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Depression and Anxiety in Patients with COPD: A Focus on Psychological Treatments in Ambulatory Care Settings Joseph Mignogna1,2 and Jeffrey A. Cully*,2,3,4 1

Department of Psychology, University of Alabama, Tuscaloosa, AL, USA

2

VA HSR&D Houston Center of Excellence, Michael E. DeBakey VA Medical Center, Houston, TX, USA

3

Baylor College of Medicine, Houston, TX, USA

4

VA South Central Mental Illness Research, Education and Clinical Center, USA Abstract: Depression and anxiety are highly comorbid with chronic obstructive pulmonary disease (COPD) and are associated with poor treatment adherence, increased rates of physical disability, functional disability, mortality, healthcare costs, and a worsening quality of life. Despite its prevalence, there is a dearth of research on psychological treatments for depressed and/or anxious patients with COPD. This review examines the current evidence for psychological treatments for depression and anxiety in COPD, structured within the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework, in an effort to highlight the current practice and research needs for this important and complex patient population.

Keywords: Ambulatory care, anxiety, chronic obstructive pulmonary disease, depression, primary care, psychotherapy, REAIM. INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a progressive disease characterized by airflow limitations of the lungs [1]. Worldwide projections estimate that COPD will increase from the sixth leading cause of death, as it was in 1990, to the third leading cause in 2020 [1-4]. As with other chronic medical illnesses, patients with COPD are at increased risk for major depression [5] and/or other mental health conditions, such as anxiety [6, 7]. Although prevalence rates vary considerably (from 7% to 88%) [8-10], Yohannes and colleagues’ meta-analysis of 13 studies found an overall 40% prevalence rate of comorbid depression in patients with COPD [11]. These authors describe the wide range of prevalence rates reported in the literature is likely attributable to varying methods for identifying and describing mental health difficulties (e.g. by symptom severity or by diagnostic criteria), variability of diagnostic tools, and heterogeneous research and/or clinical settings. These same methodological issues complicate efforts to identify the prevalence of anxiety in patients with COPD. A recent review of the literature found that COPD patients meeting diagnostic criteria for an anxiety disorder or having anxiety symptomatology vary between 16% to 55%, and 6% to 74%, respectively [8]. Generalized anxiety disorder and panic disorder are the most notably elevated among anxiety disorders in COPD [12]. Importantly, diagnostic levels of anxiety are most frequently observed in depressed rather than non-depressed patients with COPD [11], suggesting significant overlap between these mental health conditions.

*Address correspondence to this author at the VA HSR&D Houston Center of Excellence (MEDVAMC 152), 2002 Holcombe Blvd., Houston, TX 77030, USA; Tel: 713-794-8526; Fax: 713-748-7359; E-mail: [email protected]

1875-6387/12 $58.00+.00

The pervasive impact of depression and anxiety can reduce the ability of patients with COPD to adequately cope with difficult physical symptoms and adhere to medicaltreatment recommendations [13, 14]. Furthermore, this comorbidity is associated with increased physical disability, functional disability, mortality, and healthcare costs, plus worsening quality of life [8, 15-20]. While the prevalence and impact of depression and anxiety on patients with COPD have been well documented, available psychological interventions have a limited evidence base; and additional research is needed, especially related to avenues for implementation of known best practices [21]. Multiple means of treating depression and anxiety in patients with COPD have been tested, including medication management, components of pulmonary rehabilitation programs, psychological interventions, and multi-faceted or collaborative-care interventions [8, 22]. This article focuses on psychological interventions, given the relative dearth of information about these treatment options and the increasing need to adapt and modify these interventions to complement existing medical-care processes within settings such as ambulatory medical care settings rather than specialty mental health care. The literature yields few psychological intervention studies, and these studies provide limited effectiveness for depression and/or anxiety in COPD [8, 15, 21]. Consequently, while treatment guidelines highlight the importance of recognizing and treating depression and anxiety in patients with COPD [1], there are few clear evidence-based pathways for the treatment of depression and anxiety. Although additional effectiveness research is needed, research on comorbid depression and anxiety in COPD must seek to identify feasible and effective mechanisms for eventual applications within the health care setting. The REAIM (Reach, Effectiveness, Adoption, Implementation and © 2012 Bentham Science Publishers

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Maintenance) framework is a conceptual model [23, 24] for evaluating the overall impact of treatments across dimensions ranging from reach (the proportion of patients treated) to clinical effectiveness, to implementation outcomes such as adoption, fidelity, and ability to maintain the intervention over a sustained period of time. The REAIM framework is one mechanism to help bridge the gap between research and practice [25] and can be employed as a tool in guiding treatment programs planning to maximize public health impact [24, 26]. The need for patient-centered, system-level feasible psychological interventions for depression and/or anxiety in COPD is clear. Coupled with the current lack of effectiveness data, hybrid research designs such as those proposed by Curran et al. [27] hold the potential to simultaneously provide critical information on both effectiveness and implementation processes and outcomes. For example, a trial that seeks to test the effectiveness of a psychological intervention within an established COPD clinic would be able to not only examine patient outcomes of the intervention but also provider and system data related to the percentage of patients treated relative to the overall clinic population, the number of providers who were able to adopt and embed the intervention into their practice, and the fidelity of the treatment provided by these frontline practitioners. Longer term follow-ups might examine 6- or 12-month patient outcomes but might also examine processes related to practitioner and clinic intervention maintenance. This review explores the evidence and factors related to patient engagement and adherence to psychological treatments for depression and anxiety in COPD. Although the literature on this subject is limited, the review attempts to identify important future clinical and research needs on the topic by evaluating the literature in terms of the RE-AIM framework. Notably, it explores patient, provider, and system barriers [8, 15, 28, 29] to mental health care for patients with COPD in an effort to improve care practices and promote research that produces not only effective but also adoptable and enduring interventions. METHODS A narrative review of relevant literature was conducted for the current article using Scopus, Pubmed, and PsychInfo. Search terms included chronic obstructive pulmonary disease or COPD combined with review and/or psychological or psychotherapy to identify relevant studies and published manuscripts. Once critical articles were identified, reference lists were checked for additional articles as well as studies citing these seminal articles looking forward using Scopus. Finally, a search of these same databases using the search term RE-AIM, as well as a review of the literature cited on the RE-AIM website [24], provided additional relevant literature. Reach Reach refers to the representativeness and participation of the targeted population in an intervention. Determining factors of reach include the characteristics and size of the patient population as well as patient-level barriers to

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treatment [23, 26, 30]. A primary question when evaluating reach is, What percent of the targeted population will participate in the program? [26]. Given the high prevalence and limited recognition of depression and/or anxiety in COPD, the challenge of an intervention’s reach can be formidable. A review of the literature highlights three important problems related to reach: 1) physical and emotional symptom overlap contributing to limited mental health recognition; 2) limited knowledge, mental health stigma, and other patient-level barriers to mental health treatment; and 3) limited availability of mental health providers and services for patients with COPD. Physical and Emotional Health Symptom Overlap — Limited Mental Health Recognition Depression and anxiety in patients with COPD continue to be under-diagnosed and under-treated [7, 16, 21, 31-34]. The overlap of symptoms used to diagnose depression, anxiety, and COPD is thought to be a significant factor contributing to under-diagnosis. Overlapping symptoms include increased fatigue, decreased energy, decreased appetite, sleep loss, difficulty concentrating, anhedonia, dyspnea, and reduced physical activity [8]. Despite proposals to use alternative criteria to diagnose depression in persons with comorbid chronic medical conditions [35-37], an empirical basis for changing current diagnostic standards is lacking [38, 39]. Specifically, Yates and colleagues [39] found in a large multisite sample (n = 1500) that depressed patients with a comorbid medical illness, compared with those without, were similar in the prevalence rates of common depressive symptoms (e.g., fatigue, sleep disturbances, and changes in appetite) and did not differ in anxiety symptoms. Similarly, Simon and Von Korff’s longitudinal study [38] compared the symptoms of depression in patients enrolled in treatment for depression with a chronic medical condition (i.e., ischemic heart disease, diabetes, and COPD; N = 235) or not (N = 204), and found only limited evidence for the assertion that overlapping symptoms were less useful indicators of depression; they consequently did not recommend significant changes to the Diagnostic and Statistical Manual—Fourth Edition (DSM-IV) [40] criteria for diagnosing depression among patients with chronic medical conditions. Interestingly, Simon and Von Korff [38] also reported how “remarkably similar” somatic symptoms of depression improved during treatment; namely, that in patients with and without chronic medical conditions, fatigue and psychomotor agitation/retardation improved “dramatically” during the first 2 months of treatment, while weight and appetite improved less dramatically as depression improved. While recognition of mental health problems in persons with COPD remains problematic, Maurer and colleagues’ (2008) review of the literature [15] identified 11 variables associated with their co-occurrence, namely, physical disability, low body mass index, severe dyspnea, long-term oxygen therapy, less than 50% of predicted FEV1, poor quality of life, presence of comorbidity, living alone, being female, low social class status, and being a current smoker. Additionally, in comparison with other medical conditions, depression in patients with COPD may be associated with a

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psychiatric history and the presence of stressful life events [41]. Limited Patient and Provider Mental Health Knowledge A lack of knowledge and awareness about depression and anxiety by patients and providers, as well as potentially stigmatizing beliefs associated with mental health disorders, presents barriers to the reach of psychological interventions [8]. Physicians can falsely attribute depressive symptoms to “normal aging”, physical illness, grief, and/or dementia and can minimize the value of addressing depressive symptoms with treatment [42]. Cole and colleagues have described this attribution error as the “fallacy of good reasons” [43]. Similarly, patients with chronic illness may also falsely attribute mental and physical health difficulties to a consequence of their deteriorating physical condition and avoid specialty mental health care [44-46]. Not surprisingly, patient- and provider-level barriers to care stemming from knowledge gaps and poor recognition of mental health problems are compounded when considering the stigmatizing beliefs associated with mental illness and other patient-level barriers to depression help-seeking in primary care. Mental Health Treatment Expectations, Stigma, and Relational Barriers Generational and cultural factors may relate to negative treatment expectations and concerns about stigma in depression/anxiety treatment. These expectations and concerns among patients may further complicate mental healthcare-seeking behaviors [8, 12, 41, 47]. Interestingly, when seeking mental health care, patients with COPD and comorbid depression and/or anxiety often prefer psychosocial over pharmacological treatments [48, 49]. This finding is supported by numerous studies demonstrating how, particularly, older adults judge psychosocial treatments for depression as having at least as much (and often more) credibility and acceptability as psychopharmacological treatments [49]. In the primary care setting, physicians have judged patient factors as primarily responsible for patient failure to engage in mental health treatment [50]. In fact, Nutting and colleagues found that patient-level barriers (i.e., categorized as patient resistance) accounted for 68% of patients non-adherent to acute-stage depression treatment guidelines among a medically mixed sample of primary care patients [50]. Among the barriers categorized in the patient resistance cluster and assigned the greatest weight were patient resistant to starting medication, patient underestimated the seriousness of the problem, patient did not understand the need for treatment, and patient felt other medical condition(s) were a higher priority for treatment. Recognition of Depression and Anxiety and Utilization of Mental Health Services for Patients with COPD In a national sample of 1,636 U.S. adults (not restricted to COPD) who had visited a health care provider in the previous year, only 30% had received appropriate mental health services [51]. In another national sample of Veterans, Cully et al. used electronic medical-record reviews to examine psychotherapy utilization [52]. The study found that

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78% of 410,923 outpatient Veterans (not restricted to patients with comorbid COPD) newly diagnosed with depression, anxiety, or post-traumatic stress disorder did not receive any psychotherapy in the year following their mental health diagnosis and that 95% of this sample received less than eight sessions. With regard to COPD-specific samples, Roundy and colleagues conducted a retrospective medical-record review of patients identified as having COPD and comorbid depressive or anxiety disorders at the Veterans Administration (VA) and found that about half the patients with depressive and anxiety symptoms were recognized in primary care [31]. Recognition of these symptoms in the VA has been augmented by routinely screening all patients, regardless of health status. However, on the basis of medical-record review, patients followed only by primary care and not co-managed with mental healthcare providers were less likely to receive guideline-adherent care [31]. Similarly, in the United Kingdom, only 11% of 182 patients treated for severe COPD at 3 hospitals were prescribed psychotropic medications, despite 25% and 33% scoring in the “definite” range for likelihood of anxiety and depression, respectively [53]. EFFECTIVENESS Effectiveness is an individual-level measure of treatment impact on targeted outcomes and encompasses what is commonly referred to in the literature as efficacy and effectiveness of a treatment. In the RE-AIM framework, effectiveness also includes the impact of treatment on factors less commonly reported, including quality of life, participant satisfaction, and economic impact [23]. To avoid an unnecessarily detailed review, this section briefly reviews the literature for the use of psychotherapy in patients with COPD and comorbid depression and/or anxiety. Additionally, it evaluates the state of effectiveness of current psychotherapies in COPD and highlights potential avenues for improved intervention potency. Psychological Treatments Nine studies were included in the most recent published systematic review and meta-analysis of psychological interventions for depression and/or anxiety in COPD [21] (studies published up to September 2009). Between October 2009 and May 2011, three additional studies were identified [54-56]. The most recent review by Baraniak and Sheffield [21] deemed the quality of the nine included studies to be “good.” Most (six of nine) of the psychologically based interventions identified in the literature involved cognitivebehavioral treatments (CBT) [57-62]. The remaining three interventions [63-65] discussed in the review used other forms of psychotherapy or a focused relaxation exercise. Intervention structure and delivery varied between the six CBT studies [21], ranging from one 2-hour session [60] to weekly sessions over 8 weeks [61], delivered in both individual [59] and group formats [57, 58, 60-62]. CBT interventionists included psychiatrists [57, 60], a psychologist [58], psychology interns and postdoctoral fellows [61], and a nurse [59]; and the clinical role of one interventionist was unclear [62]. The two non-CBT


individual psychotherapies were provided over the course of eight [65] and 12 [64] weekly sessions, and the remaining intervention [63] relied on a recording of a relaxation exercise over four weekly sessions. Most of the interventions (six of nine) were provided in a physician’s office or medical clinic [57-60, 63, 65]. Although four studies were described as randomized controlled trials [58, 60, 61, 64], two reported randomizing participants to treatment groups [63, 65]; and the remaining three studies did not randomize participants to treatment conditions [57, 59, 62]. A brief review of intervention utilization statistics [21] revealed that, across the eight studies reporting attrition rates, 163 (45%) of the 364 participants assigned to intervention conditions engaged in treatment (i.e., attended one or more sessions). Available reasons provided by some of the 201 (55%) lost to attrition included patients who were not interested in participating, and/or who had medical issues, time constraints, transportation problems, and/or financial distress. These process data suggest a distinct need to improve treatment engagement and to identify and develop patient-centered intervention methods that restrict access and/or create barriers to mental health treatments. Psychological Treatment Outcomes As mentioned, the variability in instruments used to measure treatment outcomes limits treatment comparisons and meta-analytic studies [8, 21]. Although anxiety measures were reported for all identified studies, only seven studies employed measures of depression; and only five studies reported quality-of-life measures. However, quality of life was consistently described as a secondary outcome measure [21]. Mixed results were observed between studies on measures of anxiety, depression, and quality of life. Withinand between-group meta-analyses of these measures yielded a significant, albeit small, within-group effect on the reduction of anxiety. While Baraniak and Sheffield [21] described the reviewed studies as of a higher caliber than in an earlier review (i.e., [66]), these authors note that the variety of measures employed between studies made combining and interpreting results difficult. They also note that interventions shown to be effective in treating anxiety and depression elsewhere in the literature appear less effective when used to treat these same psychological problems among patients with COPD. These authors hypothesized that one reason for this discrepancy in treatment efficacy is that the most effective components of traditional treatments for a non-COPD population may be impractical or ineffective for medically ill patients. Considering this discrepancy in treatment efficacy, as well as other factors that could hamper the adoption and endurance of traditionally designed and tested CBT interventions for depression and anxiety in a non-medically ill population, it is likely that further modification of the available interventions will be necessary to improve treatment efficacy. There are recent and ongoing trials of modified CBT interventions adapted to treat depression and anxiety among a COPD population. One such study conducted by Cully and colleagues uses an intervention called ACCESS, or Adjusting to Chronic Conditions Using Education, Support, and Skills [22, 55]; information for both patients and

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clinicians is available at http://vaprojectaccess.org. Not included in the Baraniak and Sheffield meta-analysis because of the recent publication of the results of this open trial, ACCESS is a modified CBT intervention specifically developed to fit within the primary care setting and meet the unique needs of medically ill persons with depression and/or anxiety [55]. ACCESS was adapted from an efficacysupported intervention used for a medically ill population [67] and is currently undergoing effectiveness and implementation testing in a large, multisite, randomized trial. Results from a small (N = 23) open trial of the ACCESS intervention were encouraging and support its impact on both emotional and physical health outcomes [55]. In addition, patients reported that ACCESS was highly satisfactory and patient-centered; possibly more importantly, it produced high rates of treatment engagement and adherence, with 87%, (or N = 20) completing at least one session, and 74%, or N = 17, attending all six sessions. Overall, there are mixed results among the treatment outcome literature for psychological treatments for depression and anxiety in patients with COPD; however, recent and on-going attempts to adapt traditional CBT for depression and anxiety among a medically ill population show promise. ADOPTION AND IMPLEMENTATION Both adoption and implementation refer to setting/organizational-level considerations and ultimately are designed to test the applicability of evidence-based interventions for use within the current health care setting. While adoption is concerned with evaluating which and how many settings will adopt a treatment program, implementation is concerned with assessing the fidelity with which a treatment program is delivered [25, 26]. These constructs are critical for intervention development, not only to address issues related to efficacy but to construct interventions that have a high potential for "uptake" within the most representative healthcare setting. The current literature suggests that adoption and implementation for depression and anxiety interventions in patients with COPD are limited and need dedicated attention and development by clinicians and researchers. Presently, mental health services are often unavailable and underused in primary care settings [42, 52]. In addition, psychological interventions are generally under-utilized, even within integrated-care settings such as the VA [52]. Notably, the VA has dedicated immense resources to improve the mental healthcare practices in VA primary care settings, including the provision of evidence-based psychological treatments. However, although robust initiatives are underway, much remains to be understood about how such advancements will translate into sustained, effective practices, especially for medically ill patients, such as those with COPD. Tailoring Psychotherapy for Depressed and Anxious COPD Patients for the Primary Care Setting Given that many COPD patients are treated within the primary care setting, it is paramount for mental health interventions to adapt not only to the unique needs of medically ill patients but also to the current primary care

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environment. As noted previously, interventions such as ACCESS [22, 55] seek to provide not only effective intervention strategies but also an intervention structure that will be amenable to the primary care setting. As an example, ACCESS employs a manualized, modular approach to address the complex needs of patients with congestive heart failure and COPD and emphasizes the interplay between physical and emotional health [55]. This intervention blends CBT with disease self-management techniques that aim to treat symptoms of depression and anxiety and improve the mental and physical health of patients with COPD and/or heart failure. Notably, ACCESS focuses the selfmanagement skills acquisition and practice and allows patients to select both the content (modules and physical vs emotional health foci) and modality of care delivery (inperson or by telephone) [22]. This overlap between physical and emotional health is viewed as critical to better align the multifaceted care processes within primary and specialty medical care settings and those of mental health treatments. Additionally, ACCESS seeks to emulate the primary care environment by providing brief and focused care over a period of 6 weeks using 45-minute active treatment sessions and up to three telephone booster sessions. While not specific to the focus of this review, two recent studies describing the success of collaborative care interventions that include the coordination of care of psychopharmacological [68] and combination [69] treatments to address depression among a medically ill (not specific or even necessarily inclusive of a COPD population) in a primary care setting are worth noting for the interested reader. These studies detail sophisticated mental health interventions that blend mental health medication management and psychological treatments. Given the blended interventional focus, these studies did not focus on psychological treatments per se and were viewed as qualitatively distinct. MAINTENANCE The evaluative dimension of maintenance occurs at the system level as a measure of the institutionalization of a program over time and as a measure of the endurance of treatment effects at the individual level [30]. Given the limited number of effectiveness studies and how understudied implementation and adoption are in the COPD patient population, it is not at all surprising that no studies have focused on the maintenance of psychological interventions for COPD patients at the organizational level. At the individual level, some studies have sought to measure the endurance of treatment effects; but no trials have examined the ability of an intervention to be used within the healthcare setting after cessation of the study. CONCLUSIONS AND RECOMMENDATIONS This review explored the current effectiveness and implementation status of psychological treatments for patients with COPD and comorbid depression and anxiety, using the RE-AIM Framework. Although the amount of attention to and research on the treatment of depression and anxiety in COPD are increasing, there appears to be a dearth of information about how to apply psychological

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interventions within real-world care settings. To improve the care practices for COPD patients with comorbid depression and/or anxiety, we propose the following recommendations. Recommendation #1: Embed Mental Health Treatment Providers within Primary Care and/or Specialty Medical Care Settings to Increase Access and Cross-Discipline Collaborations Much of the relevant psychological intervention literature does not address the care setting where treatments are of best utility [21], complicating efforts to identify the reach of treatments in the literature. Multiple factors suggest that the reach of mental health interventions would be enhanced if embedded within the primary care setting [70]. Not only are most patients diagnosed and treated for COPD in the primary care setting; it is also where patients most frequently first discuss concerns about their mental health and often the preferred setting for mental health care [71, 72]. Additionally, while up to 75% of patients referred to specialty mental health clinics fail to attend the first session, up to 90% of patients seeking mental health care are seen in the primary care setting [73]. Embedded mental health providers provide an opportunity for frontline consultation with medicine and other allied health clinicians to help educate and inform these clinicians about ways to effectively identify and address mental health conditions, including reducing stigma. For these reasons, psychological interventions taking root in a primary care setting could reduce numerous patient- and physician-level barriers to treatment, as reviewed by Yohannes and colleagues [8] and Maurer and colleagues [15]. Recommendation #2: Increase the Standardization and Routine Use of Mental Health and Physical Health Screening The US Preventive Services Task Force has recommended that all adults be screened for depression but noted that such screening should occur only if a proper system is in place to address positive screens and oversee patient well-being [74]. For patients with COPD, it is critical to routinely screen for depression and anxiety, given the high prevalence and disabling effects of these comorbidities. Numerous instruments have been used for identifying depression and anxiety in patients with COPD [75], including the Brief Assessment Schedule Depression Cards [11, 76-78], Hospital Anxiety and Depression scale [79], Geriatric Depression Scale [80, 81], Montgomery Asberg Depression Rating Scale [11], Geriatric Mental State Schedule [11], Centre for Epidemiological Studies Depression Scale [82], Clinical Global Improvement Scale [83], Hamilton Depression Rating Scale [83], and Patient Related Anxiety Scale [83]. Additionally, the Patient Questionnaire (PQ) included in the original Primary Care Evaluation of Mental Disorders [84] contains modules for depression (two items) and anxiety (three items) that have been tested as a practical screening measure [85]. The Kunik et al. study used the Patient Questionnaire as a screening tool in 1,632 patients with chronic breathing disorders and found that the instrument yielded an overall accuracy of 80.7% [85].


Perhaps just as important as identifying depression and/or anxiety in COPD is the initial identification and diagnosis of COPD. COPD is frequently under-diagnosed, like depression, until its symptoms result in significant burden on a patient’s lifestyle and a reduced quality of life [86]. Consequently, improving earlier recognition of COPD may be crucial to improving care of depression in patients with COPD [15]. As noted by Maurer and colleagues, there is “clearly” a role for collaborative care between family physicians, respiratory specialists, and mental health professionals in the diagnosis, treatment, and monitoring of depression in individuals with COPD to address this potential barrier [15]. Given that both biomedical and mental health interventions have the potential to impact physical and emotional health outcomes, researchers, clinicians, and program managers should consider a broad approach to clinical outcomes including emotional, physical, and overall quality of life. These broad approaches may also help to identify the impact of care on overlapping symptoms between depression, anxiety, and COPD. Recommendation #3: Increased Knowledge Dissemination to Primary Care Providers on the Interface Between COPD, Depression and Anxiety Maurer and colleagues [15] identified 11 variables associated with the co-occurrence of depression and/or anxiety in patients with COPD. Taken together with Koenig’s findings [41] regarding the association between depression in patients with COPD and psychiatric history and stressful life events, they could be used to guide future research attempts to develop a diagnostic algorithm based on these variables. Such an effort would greatly enhance the reach of psychological interventions [41]. Knowledge dissemination will likely be effective only if it occurs within the care environment with focused behavioral change efforts, such as increasing the potency and efficiency of provider mental health referrals and/or focused efforts for collaboration between physical and mental health providers. Knowledge alone is unlikely to create change. Recommendation #4: Increase Effectiveness and PatientCenteredness of Available Treatments Cully et al. [87] examined potential psychological treatment moderators (using both therapeutic and educationally based treatments) for patients with COPD and comorbid depression and/or anxiety, and found that patients reporting low levels of mastery in managing their COPD (as defined by the Chronic Respiratory Questionnaire Mastery subscale [4]) were more likely to engage in treatment than their respective counterparts. Similarly, patients with high self-efficacy or confidence in ability to perform physical activity report better physical functioning among patients with COPD and congestive heart failure compared to patients with low self-efficacy [88]. Consequently, patient perceptions about their physical disease, as well as their available coping resources, can be potential “gatekeepers” for engagement in mental health treatment (p. 163). To address these patient-centered barriers, focused intervention efforts are needed to improve patient engagement. Such

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efforts might include clinical techniques such as the use of modular-based approaches to increase patient choice and treatment involvement [66], acceptance-based approaches (as suggested by Baraniak and Sheffield [21]), and/or motivational interviewing techniques [89]. Structurally, the delivery of treatments that are brief in duration, use few resources, and possess flexibility for engagement (e.g., telehealth) are likely to be critical for future innovations and subsequent clinical implementation efforts. Recommendation #5: Consider Involvement of Family Interventions to Aid COPD Patients Where Possible The quality of family relationships for patients with COPD may be an important area to assess and address in treating mental health problems in these patients. Holm, Bowler, Make, et al. found that discordant family relationships were associated with psychological distress, that psychological distress was associated with impairment in health-related quality of life and dyspnea, and that discordant family relationships are indirectly associated with health-related quality of life and dyspnea via psychological distress [90]. In conclusion, the current evidence for evidence-based psychotherapies in COPD is limited. We recommend that future research efforts seek to advance not only our understanding of the effectiveness of known efficacious treatments (from other settings and patient populations) but also to examine innovative intervention modifications to content and procedure to increase patient engagement and outcomes. In addition, we recommend that research actively move towards evaluating implementation efforts. Hybrid designs, as proposed by Curran et al. [27], hold the potential to dually focus on these issues and efficiently move the field forward. ACKNOWLEDGEMENTS This work was partly supported by the VA HSR&D Houston Center of Excellence (HFP90-020). The views expressed reflect those of the authors and not necessarily those of the Department of Veterans Affairs/Baylor College of Medicine. REFERENCES [1]

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Revised: February 1, 2012

Accepted: February 11, 2012