, Canada, Israel and Spain, between 20% and 49% of all graduate specialty training programs include mental health content. In six countries - Brazil, Chile, Colombia, Croatia, Kenya, and the United States-less than 20% of all graduate specialty training programs include mental health content.

DISCUSSION

The proposal that we have made in this article should be taken into account by decision-makers, in order to complement the different postgraduate training programs with mental health issues that are frequently present with other physical symptoms. It is not our intention that the different specialists know how to treat psychiatric comorbidities, but rather pay attention to their existence and implications in the diagnosis, evolution and prognosis of many other diseases. The current fragmentation of medicine into ever finer specialties makes the management of comorbidity ever more difficult: a reorientation of post- graduate training might improve the situation.

Associations of Social Isolation with Anxiety and Depression During the Early COVID-19 Pandemic: A Survey of Older Adults in London, UK

The COVID-19 pandemic is imposing a profound negative impact on the health and wellbeing of societies and individuals, worldwide. One concern is the effect of social isolation as a result of social distancing on the mental health of vulnerable populations, including older people. Within six weeks of lockdown, we initiated the CHARIOT COVID-19 Rapid Response Study, a bespoke survey of cognitively healthy older people living in London, to investigate the impact of COVID-19 and associated social isolation on mental and physical wellbeing. The sample was drawn from CHARIOT, a register of people over 50 who have consented to be contacted for aging related research. A total of 7,127 men and women (mean age=70.7 [SD=7.4]) participated in the baseline survey, May-July 2020. Participants were asked about changes to the 14 components of the Hospital Anxiety Depression scale (HADS) after lockdown was introduced in the UK, on 23rd March. A total of 12.8% of participants reported feeling worse on the depression components of HADS (7.8% men and 17.3% women) and 12.3% reported feeling worse on the anxiety components (7.8% men and 16.5% women). Fewer participants reported feeling improved (1.5% for depression and 4.9% for anxiety). Women, younger participants, those single/widowed/divorced, reporting poor sleep, feelings of loneliness and who reported living alone were more likely to indicate feeling worse on both the depression and/or anxiety components of the HADS. There was a significant negative association between subjective loneliness and worsened components of both depression (OR 17.24, 95% CI 13.20, 22.50) and anxiety (OR 10.85, 95% CI 8.39, 14.03). Results may inform targeted interventions and help guide policy recommendations in reducing the effects of social isolation related to the pandemic, and beyond, on the mental health of older people.

Impact of a Mobile Health Intervention on Long-term Nonadherence After Lung Transplantation: Follow-up After a Randomized Controlled Trial

BACKGROUND

In a randomized controlled trial, lung transplant recipients (LTRs) using a mobile health intervention, Pocket Personal Assistant for Tracking Health (Pocket PATH), showed better adherence to the medical regimen than LTRs receiving usual care during the first year posttransplant. We examined whether these effects were maintained beyond the end of the trial and evaluated other potential risk factors for long-term nonadherence.

METHODS

Adherence in 8 areas was evaluated at follow-up in separate LTR and family caregiver (collateral) assessments. Pocket PATH and usual care groups' nonadherence rates were compared; multivariable regression analyses then examined and controlled for other patient characteristics' associations with nonadherence.

RESULTS

One hundred five LTRs (75% of survivors) were assessed (M = 3.9 years posttransplant, SD = 0.8). Nonadherence rates in the past month were 23%-81% for self-care and lifestyle requirements (diet, exercise, blood pressure monitoring, spirometry), 13%-23% for immunosuppressants and other medications, and 4% for tobacco use, with 31% clinic appointment nonadherence in the past year. In multivariable analysis, the Pocket PATH group showed lower risk of nonadherence to lifestyle requirements (diet/exercise) than the usual care group (P < 0.05). Younger age and factors during the first year posttransplant (acute graft rejection, chronically elevated anxiety, less time rehospitalized, nonadherence at the final randomized controlled trial assessment) were each associated with nonadherence in at least 1 area at follow-up (P < 0.05).

CONCLUSIONS

Pocket PATH did not have sustained impact on most areas of the regimen, although we identified other risk factors for long-term nonadherence. Future work should explore strategies to facilitate sustained effects of mobile health interventions.

Recurrent episodes of hypercapnic respiratory failure triggered by panic attacks in a patient with chronic obstructive pulmonary disease

A 67-year old female with moderate chronic obstructive pulmonary disease (COPD) and generalized anxiety disorder presents with three episodes of severe hypercapnic respiratory failure over the previous three months without a clear precipitant that were treated with invasive and non-invasive ventilation. These episodes were labelled as acute exacerbations of COPD, however she lacked any typical features or triggers and responded faster than expected to treatment and she underwent extensive investigations to identify an alternative etiology. While admitted and under observation, she became extremely anxious, began to hyperventilate and went into hypercapnic respiratory failure, which was successfully aborted with sublingual lorazepam causing resolution of tachypnea. It became clear that the patient was suffering from panic attacks as the precipitant for her respiratory failure and she was successfully treated with psychiatric medication and breakthrough anxiolytics. Anxiety and panic disorders are more prevalent in patients with COPD than the general population and effective management is important as patient's with anxiety and COPD have worse clinical outcomes than with COPD alone. Additionally, panic attacks should be considered as an etiology for hypercapnic respiratory failure in patients with COPD and anxiety when the clinical presentation is atypical.

The effect of anxiety on brain activation patterns in response to inspiratory occlusions: an fMRI study

Respiratory sensations such as breathlessness are prevalent in many diseases and are amplified by increased levels of anxiety. Cortical activation in response to inspiratory occlusions in high- and low-anxious individuals was found different in previous studies using the respiratory-related evoked potential method. However, specific brain areas showed different activation patterns remained unknown in these studies. Therefore, the purpose of this study was to compare cortical and subcortical neural substrates of respiratory sensation in response to inspiratory mechanical occlusion stimuli between high- and low-anxious individuals using functional magnetic resonance imaging (fMRI). In addition, associations between brain activation patterns and levels of anxiety, and breathlessness were examined. Thirty-four (17 high- and 17 low-anxious) healthy non-smoking adults with normal lung function completed questionnaires on anxiety (State Trait Anxiety Inventory - State), and participated in a transient inspiratory occlusion fMRI experiment. The participants breathed with a customized face-mask while respiration was repeatedly interrupted by a transient inspiratory occlusion of 150-msec, delivered every 2 to 4 breaths. Breathlessness was assessed by self-report. At least 32 occluded breaths were collected for data analysis. The results showed that compared to the low-anxious group, the high-anxious individuals demonstrated significantly greater neural activations in the hippocampus, insula, and middle cingulate gyrus in response to inspiratory occlusions. Moreover, a significant relationship was found between anxiety levels and activations of the right inferior parietal gyrus, and the right precuneus. Additionally, breathlessness levels were significantly associated with activations of the bilateral thalamus, bilateral insula and bilateral cingulate gyrus. The above evidences support stronger recruitment of emotion-related cortical and subcortical brain areas in higher anxious individuals, and thus these areas play an important role in respiratory mechanosensation mediated by anxiety.

Modern Innovative Solutions in Improving Outcomes in Chronic Obstructive Pulmonary Disease (MISSION COPD): Mixed Methods Evaluation of a Novel Integrated Care Clinic

Background

Chronic obstructive pulmonary disease (COPD) is the second-leading cause of death in the United Kingdom and accounts for 1.7% of bed days in acute hospitals. An estimated two-third of patients with COPD remain undiagnosed.

Objective

Modern Innovative Solutions in Improving Outcomes in Chronic Obstructive Pulmonary Disease (MISSION COPD) aimed to proactively identify patients from primary care who were undiagnosed or had uncontrolled COPD and to provide a comprehensive integrated multidisciplinary clinic to address the needs of this complex group for improving diagnosis, personalizing therapy, and empowering patients to self-manage their condition.

Methods

This clinic was led by a respiratory specialist team from Portsmouth Hospitals NHS Trust working with five primary care surgeries in Wessex. A total of 108 patients were reviewed, with 98 patients consenting to provide additional data for research. Diagnoses were changed in 14 patients, and 32 new diagnoses were made.

Results

Reductions were seen across all aspects of unscheduled care as compared to the prior 12 months, including in emergency general practitioner visits (3.37-0.79 visits per patient, P<.001), exacerbations (2.64-0.56 per patient, P=.01), out-of-hours calls (0.16-0.05 per patient, P=.42), and hospital admissions (0.49-0.12 per patient, P=.48). Improvements were observed in the quality of life and symptom scores in addition to patient activation and patient-reported confidence levels.

Conclusions

This pilot demonstrates that the MISSION model may be an effective way to provide comprehensive gold-standard care that is valued by patients and to promote integration across sectors.

The role of cognitive behavioural therapy in living well with COPD

Psychological ill health is very common in COPD; CBT may be a key step towards improving the care of COPD patients http://ow.ly/fb8j30onfPj.

A Virtual Agent to Support Individuals Living With Physical and Mental Comorbidities: Co-Design and Acceptability Testing

Background

Individuals living with long-term physical health conditions frequently experience co-occurring mental health problems. This comorbidity has a significant impact on an individual’s levels of emotional distress, health outcomes, and associated health care utilization. As health care services struggle to meet demand and care increasingly moves to the community, digital tools are being promoted to support patients to self-manage their health. One such technology is the autonomous virtual agent (chatbot, conversational agent), which uses artificial intelligence (AI) to process the user’s written or spoken natural language and then to select or construct the corresponding appropriate responses.

Objective

This study aimed to co-design the content, functionality, and interface modalities of an autonomous virtual agent to support self-management for patients with an exemplar long-term condition (LTC; chronic pulmonary obstructive disease [COPD]) and then to assess the acceptability and system content.

Methods

We conducted 2 co-design workshops and a proof-of-concept implementation of an autonomous virtual agent with natural language processing capabilities. This implementation formed the basis for video-based scenario testing of acceptability with adults with a diagnosis of COPD and health professionals involved in their care.

Results

Adults (n=6) with a diagnosis of COPD and health professionals (n=5) specified 4 priority self-management scenarios for which they would like to receive support: at the time of diagnosis (information provision), during acute exacerbations (crisis support), during periods of low mood (emotional support), and for general self-management (motivation). From the scenario testing, 12 additional adults with COPD felt the system to be both acceptable and engaging, particularly with regard to internet-of-things capabilities. They felt the system would be particularly useful for individuals living alone.

Conclusions

Patients did not explicitly separate mental and physical health needs, although the content they developed for the virtual agent had a clear psychological approach. Supported self-management delivered via an autonomous virtual agent was acceptable to the participants. A co-design process has allowed the research team to identify key design principles, content, and functionality to underpin an autonomous agent for delivering self-management support to older adults living with COPD and potentially other LTCs.

Toward a personalized therapy for panic disorder: preliminary considerations from a work in progress

Although several treatment options for panic disorder (PD) are available, the best intervention for each individual patient remains uncertain and the use of a more personalized therapeutic approach in PD is required. In clinical practice, clinicians combine general scientific information and personal experience in the decision-making process to choose a tailored treatment for each patient. In this sense, clinicians already use a somehow personalized medicine strategy. However, the influence of their interpretative personal models may lead to bias related to personal convictions, not sufficiently grounded on scientific evidence. Hence, an effort to give some advice based on the science of personalized medicine could have positive effects on clinicians' decisions. Based on a narrative review of meta-analyses, systematic reviews, and experimental studies, we proposed a first-step attempt of evidence-based personalized therapy for PD. We focused on some phenomenological profiles, encompassing symptoms during/outside panic attacks, related patterns of physiological functions, and some aspects of physical health, which might be worth considering when developing treatment plans for patients with PD. We considered respiratory, cardiac, vestibular, and derealization/depersonalization profiles, with related implications for treatment. Given the extensiveness of the topic, we considered only medications and some somatic interventions. Our proposal should be considered neither exhaustive nor conclusive, as it is meant as a very preliminary step toward a future, robust evidence-based personalized therapy for PD. Clearly much more work is needed to achieve this goal, and recent technological advances, such as wearable devices, big data platforms, and the application of machine learning techniques, may help obtain reliable findings. We believe that combining the efforts of different research groups in this work in progress can lead to largely shared conclusions in the near future.

Epidemiology of panic attacks, panic disorder and the moderating role of age: Results from a population-based study

BACKGROUND

The aim of this study was to investigate the prevalence of panic attacks (PA) and panic disorder (PD) over the lifespan, determine the main correlates and analyze the potential moderating role of age.

METHOD

We analyzed cross-sectional data from a nationally-representative sample of 4,569 non-institutionalized adults. Three panic groups were created according to results in the CIDI interview: non-panic, PA (without PD) and PD. Panic groups were used as outcomes in adjusted multinomial regression models where several correlates were investigated. Interactions between each covariate and age were explored.

RESULTS

The highest prevalence rates of PA (9.5%) and PD (3.3%) were found in people aged 30-39 and 40-49, respectively. Respondents aged 80 + presented the lowest rates. In the adjusted multinomial model, younger ages, having depression, and poorer levels of quality of life were significant correlates for both PA and PD, whereas being female and having 2 or more chronic conditions were only significant for PA (not for PD) and being a frequent drinker (last 12-months) only for PD. Age significantly interacted with frequent alcohol consumption in the last 12-months for PD. The predicted probability of having PD decreased with age for life-abstainer or occasional drinkers, whereas the probability increased with older ages for frequent drinkers.

LIMITATIONS

Low prevalence of PA and PD resulted in large confidence intervals whereas self-reports could be affected by recall bias.

CONCLUSIONS

Overall, our results suggest that the probability of having PA and PD decreases as people age and that the significant risk factors are independent of age. However, older adults with a frequent drink pattern seem to be at higher risk of PD. Future longitudinal studies are needed to determine the trajectories of PD and alcohol consumption over the lifespan.

Is the high intensity symptoms experienced by patients admitted with chronic obstructive pulmonary disease documented by health professionals? - a prospective survey with comparison of patient reported outcomes and medical records

Context: Patients with chronic obstructive pulmonary disease (COPD) have a high symptom burden and reduced quality of life. There is an increasing attention on palliation for patients with COPD. Recognition of symptoms is a prerequisite for palliation. Objectives: We aim to investigate the extent to which symptoms in patients with COPD are recognized in the documentation of the health professionals, indicated in 'Doctors Symptom Recognition Rate' (DSR), 'Nurses Symptom Recognition Rate' (NSR) or 'Doctors and/or Nurses Symptom Recognition rates '(DNSR) as a team, respectively. Methods: Patients with COPD (n = 40) admitted in two respiratory units, responded within 48 h on two symptom-screening-tools that access quality of life; COPD assessment test (CAT) used for the treatment of COPD and EORTC-QLQ-C15-PAL used for palliation in patients with cancer. Patient-described symptomatology was compared to the symptoms as recognized in the documentation of doctors and/or nurses. Results: There was a significant discrepancy between the symptomatology indicated by patients with COPD on CAT and EORTC-QLQ-C15-PAL, and the degree by which it was recognized in the medical records indicated in DSR or NSR. In 30 out of 44 items DSR or NSR were < 70%. There was a significant difference between DNSR versus DSR or NSR, respectively, in 19 out of 22 items.Conclusion: A team-based symptom recognition DNSR is superior when compared to DSR or NSR. Team-based systematic screening is suggested as a pathway to increase symptom recognition in patients with COPD. Increased rates of symptom recognition may improve symptom alleviation and thus palliation.

A randomized placebo-controlled trial of paroxetine for the management of anxiety in chronic obstructive pulmonary disease (PAC Study)

BACKGROUND

Despite the high prevalence of anxiety in COPD patients and its impact on quality of life, evidence to support the effectiveness of various anxiety treatment options is insufficient, leading to the need for further research in this field.

AIM

The aim of this study was to assess the efficacy and safety of paroxetine for the management of anxiety in COPD and the impact of treatment on patients' quality of life and rate of hospitalization.

PATIENTS AND METHODS

In a double-blind, randomized, controlled trial, COPD patients were allocated into groups that either received paroxetine 20 mg or placebo pills daily, for four months. Differences in outcomes were assessed based on an intention-to-treat analysis using linear mixed effects models. A chi-square test was used to compare the number of COPD-related admissions.

RESULTS

Thirty-eight participants were recruited. Twenty-two of these completed the trial. A clinically and statistically significant reduction was noted in anxiety symptoms after four months of treatment compared to the placebo. Clinically important improvement was noted in depression symptoms, with no statistically significant differences in walking distance or quality-of-life measure outcomes. The intervention group had less COPD-related admissions compared to the placebo group but experienced medication-related side effects.

CONCLUSION

Treatment with paroxetine significantly improved anxiety levels, but this difference did not translate into improved quality of life at four months follow-up.

Breathlessness amplifies amygdala responses during affective processing

Breathlessness is an aversive symptom in many prevalent somatic and psychiatric diseases and is usually experienced as highly threatening. It is strongly associated with negative affect, but the underlying neural processes remain poorly understood. Therefore, using fMRI, the present study examined the effects of breathlessness on the neural processing of affective visual stimuli within candidate brain areas including the amygdala, insula, and anterior cingulate cortex (ACC). During scanning, 42 healthy volunteers, mean (SD) age: 29.0 (6.0) years, 14 female, were presented with affective picture series of negative, neutral, and positive valence while experiencing either no breathlessness (baseline conditions) or resistive-load induced breathlessness (breathlessness conditions). Respiratory measures and self-reports suggested successful induction of breathlessness and affective experiences. Self-reports of breathlessness intensity and unpleasantness were significantly higher during breathlessness conditions, mean (SD): 45.0 (16.6) and 32.3 (19.8), as compared to baseline conditions, mean (SD): 1.9 (3.0) and 2.9 (5.5). Compared to baseline conditions, stronger amygdala activations were observed during breathlessness conditions for both negative and positive affective picture series relative to neutral picture series, while no such effects were observed in insula and ACC. The present findings demonstrate that breathlessness amplifies amygdala responses during affective processing, suggesting an important role of the amygdala for mediating the interactions between breathlessness and affective states.

[Chronic cerebral ischemia in obstructive pulmonary diseases]

Chronic obstructive pulmonary disease (COPD) is one of the main causes of disease and death incidences worldwide. Different organs and systems are involved in COPD activating tissue hypoxia. It affects especially tissue functioning with the high level of intensity of metabolic processes, and the nervous system suffers first. Neuroimaging studies show white and grey matter damage and cerebral atrophy, which may clinically manifest themselves in different neurological symptoms depended on vascular system lesions, and cognitive and affective impairments. Despite of its potential importance, encephalopathy in COPD remains a little-studied concomitant pathology. Application of cytoprotective drugs is pathogenetically justified in this case and must be included in COPD complex therapy. In particular, the inclusion of mexicor in the treatment of patients with chronic pulmonary heart increases the efficacy of treatment of the main and associated diseases (chronic cerebral ischemia, cardiac insufficiency and arrhythmia).

Unpredictable episodic breathlessness in patients with advanced chronic obstructive pulmonary disease and lung cancer: a qualitative study

PURPOSE

The internationally consented definition and categorization describe two categories of episodic breathlessness: predictable (with known triggers) and unpredictable. The link of known triggers only to predictable episodes can be read that unpredictable episodes have none known trigger. Our aim was to illuminate patients' experiences with episodes of unpredictable breathlessness, to collect descriptions of the episodes' impact on the patients' lives, and, in turn, the patients' individual coping strategies in this connection.

DESIGN

Qualitative study using semi-structured in-depth interviews with patients suffering from unpredictable episodes of breathlessness and chronic obstructive pulmonary disease (COPD; Global Initiative for Obstructive Lung Disease III and IV) or lung cancer (all stages). Interviews were audio-recorded, transcribed verbatim, and analyzed using Framework Analysis.

RESULTS

One hundred one patients were screened in a large university hospital; ten participants fulfilled the inclusion criteria and provided consent. The experienced episodes were evaluated as unpleasant and with higher intensity compared to predictable episodes. Non-pharmacological interventions were identified as useful coping strategies. Interestingly, although patients experienced the episodes in an unpredictable manner, a trigger could be detected retrospectively for the majority of cases (mostly emotions (especially panic) and, occasionally, physical exertion). Unpredictable episodes are less frequent than previously assumed.

CONCLUSION

The unpredictability of unpredictable breathless episodes refers to the patients' experience that these episodes occur "out-of-the-blue." However, a known trigger can be identified for the majority of unpredictable breathless episodes. These are therefore triggered as well. Further research needs to describe more possible triggers, to inquire the prevalence of unpredictable episodic breathlessness, and to develop effective management strategies.

Psychiatric Aspects of Lung Disease in Critical Care

Respiratory conditions are some of the most common indications for admission to critical care units. Psychiatric disorders and symptoms are highly comorbid with lung disease. They can occur as a risk factor to lung disease, as a co-occurring condition, as a consequence of a pulmonary condition, or as a treatment side effect either from medications or assistive devices. Patients can experience a myriad of mood, anxiety, and cognitive disorder symptoms and conditions in critical care units. Intensivists and psychiatrists must be aware of the interplay between pulmonary and psychiatric symptoms as well as medication effects and interactions.

Psychological therapies for the treatment of anxiety disorders in chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) (commonly referred to as chronic bronchitis and emphysema) is a chronic lung condition characterised by the inflammation of airways and irreversible destruction of pulmonary tissue leading to progressively worsening dyspnoea. It is a leading international cause of disability and death in adults. Evidence suggests that there is an increased prevalence of anxiety disorders in people with COPD. The severity of anxiety has been shown to correlate with the severity of COPD, however anxiety can occur with all stages of COPD severity. Coexisting anxiety and COPD contribute to poor health outcomes in terms of exercise tolerance, quality of life and COPD exacerbations. The evidence for treatment of anxiety disorders in this population is limited, with a paucity of evidence to support the efficacy of medication-only treatments. It is therefore important to evaluate psychological therapies for the alleviation of these symptoms in people with COPD.

OBJECTIVES

To assess the effects of psychological therapies for the treatment of anxiety disorders in people with chronic obstructive pulmonary disease.

SEARCH METHODS

We searched the specialised registers of two Cochrane Review Groups: Cochrane Common Mental Disorders (CCMD) and Cochrane Airways (CAG) (to 14 August 2015). The specialised registers include reports of relevant randomised controlled trials from The Cochrane Library, MEDLINE, Embase, and PsycINFO. We carried out complementary searches on PsycINFO and CENTRAL to ensure no studies had been missed. We applied no date or language restrictions.

SELECTION CRITERIA

We considered all randomised controlled trials (RCTs), cluster-randomised trials and cross-over trials of psychological therapies for people (aged over 40 years) with COPD and coexisting anxiety disorders (as confirmed by recognised diagnostic criteria or a validated measurement scale), where this was compared with either no intervention or education only. We included studies in which the psychological therapy was delivered in combination with another intervention (co-intervention) only if there was a comparison group that received the co-intervention alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened citations to identify studies for inclusion and extracted data into a pilot-tested standardised template. We resolved any conflicts that arose through discussion. We contacted authors of included studies to obtain missing or raw data. We performed meta-analyses using the fixed-effect model and, if we found substantial heterogeneity, we reanalysed the data using the random-effects model.

MAIN RESULTS

We identified three prospective RCTs for inclusion in this review (319 participants available to assess the primary outcome of anxiety). The studies included people from the outpatient setting, with the majority of participants being male. All three studies assessed psychological therapy (cognitive behavioural therapy) plus co-intervention versus co-intervention alone. We assessed the quality of evidence contributing to all outcomes as low due to small sample sizes and substantial heterogeneity in the analyses. Two of the three studies had prespecified protocols available for comparison between prespecified methodology and outcomes reported within the final publications.We observed some evidence of improvement in anxiety over 3 to 12 months, as measured by the Beck Anxiety Inventory (range from 0 to 63 points), with psychological therapies performing better than the co-intervention comparator arm (mean difference (MD) -4.41 points, 95% confidence interval (CI) -8.28 to -0.53; P = 0.03). There was however, substantial heterogeneity between the studies (I2 = 62%), which limited the ability to draw reliable conclusions. No adverse events were reported.

AUTHORS' CONCLUSIONS

We found only low-quality evidence for the efficacy of psychological therapies among people with COPD with anxiety. Based on the small number of included studies identified and the low quality of the evidence, it is difficult to draw any meaningful and reliable conclusions. No adverse events or harms of psychotherapy intervention were reported.A limitation of this review is that all three included studies recruited participants with both anxiety and depression, not just anxiety, which may confound the results. We downgraded the quality of evidence in the 'Summary of findings' table primarily due to the small sample size of included trials. Larger RCTs evaluating psychological interventions with a minimum 12-month follow-up period are needed to assess long-term efficacy.

Efficacy of a minimal home-based psychoeducative intervention in patients with advanced COPD: A randomised controlled trial

BACKGROUND

Anxiety is a common comorbidity in patients with advanced Chronic Obstructive Pulmonary Disease (COPD) with major impact on quality of life and associated with increased risk of death. The objective of this randomised controlled trial was to test the efficacy of a minimal home-based psychoeducative intervention versus usual care for reducing symptoms of anxiety in patients with advanced COPD.

METHODS

The trial included 66 participants with advanced COPD and symptoms of anxiety. The primary outcome was anxiety assessed by the Hospital Anxiety and Depression scale (HADS) subscale for anxiety (HADS-A). The secondary outcome was mastery assessed by the Chronic Respiratory Questionnaire (CRQ) domain of mastery (CRQ-M). Assessments were performed at baseline and one and three months post-intervention.

RESULTS

The intervention group had a lower post intervention HADS-A score on average, compared with the control group (p = 0.005), indicating a significant effect of the intervention. The average difference between the groups in HADS-A was 2.16 points (CI = [0.62; 3.71]) at one month and 2.32 points (CI = [0.74; 3.89]) at three months follow-up. The intervention group had a higher post intervention CRQ-M score on average compared with the control group (p = 0.016). The average differences between the groups were 0.58 points (CI = [0.09; 1.06]) after one month and 0.67 points (CI = [0.18; 1.17]) after three months.

CONCLUSIONS

The psychoeducative intervention provided sustainable symptom relief and improved the patients' self-management abilities.

A Machine-to-Machine protocol benchmark for eHealth applications - Use case: Respiratory rehabilitation

BACKGROUND

M2M (Machine-to-Machine) communications represent one of the main pillars of the new paradigm of the Internet of Things (IoT), and is making possible new opportunities for the eHealth business. Nevertheless, the large number of M2M protocols currently available hinders the election of a suitable solution that satisfies the requirements that can demand eHealth applications.

OBJECTIVES

In the first place, to develop a tool that provides a benchmarking analysis in order to objectively select among the most relevant M2M protocols for eHealth solutions. In the second place, to validate the tool with a particular use case: the respiratory rehabilitation.

METHODS

A software tool, called Distributed Computing Framework (DFC), has been designed and developed to execute the benchmarking tests and facilitate the deployment in environments with a large number of machines, with independence of the protocol and performance metrics selected.

RESULTS

DDS, MQTT, CoAP, JMS, AMQP and XMPP protocols were evaluated considering different specific performance metrics, including CPU usage, memory usage, bandwidth consumption, latency and jitter. The results obtained allowed to validate a case of use: respiratory rehabilitation of chronic obstructive pulmonary disease (COPD) patients in two scenarios with different types of requirement: Home-Based and Ambulatory.

CONCLUSIONS

The results of the benchmark comparison can guide eHealth developers in the choice of M2M technologies. In this regard, the framework presented is a simple and powerful tool for the deployment of benchmark tests under specific environments and conditions.

Personal care assistants' experiences of caring for people on home mechanical ventilation

AIM

The aim of this study was to describe personal care assistants' (PCA) experiences of working with a ventilator-assisted person at home.

METHODS

Data were collected from fifteen audiotaped semistructured interviews with PCAs supporting a child or adult using home mechanical ventilation (HMV). Thirteen women and two men participated; their working experience with HMV users ranged from one to 17 years (median 6 years). Data were subjected to qualitative content analysis in an inductive and interpretive manner.

FINDINGS

Five categories emerged from the data: Being part of a complex work situation; Taking on a multidimensional responsibility; Caring carried out in someone's home; Creating boundaries in an environment with indistinct limits; and Being close to another's body and soul.

CONCLUSIONS

The participants felt very close to the person they worked with, both physically and emotionally. They had a great responsibility and therefore a commensurate need for support, guidance and a well-functioning organisation around the HMV user. There is international consensus that advanced home care will continue to expand and personal care assistance is key in this development. We suggest that one way to move forward for PCAs working with HMV users is to create multiprofessional teams led by a key-person who coordinates the individual needs. More research is needed within this area from a broad perspective including the HMV-assisted persons, relatives, personal care assistants and management organisations.

Efficacy of a minimal home-based psychoeducative intervention versus usual care for managing anxiety and dyspnoea in patients with severe chronic obstructive pulmonary disease: a randomised controlled trial protocol

INTRODUCTION

In its final stages, chronic obstructive pulmonary disease is a severely disabling condition that is characterised by dyspnoea, which causes substantial anxiety. Anxiety is associated with an impaired quality of life and increased hospital admissions. Untreated comorbid anxiety can have devastating consequences for both patients and their relatives. Non-pharmacological interventions, including cognitive-behavioural therapy, have been effective in managing anxiety and dyspnoea in patients with chronic obstructive pulmonary disease. However, the majority of existing interventions have tested the efficacy of relatively intensive comprehensive programmes and primarily targeted patients who have moderate pulmonary disease. We present the rationale and design for a trial that focused on addressing the challenges experienced by severe pulmonary disease populations. The trial investigates the efficacy of a minimal home-based psychoeducative intervention versus usual care for patients with severe chronic obstructive pulmonary disease.

METHODS AND ANALYSIS

The trial is a randomised controlled trial with a 4-week and 3-month follow-up. 66 patients with severe chronic obstructive pulmonary disease and associated anxiety will be randomised 1:1 to either an intervention or control group. The intervention consists of a single psychoeducative session in the patient's home in combination with a telephone booster session. The intervention is based on a manual, with a theoretical foundation in cognitive-behavioural therapy and psychoeducation. The primary outcome is patient-reported anxiety as assessed by the Hospital and Anxiety and Depression Scale (HADS).

ETHICS AND DISSEMINATION

This trial complies with the latest Declaration of Helsinki, and The Ethics Committee of the Capital Region of Denmark (number H-1-2013-092) was queried for ethical approval. Trial results will be disseminated in peer-reviewed publications and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT02366390.

A Breathlessness Catastrophizing Scale for chronic obstructive pulmonary disease

OBJECTIVE

Catastrophizing about breathlessness may be related to disability in patients with chronic obstructive pulmonary disease (COPD), but assessment options are limited. This study reports the initial validation of a 13-item Breathlessness Catastrophizing Scale (BCS).

METHOD

Pulmonary rehabilitation inpatients completed spirometric, functional performance and questionnaire assessments at admission (N=242) and discharge (n=186).

RESULTS

The BCS comprised a unifactorial scale that demonstrated excellent internal consistency (Cronbach's alpha=.96) and correlated with measures of anxiety sensitivity, depression, and self-efficacy, but not with performance on walk and stair-climbing tests. BCS scores improved robustly with rehabilitation, approaching a medium effect size (d=.43), and demonstrated a modest association with enhanced performance in a stair-climbing test of exercise tolerance.

CONCLUSION

The BCS is a reliable measure of catastrophizing in severe COPD that has good convergent validity and sensitivity to change. Its association with functional performance requires further investigation. However, it appears that a high level of catastrophizing about breathlessness is not a barrier to functional improvement with inpatient pulmonary rehabilitation.

Cognitive behaviour therapy reduces dyspnoea ratings in patients with chronic obstructive pulmonary disease (COPD)

There is evidence that psychological factors contribute to the perception of increased difficulty of breathing in patients with chronic obstructive pulmonary disease (COPD), and increase morbidity. We tested the hypothesis that cognitive behaviour therapy (CBT) decreases ratings of perceived dyspnoea in response to resistive loading in patients with COPD. From 31 patients with COPD, 18 were randomised to four sessions of specifically targeted CBT and 13 to routine care. Prior to randomisation, participants were tested with an inspiratory external resistive load protocol (loads between 5 and 45cmH2O/L/s). Six months later, we re-measured perceived dyspnoea in response to the same inspiratory resistive loads and compared results to measurements prior to randomisation. There was a significant 17% reduction in dyspnoea ratings across the loads for the CBT group, and no reduction for the routine care group. The decrease in ratings of dyspnoea suggests that CBT to alleviate breathing discomfort may have a role in the routine treatment of people with COPD.

The relation between past exposure to fine particulate air pollution and prevalent anxiety: observational cohort study

OBJECTIVE

To determine whether higher past exposure to particulate air pollution is associated with prevalent high symptoms of anxiety.

DESIGN

Observational cohort study.

SETTING

Nurses' Health Study.

PARTICIPANTS

71,271 women enrolled in the Nurses' Health Study residing throughout the contiguous United States who had valid estimates on exposure to particulate matter for at least one exposure period of interest and data on anxiety symptoms.

MAIN OUTCOME MEASURES

Meaningfully high symptoms of anxiety, defined as a score of 6 points or greater on the phobic anxiety subscale of the Crown-Crisp index, administered in 2004.

RESULTS

The 71,271 eligible women were aged between 57 and 85 years (mean 70 years) at the time of assessment of anxiety symptoms, with a prevalence of high anxiety symptoms of 15%. Exposure to particulate matter was characterized using estimated average exposure to particulate matter <2.5 μm in diameter (PM2.5) and 2.5 to 10 μm in diameter (PM2.5-10) in the one month, three months, six months, one year, and 15 years prior to assessment of anxiety symptoms, and residential distance to the nearest major road two years prior to assessment. Significantly increased odds of high anxiety symptoms were observed with higher exposure to PM2.5 for multiple averaging periods (for example, odds ratio per 10 µg/m(3) increase in prior one month average PM2.5: 1.12, 95% confidence interval 1.06 to 1.19; in prior 12 month average PM2.5: 1.15, 1.06 to 1.26). Models including multiple exposure windows suggested short term averaging periods were more relevant than long term averaging periods. There was no association between anxiety and exposure to PM2.5-10. Residential proximity to major roads was not related to anxiety symptoms in a dose dependent manner.

CONCLUSIONS

Exposure to fine particulate matter (PM2.5) was associated with high symptoms of anxiety, with more recent exposures potentially more relevant than more distant exposures. Research evaluating whether reductions in exposure to ambient PM2.5 would reduce the population level burden of clinically relevant symptoms of anxiety is warranted.

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.

Predictors of post-traumatic psychological growth in the late years after lung transplantation

BACKGROUND

Although lung transplantation improves quality of life, most psychosocial research focuses on adverse psychological and social functioning outcomes. Positive effects, particularly in the late-term years as physical morbidities increase, have received little attention. We provide the first data on a psychological benefit - post-traumatic growth (PTG) - and we focused on long-term (>5 yr) survivors.

METHODS

Among 178 patients from a prospective study of mental health during the first two yr post-transplant, we recontacted survivors 6-11 yr post-transplant. We assessed PTG (i.e., positive psychological change resulting from the transplant) and examined its relationship to other patient characteristics with multivariable regression analyses.

RESULTS

Sixty-four patients (86% of survivors) were assessed (M = 8.1 yr post-transplant, SD = 1.2). Mean PTG exceeded the scale's midpoint (M = 38.6, SD = 10.0; scale midpoint = 25). Recipients experiencing greater PTG were female (p = 0.022), less educated (p = 0.014), and had a history of post-transplant panic disorder (p = 0.005), greater friend support (p = 0.048), and better perceived health (p = 0.032). Neither other pre- or post-transplant mood and anxiety disorders nor transplant-related morbidities (acute rejection, bronchiolitis obliterans syndrome) predicted PTG.

CONCLUSIONS

PTG exceeded levels observed in other chronic disease populations, suggesting that lung transplantation may uniquely foster positive psychological change in long-term survivors. PTG occurs despite physical and psychiatric morbidities. Whether PTG promotes other positive post-transplant psychosocial outcomes deserves attention.

Overview of the prevalence, impact, and management of depression and anxiety in chronic obstructive pulmonary disease

More than one third of individuals with chronic obstructive pulmonary disease (COPD) experience comorbid symptoms of depression and anxiety. This review aims to provide an overview of the burden of depression and anxiety in those with COPD and to outline the contemporary advances and challenges in the management of depression and anxiety in COPD. Symptoms of depression and anxiety in COPD lead to worse health outcomes, including impaired health-related quality of life and increased mortality risk. Depression and anxiety also increase health care utilization rates and costs. Although the quality of the data varies considerably, the cumulative evidence shows that complex interventions consisting of pulmonary rehabilitation interventions with or without psychological components improve symptoms of depression and anxiety in COPD. Cognitive behavioral therapy is also an effective intervention for managing depression in COPD, but treatment effects are small. Cognitive behavioral therapy could potentially lead to greater benefits in depression and anxiety in people with COPD if embedded in multidisciplinary collaborative care frameworks, but this hypothesis has not yet been empirically assessed. Mindfulness-based treatments are an alternative option for the management of depression and anxiety in people with long-term conditions, but their efficacy is unproven in COPD. Beyond pulmonary rehabilitation, the evidence about optimal approaches for managing depression and anxiety in COPD remains unclear and largely speculative. Future research to evaluate the effectiveness of novel and integrated care approaches for the management of depression and anxiety in COPD is warranted.

Dyspnea and panic among patients with newly diagnosed non-small cell lung cancer

CONTEXT

Among patients with lung cancer, dyspnea is associated with psychological distress, fatigue, and poor coping. Respiratory symptoms are also a common trigger for panic attacks in the general population. Minimal research has addressed the prevalence of panic disorder or the association of dyspnea with the risk of panic disorder in lung cancer.

OBJECTIVES

We explored the frequency of panic disorder symptoms and the association of dyspnea with the risk of panic disorder symptoms among patients with newly diagnosed non-small cell lung cancer.

METHODS

During 2006-2010, consecutive patients presenting for initial consultation at a thoracic oncology clinic completed a survey of current symptoms, including dyspnea and panic disorder symptoms. We evaluated the frequency of panic disorder symptoms. Logistic regression was used to test the association of dyspnea with the risk of panic disorder symptoms, adjusting for age, gender, disease stage, performance status, and major depression symptoms.

RESULTS

Among 624 patients (mean age=63.7; standard deviation=12.1; 52.6% female), 48.1% reported that breathing was at least somewhat difficult and 11.2% endorsed panic disorder symptoms. Dyspnea was independently associated with higher risk of panic disorder symptoms (odds ratio=2.19, 95% confidence interval=1.11-4.31, P=0.02). Younger age and major depression symptoms also were associated with higher risk (P<0.01).

CONCLUSION

Almost half of the patients with newly diagnosed non-small cell lung cancer reported dyspnea, and patients with dyspnea were more than twice as likely to endorse panic disorder symptoms relative to patients without dyspnea. Results highlight the need to differentiate panic disorder symptoms among patients who report dyspnea, particularly those who are younger or experiencing major depression symptoms.

Effectiveness of cognitive behavioural therapy (CBT) interventions for anxiety in patients with chronic obstructive pulmonary disease (COPD) undertaken by respiratory nurses: the COPD CBT CARE study: (ISRCTN55206395)

Background

Anxiety and depression are common co-morbidities in patients with chronic obstructive pulmonary disease (COPD). Serious implications can result from psychological difficulties in COPD including reduced survival, lower quality of life, and reduced physical and social functioning, increased use of health care resources and are associated with unhealthy behaviours such as smoking. Cognitive behavioural therapy (CBT) is a psychological intervention which is recommended for the treatment of many mental health problems including anxiety and depression. Unfortunately access to trained CBT therapists is limited. The aim of this study is to test the hypothesis that CBT delivered by respiratory nurses is effective in the COPD population. In this paper the design of the Newcastle Chronic Obstructive Pulmonary Disease Cognitive Behavioural Therapy Study (Newcastle COPD CBT Care Study) is described.

Methods/Design

This is a prospective open randomised controlled trial comparing CBT with self-help leaflets. The primary outcome measure is the Hospital Anxiety & Depression Scale (HADS) – anxiety subscale. Secondary outcome measures include disease specific quality of life COPD Assessment Tool (CAT), generic quality of life (EQ5D) and HADS-depression subscale. Patients will be followed up at three, six and 12 months following randomisation.

Discussion

This is the first randomised controlled trial to evaluate the use of cognitive behavioural therapy undertaken by respiratory nurses. Recruitment has commenced and should be complete by February 2014.

Trial registration

Current Controlled Trials, ISRCTN55206395

Meeting the mental health needs of people with chronic obstructive pulmonary disease: a qualitative study

OBJECTIVES

This study aimed to understand the mental health needs of people living with chronic obstructive pulmonary disease: what they were experiencing, what they wanted (or did not want) which might be described as 'felt need', what they had accessed or received ('expressed need') and how, from their perspective, their emotional needs might be more effectively met by health care services.

METHODS

Qualitative study with 14 patients with a confirmed diagnosis of chronic obstructive pulmonary disease, where a member of the clinical team had recognised that the patient was suffering from associated emotional distress.

RESULTS

Three themes emerged: a sense of assuming a different identity as the disease challenged abilities, the experience of social isolation with fear of dependence and barriers the participants encountered acting as obstacles to coping, adapting and accessing treatments. There were mixed feelings about the value of talking about problems, with both psychological and physical barriers strongly militating against both expression of need and utilization of care offered.

CONCLUSIONS

Innovative research and clinical care should be aimed towards development of skills, strategies and systems required to engage sensitively and negotiate needs for care, in a patient-centred manner, with people who do not necessarily see the need to ask for emotional support.

Behavioral medicine approaches to chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a prevalent respiratory disease and associated with considerable individual and socioeconomic burden. Recent research started examining the role of psychosocial factors for course and management of the disease.

PURPOSE

This review provides an overview on recent findings on psychosocial factors and behavioral medicine approaches in COPD.

RESULTS

Research has identified several important psychosocial factors and effective behavioral medicine interventions in COPD. However, there is considerable need for future research in this field.

CONCLUSIONS

Although beneficial effects of some behavioral medicine interventions have been demonstrated in COPD, future research efforts are necessary to study the effects of distinct components of these interventions, to thoroughly examine promising but yet not sufficiently proven interventions, and to develop new creative interventions.

Catastrophic interpretations and anxiety sensitivity as predictors of panic-spectrum psychopathology in chronic obstructive pulmonary disease

OBJECTIVE

Panic-spectrum psychopathology (denoting panic attacks and panic disorder) is highly prevalent in chronic obstructive pulmonary disease (COPD), and the cognitive model of panic has been proposed as an explanation of this high prevalence. In the current cross-sectional study we investigated factors predicting panic-spectrum psychopathology in COPD, and hypothesized that, consistent with the cognitive model, both the catastrophic interpretation of shortness of breath and elevated anxiety sensitivity would be significant predictors when variance shared with confounding variables was controlled.

METHODS

Sixty-two participants with COPD were interviewed with the Anxiety Disorders Interview Schedule for DSM-IV, Panic Disorder section, and completed measures of interpretation of breathing difficulty, anxiety sensitivity, anxiety, depression, disease-specific quality of life, and stressful life events. Objective disease severity was measured using forced expiratory volume in the first second.

RESULTS

Direct logistic regression was performed, and worse depressive symptoms, more catastrophic interpretations of shortness of breath, higher anxiety sensitivity, higher magnitude of recent stressful life events, and worse disease severity were each found to be significant unique predictors of panic-spectrum psychopathology in COPD after shared variance was controlled.

CONCLUSIONS

The results of the study provide support for the cognitive model of panic, and also suggest a diathesis-stress explanation of the development of panic-spectrum psychopathology in COPD. The findings have implications for future preventative psychological interventions.

Neurobiology of panic and pH chemosensation in the brain

Panic disorder is a common and disabling illness for which treatments are too frequently ineffective. Greater knowledge of the underlying biology could aid the discovery of better therapies. Although panic attacks occur unpredictably, the ability to provoke them in the laboratory with challenge protocols provides an opportunity for crucial insight into the neurobiology of panic. Two of the most well-studied panic provocation challenges are CO(2) inhalation and lactate infusion. Although it remains unclear how these challenges provoke panic animal models of CO(2) and lactate action are beginning to emerge, and offer unprecedented opportunities to probe the molecules and circuits underlying panic attacks. Both CO(2) and lactate alter pH balance and may generate acidosis that can influence neuron function through a growing list of pH-sensitive receptors. These observations suggest that a key to better understanding of panic disorder may He in more knowledge of brain pH regulation and pH-sensitive receptors.

Onset and risk factors for anxiety and depression during the first 2 years after lung transplantation

OBJECTIVE

Anxiety disorders are prominent in chronic lung disease; lung transplant recipients may therefore also be at high risk for these disorders. We sought to provide the first prospective data on rates and risk factors for anxiety disorders as well as depressive disorders during the first 2 years after transplantation.

METHOD

A total of 178 lung recipients and a comparison group (126 heart recipients) received psychosocial and Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition assessments at 2, 7, 12, 18 and 24 months posttransplant. Survival analysis determined onset rates and risk factors.

RESULTS

The panic disorder rate was higher (P<.05) in lung than heart recipients (18% vs. 8%). Lung and heart recipients did not differ on rates of transplant-related posttraumatic stress disorder (15% vs. 14%), generalized anxiety disorder (4% vs. 3%) or major depression (30% vs. 26%). Risk factors for disorders included pretransplant psychiatric history, female gender, longer wait for transplant, and early posttransplant health problems and psychosocial characteristics (e.g., poorer caregiver support and use of avoidant coping).

CONCLUSIONS

Heightened vigilance for panic disorder in lung recipients and major depression in all cardiothoracic recipients is warranted. Strategies to prevent psychiatric disorder should target recipients based not only on pretransplant characteristics but on early posttransplant characteristics as well.