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424

Anxiety and Depression in Chronic Obstructive Pulmonary Disease:


A N e w Intervention and Case Report
Melinda A. Stanley, Baylor College of Medicine, Houston Center for Quahty of Care and
Utzlzzatzon Studzes, a n d Michael E. DeBakey Veterans Affairs Medzcal Center
C o n n i e Veazey, Northwestern State University of Louisiana
D e r e k H o p k o , Unwersity of Tennessee-Knoxville
G r e t c h e n Diefenbach, The Institute of Lw~ng
Mark E. Kunik, Baylor College of Medzcine, Mzchael E. DeBakey Veterans Affazrs Medical Center, a n d
Veterans Affairs South Central Mental Illness Research, Educatzon, and Clinical Center

Anxzety and depmsston coexistfrequently zn chronzc obstructwepulmona~:y dzsease and compound the tmpact of the dzsease on qual-
ity of bfe and functzonal status Howev~ httle attentzon has been gwen to the development of treatment strategtesfor thzs subset of
patzents. The current artzcle describes the development of a new, mult~component cognztzve behavzoral treatmentfor reduczng anxzety
and depresswn among patzents wtth respiratory dzsease (CBT-RADAR). Outcome data from a group of 5 patzents who partzczpated
zn an ongoing clzn~cdlthai are revzewedto dlu~trate the strengths and hmztatlons of thzs mterventwn

(COPD) i s a rates are evident using self-report case identification


C
H R O N I C OBSTRUCTIVE PULMONARY DISEASE

serious and progressive medical illness with a pro- strategies (Aydin & Ulusahin, 2001; Moore & Zebb, 1999;
found impact on life function, economic burden, and van Manen et al., 2002; Yohannes, Baldwin, & Connolly,
mortality. Physical symptoms include shortness of breath, 2003). Subclinical anxiety or depressive symptoms (de-
chest pain, cough, weakness, fatigue, poor exercise toler- fined as the presence of clinically significant anxiety or
ance, nutritional abnormalities, and damage to the heart depression regardless of psychiatric diagnostic status)
and brain. The disease affects 14 to 20 million people and also are more common, with reported prevalence as high
is the fourth leading cause of death in the United States as 50% (Borson et al, 1998; Brenes, 2003). The presence
(Centers for Disease Control, 2003). Hospital readmis- of anxiety a n d / o r depressive symptoms in COPD, even
sion occurs frequently, and general rates of service use without confirmed psychiatric diagnosis, compounds the
are high (Centers for Disease Control, 2005). Associated impact of the disease on quality of life and functional sta-
economic costs are estimated at $24 billion per year (Sul- tus even when controlling for disease severity (Brenes,
livan, Ramsey, & Lee, 2000). Quality of life and functional 2003; Kim et al., 2000; Moore & Zebb, 1998; Peruzza et
status are severely impaired as a result of both the physi- al., 2003; Yohannes et al., 2003). For patients with COPD,
cal symptoms and limitations of COPD and frequently anxiety and depressive symptoms are associated vnth
coexistent psychological difficulties. more frequent hospital admissions (Yohannes, Baldwin,
Coexistent anxiety and depression are particularly & Connolly, 2000), greater duration of hospitalization
common in COPD (Borson, Claypoole, & McDonald, 1998, (Yohannes et al., 2000), increased avoidance of potenually
Brenes, 2003). In many cases, the symptoms of COPD over- therapeutic activities that require exeruon Cgellowlees et al.,
lap with those of anxiety or depression (e.g., sleep dis- 1987), and poorer outcomes following emergency treat-
turbance, decreased energy, shortness of breath, and cat- ment (Dahl6n &Janson, 2002).
astrophic thoughts about physical symptoms) and Usual care for COPD typically focuses on manage-
differential diagnosis is difficult. Nevertheless, anxiety ment of physiological symptoms, with long-acting bron-
and depressive diagnoses have been established via chni- chodilators, inhaled cortlcosteroids, and oxygen therapy
cal interview in 16% to 34% of patients with COPD associated with symptom reduction (Sin, McAlister, Man,
(Karajgi, Rlfkin, Doddi, & Kolh, 1990; Yellowlees, Alpers, & Anthonxsen, 2003). Comprehensive, multidisciphnary
Bowden, Bryant, & Ruffin, 1987). Higher prevalence rehabalitataon programs (i.e., "pulmonary rehabilitation")
that incorporate exercise training, patient/family educa-
tion, and psychosocial intervention (e.g., stress manage-
Cognitive and Behavioral Practice 12, 4 2 4 - 4 3 6 , 2005
ment) may significantly improve health status and quality
1077-7229/05/424-43651 00/0
Copyright 2005 by Association for Advancement of Behavmr of life (American Thoracic Society, 1999). The impact of
Therapy. All rights of reproduction m any form reserved psychosocial components of rehabilitation, however, is
Anxiety and Depression in COPD 425

not always clear. Some studies show positive effects of get the treatment of anxiety a n d / o r depressive symptoms
stress management (e.g., education, relaxation, cognitive as experienced by patients with COPD (Rose et al., 2002).
interventions, etc.) for reducing anxiety and depressive In one study, patients with COPD and coexistent anxiety
symptoms and increasing functional status among pa- were treated with psychotherapy that focused on educa-
tients with COPD (Blake, Vandiver, Braun, Bertuso, & tion about the role of anxiety in breathlessness and coping
Straub, 1990; de Godoy & de Godoy, 2003; Gift, Moore, skills (e.g., relaxation training) aimed at anxiety reduction
& Soeken, 1992), while other studies demonstrate no (Eiser, West, Evans,Jeffers, & Quirk, 1997). Increased exer-
unique benefits of stress management over and above tra- cise tolerance was demonstrated relative to a control con-
ditional rehabilitation strategies (Emery, Schein, Hauck, dition, but sample size was small and pretreatment group
& MacIntyre, 1998; Sassi-Dambron, Eakin, Ries, & Kap- differences were evident. Furthermore, the psychosocial
lan, 1995). None of these studies, however, focused on intervention was limited in scope. A broader and more
the treatment of patients with clinically significant anxi- comprehensive treatment model that simultaneously ad-
ety a n d / o r depressive symptoms. A more systematic ef- dressed clinically significant anxiety and depressive symp-
fort toward investigating the potenual benefits of psycho- toms in the context of the symptoms and consequences of
social treatment for anxiety and depressive symptoms in severe respiratory difficulties would be useful in delineat-
patients with COPD is needed. The potential importance ing the benefit of CBT for people with COPD.
of such an effort aimed at improving quality of life for pa- Very little psychosocial outcome work has focused spe-
tients with COPD, even when full diagnostic criteria for cifically on the concurrent treatment of anxiety and de-
anxiety and depression are not met, is underscored by pressive symptoms, despite high rates of coexistence and
data documenting the impact of subthreshold cases of evidence that changes in anxiety and depression co-occur
anxiety or depression on functional status, health care, following treatment (Persons, Roberts, & Zalecki, 2003).
and increased risk for developing a psychiatric disorder In patients with chronic medical illness, where differen-
(Cuijpers & Smit, 2004; de Beurs et al., 1999; Katon, Lin, tial diagnosis of mental health problems is complicated
Russo, & Uniitzer, 2003). and the presence of anxiety a n d / o r depressive symptoms
Only two controlled studies and a series of case studies may further impair functional status, a broad treatment
have examined the efficacy of pharmacological treat- designed to accommodate a variety of symptom patterns
m e n t for anxiety a n d / o r depressive symptoms in COPD, representing anxiety, depressmn, and somatic complaints
with some support for the utility of sertraline and bus- would be optimal (Lenze et al., 2001). In a preliminary
pirone (Argyropoulou, Patakas, Koukou, Vasiliadis, & study exploring this hypothesis, 53 patients with COPD
Georgopoulos, 1993; Borson et al., 1992; Papp et al., were assigned randomly to receive a single 2-hour group
1995; Smoller, Pollack, Systrom, & Kradin, 1998). How- session of CBT or COPD-education, with six subsequent
ever, because other research has indicated no benefits of weekly follow-up calls (Kunik et al., 2001 ). Outcome data
pharmacological treatment (Borson et al., 1998), more suggested a decrease in anxiety and depressive symptoms
controlled trials are needed to evaluate the efficacy and from pre- to posttreatment in CBT, relative to COPD-
effectiveness of antidepressant and antianxiety medica- education, and adequate patient satisfaction in both groups.
tions. Moreover, given the complications and potential Sample size was small, however, and patients were not se-
limitauons of prescribing psychotropic medications for lected based on the presence of coexistent anxiety a n d /
patients with a serious medical illness, nonpharmacologi- or depressive symptoms. In addition, CBT components
cal treatments for managing anxiety and depression in were limited to those typically utilized for the treatment
COPD should be considered. of anxiety (education, relaxation, cognitive strategies,
In this domain, the potential benefits of cognitive be- and fear-based exposure). The role of other potentially
havior therapy (CBT) for treating anxiety and depression important interventions for anxious a n d / o r depressed
in COPD are of particular interest given the established patients with medical illness (e.g., problem-solving, sleep
efficacy of this approach (Barlow, 2003; DeRubeis & Crits- hygiene, behavioral activation) was not explored.
Christoph, 1998; Martell, Addis, &Jacobson, 2001). The This article describes a more comprehensive approach
direct, collaborative, short-term nature of CBT to symp- to treating anxiety a n d / o r depressive symptoms in pauents
tom management is well suited to both medically ill and with severe respiratory difficulties. The notion of integrated
aging populations (e g., Zeiss & Steffan, 1996), and re- treatment for anxiety and depression has been advocated in
cent surveys indicate that older medical patients often recent theoretical articles and case reports (Barlow, Allen &
prefer and benefit from CBT (Are~in & Miranda, 1997; Choate, 2004; Hopko, Lejuez, & Hopko, 2004; Westra,
Landreville, Landry, Bailtargeon, Guerette, & Matteau, 2004). The treatment described here, currently under-
2001; Stanley, Hopko, et al., 2003; Umitzer et al., 2002). going efficacy testing in a randomized controlled trial
Insufficient attention, however, has been given to the de- (RCT), integrates two intervention models with docu-
velopment of a cognitive behavioral intervention to tar- mented efficacy and potential utility for medical patients:
426 Stanley et al.

* CBT-GAD/PC. a cognitive behavioral approach for s u b s e q u e n t c o n f i r m a t i o n of COPD via portable spirome-


treating anxiety m older medical patients (Stanley, try (a device that measures how well lungs exhale), a n d
Diefenbach, & Hopko, 2004) identification of clinically significant anxiety a n d / o r de-
Behavioral activation (BA): a key c o m p o n e n t of pressive symptoms according to a score of 16 or higher
CBT treatments for depression (Hopko, Lejuez, o n the Beck Anxiety Inventory (BAI; Beck & Steer, 1993)
Ruggiero, & Eifert, 2003; Jacobson, Martell, & Di- a n d / o r a score of 14 or higher o n the Beck Depression
midjian, 2001; Lejuez, Hopko, & Hopko, 2002; Mar- Inventory-II (BDI-II: Beck, Steer, & Brown, 1996).1 Eligi-
tell et al., 2001) ble patients also d e m o n s t r a t e d adequate cognitive func-
t i o n i n g as d e t e r m i n e d by a Mini Mental State Examina-
CBT-GAD/PC incorporates a range of coping skills (edu-
tion score of 24 or higher (MMSE; Folstein, Folstein, &
cation/awareness, relaxation training, cognitive therapy,
McHugh, 1975). After they were d e t e r m i n e d eligible for
problem-solving skills training, a n d sleep m a n a g e m e n t
inclusion, patients were interviewed using the Structured
skalls) to target symptoms of generalized anxiety dxsorder
Diagnostic Interview for D S M - I V (SCID; First, Spitzer,
(GAD) in later life. Initial o u t c o m e data suggest improve-
Gibbon, & Williams, 1996) to characterize the sample ac-
m e n t s following CBT-GAD/PC, relative to usual care, for
cording to psychiatric diagnostic status for secondary out-
both anxiety a n d depressive symptoms in older medical
come analyses in the RCT. Patients were assigned randomly
patients (Stanley, Hopko, et al., 2003). However, a key
in small groups to CBT-RADAR or COPD-education. T h e
c o m p o n e n t of CBT for depression, namely, BA t a r g e u n g
five patients to be discussed here were assigned r a n d o m l y
non-fear-related behaviors, was n o t i n c l u d e d given the
to o n e CBT-RADAR group within the RCT. This group
focus of CBT-GAD/PC o n anxiety. I n light of r e c e n t data
was selected as a case example given the wide range of
highlighting BA as the potential primary m e c h a n i s m of
clinical symptoms a n d experiences represented. All pa-
change in r e d u c i n g depression symptoms (Hopko et al.,
tients were treated in the same g r o u p by the same thera-
2003; Martell et al., 2001), a n d because patients with res-
pist (Veazey), with clinical supervision by the first a u t h o r
piratory difficulties often experience significant decreases
(Stanley) a n d r a n d o m review of session audiotapes by an in-
m ability to carry out previously rewarding activities
d e p e n d e n t expert in both CBT-GAD/PC a n d BA (Hopko).
(whether due to real or i m a g i n e d physical limitations),
Descriptive data for these five patients, i n c l u d i n g D S M - I V
systematic i n c o r p o r a t i o n of c o n t e m p o r a r y BA strategies
dlagnosuc status according to the SCID, are p r e s e n t e d in
was d e e m e d i m p o r t a n t for the d e v e l o p m e n t of a compre-
Table 1. Baseline scores o n all o u t c o m e measures are
hensive i n t e r v e n t i o n for patients with coexistent COPD
i n c l u d e d in Table 2.
a n d anxiety/depressive symptoms.
Bill experienced moderately severe COPD, a n d his
This article describes CBT-RADAR, a new multi-
baseline BAI a n d BDI-II indicated anxiety a n d depressive
c o m p o n e n t cognitive behavioral i n t e r v e n t i o n for reduc-
symptoms well above study cutoffs. Bill r e p o r t e d worry
ing anxiety a n d depression a m o n g patients with respira-
a b o u t m a n y topics, i n c l u d i n g the state of the country
tory disease. CBT-RADAR allows pauents to develop a
since September 11, the economy, his m o t h e r (who was
b r o a d "toolbox" of slolls that can be used to m a n a g e clin-
currently sick with breast cancer), his j o b security, a n d
ically significant anxiety, depressive a n d somatic symptoms,
the safety of the p l a n t in which he worked. He acknowl-
a n d ultimately increase the quality of llfe a n d functional
status of individuals with chronic illness All t r e a t m e n t
c o m p o n e n t s can be administered in a direct b u t collabo- 1A B~d cutoff score of 16 was selected given that scores of this
magnitude represent moderate to severe anxiety (Beck & Steer, 1993)
rative m a n n e r over a relatively brief t r e a t m e n t interval and because a cut point at this level balances well specificity(67) and
(eight sessions). A group format was selected to reduce sensiuvlty (.62) for ldennfymg anxiety among older adult psychiatric
potentml costs a n d increase social support. Here, the patients (Kabacoff, Segal, Hersen, & Van Hasselt, 1997) This score
t r e a t m e n t m o d e l is described along with five case exam- also represents anxiety seventy that Is approximately two standard
ples from a n o n g o i n g RCT to illustrate the use of CBT- deviations above the mean for an older normal commumty sample
(age 45-65, Gilhs, Haaga, & Ford, 1995, mean = 4 4, SD = 6.3) and
RADAR a m o n g patients with COPD. one standard dewatlon above the mean for an older medical sample
(age 60-84, Steer. Wallman,Kay,& Beck, 1994, mean = 7 2; SD = 6 78)
A BDI-II cutoff of 14 represents depressive symptoms in the mild
Method range according to the manual (14-19; Beck et al, 1996), but this
score corresponds with an empiricallyderived cutoff for the BDI that
Participants differentiated community and clinically symptomatic samples of
Participants i n c l u d e d five male veterans recruited for adults (cutoff = 14 3, Seggar, Lambert, & Hansen, 2002) A score of
14 also IS shghfly higher, and therefore more conservauve, than an
an RCT of CBT-RADAR relative to a COPD-education
empmcally denved cut point for identifying dysphonc adults accord-
control c o n d i t i o n Full r e c r u i t m e n t procedures are de- lng to the BDI-II (cutoff = 13; Dozols, Dobson, &Ahnberg, 1998) and
tailed elsewhere (Kumk et al., 2005). Patients were in- a score that is one standard deviation above a BDI-It mean for male
cluded in the RCT based o n an initial t e l e p h o n e screen, primary care patients (mean = 5 8, SD = 6.9, Arnau et al, 2001)
A n x i e t y a n d D e p r e s s i o n in C O P D 427

Table 1
Descriptive Data for Five Patients With COPD Treated With CBT~RADAR

Marital Living
Age Status Situation Occupation Other Medical Problems SCID Diagnosis Medication

Bill 54 yr. Divorced Alone Lab analyst Seasonal allergies; sleep apnea; Generalized Anxiety Disorder; Busplrone
arthritis; hlgh cholesterol;, Major Depression; Panic (1 e Buspar)
eczema; migraine headache; Disorder with Agoraphobia
obesity
Brady 66 yr Marned With wife Retired t e a c h e r / None None Fluoxetine
counselor 0.e. Prozac)
Tim 60 yr. Divorced With sister & Retired off refinery Congestive heart failure, Major Depression; Bnproprion
brother- foreman coronary artery disease, Anxiety NOS
m-law hypertension; obesity
Al 80 yr. Widowed Alone Reured artist; High blood pressure, arthrius, None None
part-time work aortic aneurysm
restoring
old photographs
and paintings
Max 57 yr. Divorced Alone Retired engineer High blood pressure Major Depression; Pamc Depacote;
Disorder with Agoraphobm, Bupropnon
Bipolar Disorder

Note All patients were white males. All medications were stable across treatment. COPD = Chronic Obstructive Pulmonary Disease; CBT-
RADAR = cognitive behawor therapy for reducing anxiety and depressmn a m o n g patients with respiratory disease.

Table 2
Scores at Baseline, Posttreatment, and 1Z-Months for Five Patients With COPD and Coexistent D e p r e s s i v e
a n d / o r Anxiety S y m p t o m s Treated With CBT-RADAR

SF-36 SF-36 N u m b e r of
Patient, CRQ CRQ Physical Mental Outpauent
Tlmepomts BAI BDI Physical Emotional Health Health Visits CSQ

Bill
Basehne 35 38 2.9 24 29 1 28.1 12 N/A
Posttreatment 16 ~ 10 a 3 7a 45a 43 9 ~ 55.4 ~ -- 31
12 m o n t h s 5a 0a 59~ 66~ 28.1 60.0 ~ 3 31
Brady
Baseline 12 24 2.9 48 27 1 36.0 1 N/A
Posttreatment 3a 7a 3.7 a 54a 20 6 57.0 ~ -- 24
12 m o n t h s 14 12 ~ 2.0 46 15 5 b 54.8 ~ 2 25
Tim
Baseline 36 23 26 32 27.6 33.0 2 N/A
Posttreatment 22 a 21 1.9 b 30 31.4 29.5 -- 28
12 m o n t h s 23 a 15 ~ 1.9 b 3.1 28 1 26.3 4 28
Al
Baseline 15 16 3.1 39 35.8 36.6 2 N/A
Posttreatment 10 10 3.0 4.5 a 34 4 39.2 -- 25
12 m o n t h s 19 12 3.2 4.7 a 33 7 39.0 3 24
Max
Baseline 35 26 3.7 28 34 9 18.8 1 N/A
Posttreatment 32 28 28b 33a 30 7 23.2 -- 30
12 m o n t h s . . . . . . . .

Note COPD = Chronic Obstructive Pulmonary Disease, CBT-RADAR = cognitive behavior therapy for reducing anxiety and depression a m o n g
patients with respiratory disease; BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory, SF-36 = Medical Outcomes Survey Short
F o r m - 3 6 (PH = Physical Health; MH = Mental Health); CRQ = Chronic Respiratory Questionnaire, CSQ = Client Satisfaction Questionnaire.
a I m p r o v e m e n t from baseline
b Meaningful worsening of symptoms from baseline.
428 Stanley et al.

e d g e d that it was difficult to stop worrying, a n d r e p o r t e d Max h a d severe COPD, a n d he was on oxygen therapy
b e i n g a worrier all his life. T h e worry h a d Intensified a n d 24 hours a day. Baseline scores suggested anxiety a n d de-
b e c o m e problemanc over the past 2 years. He r e p o r t e d pressive symptoms well above study cutoffs. Max s p e n t his
trouble concentraung, irritability, muscle tension, difficulty spare time watching TV a n d writing letters. Max en-
sleeping, tiring easily, a n d avoidance o f telewsion news due d o r s e d symptoms o f d e p r e s s e d m o o d , lack o f appetite,
to worry. Bill also acknowledged two major depressive epi- p s y c h o m o t o r agitation, d e c r e a s e d energy, a n d trouble
sodes in the prior 6 months, with depressed m o o d lasting a concentrating. H e also e x p e r i e n c e d panic attacks a n d
little over 2 weeks each time. H e r e p o r t e d consistent anhe- avoided going grocery shopping, r u n n i n g o t h e r errands,
d o n i a with avoidance of prevmusly pleasurable activines a n d a t t e n d i n g c h u r c h services a n d AA meetings. H e was
(e.g., photography), loss o f appetite, difficulty sleeping, re- fearful that he would b e c o m e so short of b r e a t h that he
d u c e d energy, a n d feelings of worthlessness and guilt. Bill m i g h t die, a n d he was c o n c e r n e d a b o u t how p e o p l e
r e p o r t e d having at least two panic attacks in the prior 6 might perceive him d u e to his oxygen use.
months, d u n n g which he worried that he might be having a
heart attack. H e r e p o r t e d associated avoidance of church Measures
serwces, large crowds, a n d crowded restaurants. A~xzety and depresswn. As n o t e d earlier, the BAI a n d
Brady h a d severe COPD, a n d h e utilized oxygen ther- BDMI were used to establish inclusion criteria r e l a t e d to
apy 24 hours a day. Baseline depressive symptom severity anxiety a n d depression severity. These instruments also
was above the study cutoff, a l t h o u g h anxiety severity ac- were used to evaluate outcome. Both the BAI a n d BDMI
c o r d i n g to the BAI d i d n o t e x c e e d the cutoff. Neverthe- have substantial psychometric s u p p o r t for use a m o n g
less, Brady's inability to travel easily with his family members o l d e r adults a n d / o r medical patients (Arnau, Meagher,
on outings was a source o f anxiety a n d depression. H e Norris, & Bramson, 2001; Steer et al., 1994; Wetherell &
worried that he slowed p e o p l e down given his use o f a Arefin, 1997), a n d b o t h are sensitive to c h a n g e following
scooter for transportation. Consequently, he frequently CBT (Stanley, Beck, et al., 2003; Wetherell, Gatz, &
stayed h o m e alone instead o f going o u t with his family. Craske, 2003). Meaningful i m p r o v e m e n t on the BDI was
Tim was f o r c e d to retire 5 years p r i o r to the assessment d e f i n e d a c c o r d i n g to an empirically derived Rehable
due to a c o m p a n y layoff His COPD was severe, a n d he Change I n d e x (RCI) o f 8.5 that differentiated c o m m u -
was on oxygen t h e r a p y 24 hours a day. Baseline anxiety nity a d u l t samples from those identified as clinically
a n d d e p r e s s i o n were b o t h well above study cutoffs. H e symptomatic (Seggar, Lambert, & Hansen, 2002). Given
r e p o r t e d d e p r e s s e d m o o d on almost a daily basis since re- that no c o m p a r a b l e RCI has b e e n established for the BAI,
t i r e m e n t a n d significant social withdrawal. A l t h o u g h Tim a n d because some authors have r e c o m m e n d e d against
was socially active when he was working (he enjoyed danc- use o f this i n d e x for this m e a s u r e (Wilson, de Beurs,
ing a n d a t t e n d i n g high school sporting events), he felt Palmer, & Chambless, 1999), a c h a n g e o f o n e s t a n d a r d
that he h a d b e e n "shutting down" since his retirement. At deviation a c c o r d i n g to data for an elderly medical sample
the time o f the assessment, Tim r e p o r t e d s p e n d i n g most (6.8; Steer et al., 1994) was used to characterize m e a n i n g -
o f his time watching television. H e also r e p o r t e d diffi- ful i m p r o v e m e n t .
culty sleeping, with f r e q u e n t awakenings d u r i n g the Health-related qualzty of hfe T h e C h r o n i c Respiratory
mght, physical restlessness, r e d u c e d energy, a n d mild Q u e s t i o n n a i r e (CRQ; Guyatt, Berman, Townsend, Pugs-
m e m o r y problems. H e a c k n o w l e d g e d having thoughts ley,& Chambers, 1987) was designed to m e a s u r e c h a n g e
that he would be b e t t e r off dead, b u t he d e n i e d any plans in COPD-specific quality o f life. T h e C R Q consists o f 20
to kill himself. Tim also r e p o r t e d u n e x p e c t e d p a m c at- items a g g r e g a t e d into four dimensions: dyspnea (five
tacks over the last several years. While he was n o t con- stems); faugue (four items); emotional functioning (seven
c e r n e d that he was going crazy d u n n g these attacks, he items assessing depression, sadness, frustration, worry,
worried that he m i g h t die. These symptoms d i d n o t war- a n d anxiety) ; a n d mastery (four items that assess feelings
r a n t a diagnosis o f panic disorder, as they o c c u r r e d only o f control over the disease). Response options are pre-
at times when he was having t r o u b l e b r e a t h i n g s e n t e d as seven-point L i k e r t scales (1 = poorestfunctmn;
A1 e x p e r i e n c e d m o d e r a t e l y severe COPD. T h e arthri- 7 = optzmalfunctzon). T h e C R Q is precise, valid, respon-
tis in his h a n d s also m a d e his art restoration work diffi- sive, c o m m o n l y used, a n d d e s i g n e d for clinical trials that
cult. H e a d m i t t e d to b e i n g "slightly depressed," a n d his seek to modify e m o t i o n a l response to COPD (Guyatt,
baseline BDI-II score was above the study cutoff. A1 h a d King, Feeny, Stubbing, & Goldstein, 1999; H a r p e r et al.,
difficulty c o m p l e t i n g tasks in a timely m a n n e r ; he pro- 1997). As suggested by Guyatt (2003), scores were aver-
crastinated worl~ng on j o b s a n d spent a great deal o f time aged to create o n e m e a s u r e o f physical quality o f life
sitting a n d watching television. H e expressed a desire to (CRQ-Physical = dyspnea a n d fatigue) a n d o n e measure
increase his behaviors to accomplish tasks a n d r e p o r t e d o f e m o t i o n a l quality of life ( C R Q - E m o t i o n a l = e m o t i o n
that he currently was seeing a "motivational counselor." a n d mastery). Meaningful c h a n g e on C R Q scores was
Anxiety and Depression in COPD 4Z9

defined according toJaeschke, Singer, and Guyall (1989) Treatment


who identified a change of 0.5 as a minimal clinically im- Sesston I. Orientation, motwationalexer c~ses, educatzon, and
portant difference (MCID) for patients with respiratory awareness. The initial session focused on therapy orienta-
problems. tion, a discussxon of ethical issues associated with group
Functwnal status. The Medical Outcomes Survey Short therapy, and an overvaew of roles and expectations for lead-
F o r m - 3 6 (SF-36; Ware, 1999) has been validated for use ers and participants. Patients were gwen notebooks to orga-
m patients with COPD (Harper et al., 1997; Mahler & nize session handouts and home practice exercises. Next,
MacKowlak, 1995) and is widely used to measure quality patients were led through motivational exercises during
of life in medical populations. Since patients with COPD which they discussed tile pros and cons of participation.
c o m m o n l y have coexisting illnesses, this scale was in- The remainder of this session involved group discus-
cluded to assess intervention effects on well being that sion of the symptoms of COPD, anxiety, and depression,
might not be detected by a disease-specific quality o f life with attention to physical symptoms, thoughts, behaviors,
instrument. The SF-36 has eight subscales measuring per- and quality of life. During this discussion, some attempt
ceived physical functioning, role disability due to physical was made to consider separately the symptoms character-
health problems, bodily pain, vitality, social functioning, istic of anxiety (e.g., expected danger, avoidance) and de-
role disability due to emotional health problems, and per- pression (e.g., perceived loss, withdrawal), but these dis-
ceptions of mental and general health. Two summary scores tinctions were not considered essential. More important
were created to assess functional status related to physical was an emphasis on recognizing the physical symptoms of
health (PH) and mental health (MH) functioning, as de- anxiety or depression (e.g., muscle tension; rapid pulse;
scribed in Ware (1999). Raw scale scores were transformed anhedonia; decreased appetite), despite potential over-
to T-scores, where 50 indicates average functioning (SD = lap with the symptoms o f COPD (e.g., difficulty breath-
10). Meaningful improvement for SF-36 PH and MH scores ing, fatigue), and idenufying specific thoughts and be-
was determined based on RCI's established by Ferguson, haviors associated with negative m o o d states. Themes of
Robinson, and Splaine (2002; SF-PH = 7.5; SF-MH -- 9.7). this discussion frequently involved thoughts and behav-
Pat~entsat~sfactzon. Patient satisfaction was assessed iors related to aging and illness (e.g., patients perceiving
with the Client Sausfaction Questionnaire (CSQ: Larsen, themselves as no longer being "head of the household"),
Attkisson, Hargreaves, & Nguyen, 1979), a widely used 8- loss of i n d e p e n d e n c e (e.g., due to inability to drive), and
item, empirically derived, self-report measure (e.g., Att- physical limitations associated with breathing difficulties.
kisson & Zwick, 1982). Psychometric properties for the In a review of behavioral symptoms, the group leader
CSQ are adequate (Attkisson & Greenfield, 1999), and emphasized that overt behaviors occur to (a) avozd nega-
the instrument has been used in prior trials of CBT for tive outcomes (those that are feared, unrewarding, or
anxiety in later-life medical patients (Stanley, Hopko, et both) a n d / o r (b) obtaln relief (by avoiding something
al., 2003). Scores range from 8 to 32. that is anxiety producing or by elicitlng environmental
rewards such as attention or sympathy from others).
Procedures Again, some attempt was made to dxfferentiate behaviors
All procedures for the RCT were approved by the Bay- characteristic of anxiety versus depression, but it was
lor College of Medicine Institutional Review Board, and m o r e important for patients to begin to notice behaviors
recruitment procedures are detailed in Kunik et al. that may create relief from anxiety/depression in the
(2005). All patients at the Houston VAMC with a diagno- short run but actually produce m o r e anxious or depres-
sis o f a chronic breathing disorder during the prior year sive symptoms in the long run. Examples of behavioral
were targeted for recruitment. Eligible and interested pa- symptoms typical for patients with COPD included pro-
tients were screened by telephone for the presence of crastinatlon (e.g., putting off beginning a prescribed ex-
breathing difficulties, anxiety, and depressive symptoms. ercise program due to fear of increased breathing diffi-
Patients were included based on d o c u m e n t e d COPD and culties), lethargic behaviors (e.g., staying in bed or in
chnically significant anxiety (BAI --> 16) a n d / o r depres- front o f the TV for excessive periods), safety checking
sive symptoms (BDMI --> 14) as noted earher. Here, treat- (e.g., repeatedly checking one's own respiration or heart
m e n t procedures and outcomes are described for one rate), failure to replace previously enjoyable activities
group of five patients treated within the o n g o i n g RCT for (e.g., deep sea fishing, hiking) with alternative activities
CBT-RADAR. Treatment consisted o f eight (1-hour) that were less physically d e m a n d i n g but still pleasurable
weekly sessions, with posttreatment assessments conducted (e.g., lake fishing, walking), a n d / o r r e d u c e d social activi-
after the final treatment session. Follow-up assessments ties due to embarrassment about breathing problems.
were conducted 12 months after treatment ended. At At the e n d o f Session 1, patients were asked to identify
baseline and follow-up, patients were queried about the one or two times each day when they could plan to com-
n u m b e r of outpatient visits over the prior 3 months. plete practice exercises and were encouraged to record
430 Stanley et al.

one or two experiences p e r day of anxiety o r depression, m a k i n g sure that activities r e p r e s e n t e d a sufficient range
noting associated physical, cognitive, a n d behavioral symp- o f difficulty a n d that the list i n c l u d e d acuvlties that would
toms. Patients also were asked to r e c o r d daily activities over p r o d u c e e n v i r o n m e n t a l r e i n f o r c e m e n t a n d activities that
a 1-week p e r i o d to p r o v i d e a baseline assessment that i n c o r p o r a t e d e x p o s u r e to anxiety-producing situations.
would guide subsequent behavioral activation assignments. O n c e these lists were created, each p a t i e n t was asked to
Session 2. Relaxatum skzlls; creatzon of activz~ hierarchy. As in select o n e "easy" activity to c o m p l e t e d u r i n g the u p c o m -
all s u b s e q u e n t sessions, Session 2 b e g a n with a review o f ing week. T h e g r o u p l e a d e r h e l p e d to ensure that the se-
c o m p l e t e d practice exercises, with f u r t h e r attention to lected activities were m a n a g e a b l e , a n d she assisted pa-
motivational techniques as needed. Two simple relaxation uents in d e t e r m i n i n g the frequency a n d d u r a t i o n o f the
training exercises were then conducted: one focused on p l a n n e d behavior. Patients also were asked to c o n t i n u e
d e e p b r e a t h i n g a n d the o t h e r on postural changes. The awareness m o n i t o r i n g a n d relaxation p r a c n c e d u r i n g the
d u r a t i o n o f the b r e a t h i n g cycle was r e d u c e d given signif- u p c o m i n g week.
icant respiratory difficulty in this population. Imaginal Sesszons 4 to 5: Changing thoughts and increaszng actzwly. In
exercises were c o n d u c t e d to facilitate covert practice o f b o t h Sessions 4 a n d 5, the focus was on increasing activity
these c o p i n g strategies in anxiety-producing situations. a n d t e a c h i n g cognitive skills. F o r the latter, the REACT
Next, p a u e n t s b e g a n to create a hierarchy o f activities acronym (Stanley et al., 2004) was used, where R = recog-
d e s i g n e d b o t h to increase pleasure a n d / o r accomplish- nizing thoughts; E = evaluating thoughts; A = alternative
m e n t a n d to provide e x p o s u r e to anxiety-producing situ- t h o u g h t g e n e r a u o n ; C = c o p i n g statements; a n d T =
ations. These different types o f activities typically are n o t t h o u g h t stopping. Given the complexity o f these skills,
c o m b i n e d in o t h e r m o d e l s o f t r e a t m e n t focused o n re- a n d a c o n t i n u e d c o n c u r r e n t focus o n behavioral activa-
d u c i n g the symptoms o f anxiety o r depression. Here, tion a n d exposure, this m a t e r i a l was t a u g h t a n d prac-
however, the goal was to e n c o u r a g e patients to begin to ticed over two sessions. Session 4 focused p r i m a r i l y on
face anxiety-producing situations a n d at the same time to the first three steps in this process: l d e n t i f ~ n g thoughts
integrate activities d e s i g n e d to p r o d u c e e n v i r o n m e n t a l a n d treating t h e m as hypotheses r a t h e r t h a n facts, recog-
rewards. In the spirit o f newer i d i o g r a p h i c m o d e l s o f be- nizing logical errors in thinking, a n d substituting alte:-
havioral activation ( H o p k o et al., 2003), a n d d u e to a fo- native, m o r e realistic thoughts. D u r i n g Session 5, patients
cus o n b o t h activation a n d exposure, attention was given were taught to use c o p i n g statements a n d t h o u g h t stop-
to behaviors likely to create a sense o f a c c o m p l i s h m e n t ping, with imaginal practice exercises to facilitate covert
a n d / o r pleasure in light o f individual patient goals, values, practice.
a n d fears. Patients were asked to t h i n k a b o u t potential In addition, Sessions 4 a n d 5 c o n t i n u e d to focus o n in-
new activities across a wide range o f life domains, includ- creasing activity. At the start o f each session, following a
ing i n t e r p e r s o n a l relationships, e m p l o y m e n t / v o l u n t e e r b r i e f review o f awareness a n d r e l a x a u o n practice, partici-
work, h o b b i e s / r e c r e a t i o n , health issues (e.g., diet, exer- pants discussed their e x p e r i e n c e s with activation a n d / o r
cise), a n d spirituality. S e l f - m o n i t o n n g records were re- e x p o s u r e exercises. F o r patients who were able to com-
viewed, a n d a pleasant events activity checklist was pro- plete a new activity, a discussion o f o u t c o m e s ensued, with
vided to h e l p patients b r a i n s t o r m a b o u t possible new particular attention to the resultant impact on m o o d (i.e.,
activities. Patients were asked to think o f behaviors across w h e t h e r c o p i n g skills were effective for m a n a g i n g anxiety
a range o f difficulty levels, identifying some that m i g h t be d u r i n g exposure-based activities; w h e t h e r patients no-
"easy," "medium," a n d "hard" to do, a n d to focus only on riced i m p r o v e d m o o d following behaviors designed to in-
behaviors that were observable a n d measurable. crease rewards). If anxiety a n d / o r depression were n o t
A m a j o r focus o f the discussion was on ways that previ- r e d u c e d as a result o f increased activity, the g r o u p l e a d e r
ously pleasurable o r rewarding activities m i g h t be modi- assisted participants in d e c i d i n g if it would be p r e f e r a b l e
fied in light o f physical limitations (e.g., mowing the lawn to r e p e a t the activity o r to select an alternative activity.
gradually over 2 days r a t h e r than in o n e m o r n i n g ) . As W h e n activities were c o m p l e t e d successfully, with concur-
part o f Session 2 h o m e practice exercises, patients were r e n t positive consequences for m o o d , the g r o u p l e a d e r
asked to c o n t i n u e to think o f potential new activities. a n d p a t i e n t worked t o g e t h e r to d e c i d e on a new activity,
They also were asked to c o n t i n u e m o n i t o r i n g experi- sometimes by increasing the frequency o r d u r a t i o n o f the
ences with anxiety o r d e p r e s s e d m o o d a n d to c o n d u c t previous activity a n d sometimes by a d d i n g a new activity
one imaginal practice exercise each day using newly at either the same o r increased level o f difficulty
a c q u i r e d relaxation skills. H o m e practice exercises for b o t h sessions involved
Sesston 3: Creatzng the actiwty hterar ehy T h e p r i m a r y c o n t i n u e d attention to awareness a n d relaxation strate-
goal o f this session was to create a full activity hierarchy gies. T h e p r i m a r y focus of the exercise was on the use o f
for each g r o u p m e m b e r , with clearly d e s i g n a t e d "easy," REACT skills to modify t h i n k i n g a n d o n progressive in-
"medium," a n d "hard" acuwties. Discussion c e n t e r e d on creases in activities to r e d u c e negauve m o o d .
Anxiety and Depression in COPD 431

Session 6: Problem-solving and incr easing actiw~. Session increasing activity a n d exposure. In addition, patients
c o n t i n u e d with reviews o f awareness, relaxation, REACT were asked to a t t e n d to the c u r r e n t sleep patterns a n d at-
skills, a n d increasing activity. T h e b u l k of this session, t e m p t to modify sleep-related behaviors to improve sleep
however, focused o n t e a c h i n g problem-solving skills, hygiene.
using the acronym SOLVED (Stanley et al., 2004), where Session 8." Review of skills an d continued practice; plannzng
S = select a p r o b l e m a n d identify goals; O = o p e n your for mazntenance ofgazns. In this session, h o m e practice ex-
m i n d to all possible solutions; L = list p r o s / c o n s o f each ercises were reviewed, as were all c o p i n g skills now in the
potential solution; V = verify the best solution a n d create "toolbox." Plans were m a d e for c o n t i n u e d practice a n d
a plan; E = e n a c t the plan; a n d D = d e t e r m i n e w h e t h e r follow-up assessments to be c o n d u c t e d over the subse-
the p l a n worked. T h e p o t e n t i a l role o f cognitive change q u e n t year.
in this process was h i g h l i g h t e d given that p e o p l e with
anxiety a n d d e p r e s s i o n often have difficulty perceiving
Results
that life p r o b l e m s are solvable. This issue is particularly
salient for patients with c h r o n i c medical illness, who may T h e RCT comparing CBT-RADAR and COPD-education
n o t have the same physical resources to solve p r o b l e m s as is n o t yet complete, so c o m p r e h e n s i v e t r e a t m e n t out-
they h a d in the past. T h e r e m a i n d e r o f the discussion fol- c o m e d a t a are n o t yet available. Here, quantitative a n d
lowed the SOLVED steps, using examples o f life prob- qualitative d a t a are p r e s e n t e d in a case r e p o r t f o r m a t to
lems identified from awareness exercises. describe p a t i e n t o u t c o m e s a n d to h i g h l i g h t p o t e n t i a l
T h e goal was for patients to leave this session with at strengths a n d weaknesses o f the intervention. Max's d a t a
least o n e p r o b l e m a n d potential solution identified. If are missing from 12-month follow-up d u e to a hospitaliza-
steps for carrying o u t the solution were identified, the pa- tion that p r e v e n t e d h i m f r o m c o m p l e t i n g the protocol.
tient was asked to take these actions in the u p c o m i n g Table 2 includes individual p a t i e n t scores at baseline,
week. Patients also were asked to identify at least o n e new posttreatment, a n d 12-month follow-up for six o u t c o m e
p r o b l e m a n d to c o m p l e t e the SOLVED exercise with this measures (BAI; BDI-II; CRQ-Physical; C R Q - E m o t i o n a l ;
p r o b l e m b e f o r e the n e x t session. O t h e r h o m e practice SF-36 PH; SF-36 MH) a n d satisfaction ratings (CSQ) at
i n c l u d e d c o n t i n u i n g with awareness m o n i t o r i n g , use o f p o s t t r e a t m e n t a n d follow-up. Meamngful i m p r o v e m e n t
relaxation a n d REACT skills, a n d at least o n e a d d i t i o n a l o n o u t c o m e s at p o s t t r e a t m e n t a n d follow-up are n o t e d ,
behavioral activation o r e x p o s u r e assignment. with definitions as d e s c r i b e d earlier (see Measures). All
Session 7: Sleep management sk~lls and ,ncr easing actiw~. A patients r e p o r t e d the ability to learn a n d use r e l a x a t i o n
review o f h o m e practice exercises h e r e e m p h a s i z e d the strategies, a n d all showed g o o d u n d e r s t a n d i n g o f c o p i n g
utility o f the SOLVED t e c h n i q u e a n d identification o f ad- statements a n d t h o u g h t stopping. O t h e r t r e a t m e n t com-
ditional behavioral activation a n d / o r e x p o s u r e exercises p o n e n t s were used with m i x e d success by different g r o u p
for the u p c o m i n g week. By this point, the goal was for pa- m e m b e r s , as d e s c r i b e d below.
tients to i n c o r p o r a t e c h o s e n activities m o r e regularly into Bill. Bill r e p o r t e d clinically m e a n i n g f u l i m p r o v e m e n t
their lives. T h e focus o f the r e m a i n d e r o f Session 7 was on across all outcomes at posttreatment. Maintenance o f gains
teaching s l e e p - m a n a g e m e n t skills using the SLEEP acro- o r further i m p r o v e m e n t were a p p a r e n t at follow-up for all
nym, as in Stanley et al. (2004), where S = set a r e g u l a r measures except the SF-36 PH, which r e t u r n e d to baseline
bedtime; L = limit use o f the b e d (to sleep o r sex) to re- levels. At follow-up, BAI a n d BDI-II scores no longer m e t
duce associations between the b e d a n d behaviors that are study inclusion criteria, m e n t a l health f u n c t i o n i n g was
n o n p r o d u c t i v e for sleep; E = exit the b e d if n o t asleep m o n e s t a n d a r d deviation above the m e a n , a n d n u m b e r o f
15 to 20 minutes; E = eliminate naps (by substituting o u t p a t i e n t visits was r e d u c e d . Bill r e p o r t e d consistently
some alternative behavior to c o m b a t daytime sleepiness high levels o f satisfaction with the intervention.
such as a walk, a t e l e p h o n e call, a trip to the store, etc.) o r D u r i n g g r o u p sessions, Bill readily identified symp-
limit daytime sleeping to o n e h o u r b e f o r e 3:00 P.M.; P = toms o f anxiety a n d depression, a n d he easily m a d e con-
p u t y o u r feet o n the floor at the same time every m o r n - nections between his c u r r e n t b r e a t h i n g difficulties, lack
ing, give o r take 30 minutes. These skills may be particu- o f activity, a n d negative mood. H e c o m p l e t e d h o m e prac-
larly i m p o r t a n t for patients with c h r o n i c medical illness tice exercises a n d r e p o r t e d particular benefit from REACT
because their levels o f activity often are r e d u c e d , result- skills. H e was able to differentiate thoughts a n d feelings,
ing in increased d i s r u p t i o n o f sleep. A l t h o u g h increasing identify logical errors, a n d substitute alternative thoughts,
activity can be useful for i m p r o v e d regulation o f sleep, particularly in situations r e l a t e d to his m o t h e r ' s d e c l i n i n g
specific sleep hygiene skills often are necessary. h e a l t h a n d functional difficulties. F o r example, Bill expe-
H o m e practice for Session 7 involved c o n t i n u e d aware- r i e n c e d sigmficant guilt after his m o t h e r fell in a n u r s i n g
ness m o n i t o r i n g a n d practice wath relaxation, REACT, h o m e , with associated thoughts that she would n o t have
a n d SOLVED skills, as well as c o n t i n u e d attention to fallen if he h a d u r g e d h e r to move in with him. H e was
432 S t a n l e y e t al.

able to use REACT skills to r e d u c e feelings o f guilt in this riding a stationery bicycle for 6 minutes a day, b u t he was
instance. In a n o t h e r s i t u a u o n , Bill r e p o r t e d negative u n a b l e to follow t h r o u g h with this assignment d u e to ill-
m o o d following receipt o f an insurance letter stating that ness. H e was e n c o u r a g e d to focus on a n d identify alterna-
his m o t h e r owed money. H e was able to identify a n d tive positive events that would require less exertion. Sub-
modify thoughts (e.g., "This is the worst thing that could sequently, he was able to obtain information about ceramic
ever h a p p e n " ; "I c a n n o t imagine how I wall h a n d l e this"; a n d o t h e r r e c r e a t i o n classes a n d to m a k e some initial
a n d "I should be able to h a n d l e this without any prob- steps toward a n o t h e r goal o f r e s u m i n g v o l u n t e e r work
lems"), with resultant i m p r o v e d m o o d a n d ability to man- with prison inmates. SOLVED skills were used to h e l p
age t h e situation. Bill's p r i m a r y b e h a v i o r a l activation Brady identify m a n a g e a b l e steps toward this latter goal.
goals i n c l u d e d b e c o m i n g m o r e physically active a n d Brady r e p o r t e d no sleep difficulties.
c l e a n i n g / o r g a n i z i n g his h o m e . H e imtially set a goal o f T,m. Tim's self-report data suggested a m e a n i n g f u l re-
walking 2 days p e r week, b u t e n c o u n t e r e d some difficul- duction m anxiety seventy (BAI) at posttreatment. This
ties with m a i n t a i n i n g this r e g u l a r r o u t i n e when he h a d i m p r o v e m e n t was m a i n t a i n e d at 12-month follow-up, at
t r o u b l e getting to a local school track to walk. SOLVED which time severity o f d e p r e s s e d m o o d also showed a
skills were used to assist Bill with establishing a m o r e reg- m e a n i n g f u l r e d u c t i o n . Both BAI a n d BDI-II scores at
ular i n - h o m e exercise p r o g r a m that involved the use o f follow-up r e m a i n e d above study cutoffs, b u t improve-
videotapes. H e also was able to begin cleaning a n d orga- m e n t in these areas was particularly n o t a b l e in light o f de-
nizing his h o m e before the e n d o f active treatment. Bill terioration in physical quahty o f life (CRQ-Physical) a n d
r e p o r t e d n o p r o b l e m s with sleep, so htfle attention was a shght increase in n u m b e r o f o u t p a u e n t wsits. Tim re-
given to the use o f SLEEP skills in his case. p o r t e d high satisfaction with the intervention, a n d he
Brady. Brady d e m o n s t r a t e d clinically m e a n i n g f u l im- p a r t i c i p a t e d well in the group. H e consistently was sup-
p r o v e m e n t at p o s t t r e a t m e n t on five o f six o u t c o m e s (BAI, portive o f o t h e r g r o u p m e m b e r s , b u t he h a d difficulty ap-
BDI-II, C R Q - E m o t i o n a l , a n d SF-36 MH). At follow-up, plying c o p i n g skills to his own situauons a n d c o m p l e t i n g
improvements in depressive symptom severity a n d mental practice assignments. With some e n c o u r a g e m e n t , h e was
health f u n c t i o n i n g were m a i n t a i n e d , the BDI-II score re- able to discuss how his c u r r e n t living situation (with his
m a i n e d below study cutoff, a n d SF-36 M H was in the nor- sister a n d brother-in-law) was a p r i m a r y source o f depres-
mal range. Anxiety severity (BAI) a n d C R Q scores, how- sion a n d anxiety, a n d he r e c o g n i z e d that he b l a m e d him-
ever, r e t u r n e d to baseline levels, p e r h a p s as a result o f self for his p o o r health a n d the loss o f his j o b . H e was en-
d e c l i n i n g physical health status (SF-36 PH) It is notable, c o u r a g e d to identify o t h e r factors c o n t r i b u t i n g to these
however, that n u m b e r o f o u t p a t i e n t visits r e m a i n e d virtu- events, i n c l u d i n g c o m p a n y downsizing a n d the laying off
ally the same from b a s e h n e to follow-up. Brady r e p o r t e d o f o l d e r employees, which were n o t u n d e r his control.
satisfaction with the intervention. However, Tim h a d consistent difficulty with identifying
Brady initially h a d difficulty c o m p l e t i n g h o m e prac- logical errors a n d substituting alternative thoughts.
tice exercises, a n d a d d i t i o n a l m o u v a t i o n a l exercises were With significant h e l p from o t h e r g r o u p m e m b e r s a n d
used to h i g h l i g h t the pros a n d cons of this acuvity. Brady the therapist, Tim set an initial behavioral goal o f riding a
also missed two sessions d u e to illness, t h o u g h he was able stationery bicycle, a n d h e m a d e some progress in this re-
to m a k e u p this time in individual a p p o i n t m e n t s with the gard. Behavioral activation also was discussed as a poten-
g r o u p leader. In Session 1, Brady readily r e c o g n i z e d the tial c o p i n g strategy for his d e p r e s s e d m o o d related to his
c o n n e c t i o n between anxiety a n d worsening o f respiratory living situation, as he felt that he was m a k i n g no contribu-
symptoms, a n d he identified situations such as catching tion to the h o u s e h o l d . T h e g r o u p h e l p e d Tim b r a i n s t o r m
the bus o n time, which l e d to b o t h increased anxiety a n d potential ways in which he could b e g i n to m a k e m o r e
e x a c e r b a t i o n o f b r e a t h i n g difficulties. H e subsequently contributions, such as h e l p i n g with yard work o r r u n n i n g
was able to identify anxiety-related thoughts associated errands. Nevertheless, he was n o t able to sustain his ini-
with a c c o m p a n y i n g his family on outings (e.g., "What if tial efforts to exercise o r to follow t h r o u g h with any o f
t h e r e ~s a c u r b that my s c o o t e r c a n n o t g e t over?" "What these alternauve activities. Tim also r e p o r t e d sleep prob-
~f the aisles at a craft show are too narrow for m e to pass lems. H e lived in a small r o o m in his sister's house, a n d
with my scooter?"). H e d e m o n s t r a t e d some iniual diffi- he spent most o f his day in the same r o o m where he slept.
culty with identifying logical e r r o r s a n d alternative H e s p e n t the majority o f his time watching television a n d
thoughts. However, by Session 8, Brady r e p o r t e d benefits often fell asleep in his chair D u r i n g a discussion o f
o f REACT skills for c o p i n g with the possibility that his SLEEP skills, the g r o u p suggested ways that Tim m i g h t
wife was d e v e l o p i n g symptoms o f d e m e n u a . With r e g a r d get o u t o f his r o o m d u r i n g the day a n d limit naps. T i m
to increasing acuvity, Brady iniually r e p o r t e d that he was u n a b l e to follow t h r o u g h with these suggestions. In
w a n t e d to start some type o f exercise p r o g r a m a n d find a the final g r o u p session, Tim i n d i c a t e d that he d i d n o t
new hobby, such as ceramics. His first goal involved want to make any m o r e changes, saying, "I am set m my
Anxiety and Depression in COPD 433

ways." Although motivational exercises were repeated was helping his daughter financially, and this was placing
t h r o u g h o u t the treatment phase, Tim may have bene- a strain on him, but he felt obligated to assist her as he de-
fited from more indiwdual attention to bolster motiva- p e n d e d u p o n her to help him run errands. He also iden-
tion and readiness for change. tified anxiety-related thoughts resulting from his oxygen
Al. A1 reported meaningful improvement in emotional use (e.g., he was not attractive to women; other people
quality of life at posttreatment and 12-month follow-up. t h o u g h t negatively of him), and he was able to use cogni-
No other improvement was noted, although he reported tive strategies to modify some o f these thoughts. His be-
satisfaction with the treatment. N u m b e r of outpatient vis- havioral goals included resuming his attendance of AA
its did not change appreciably from baseline to follow-up. meetings and church. Initially, he was able to attend AA
A1 was an enthusiastic group participant, appearing to and speak with several people in the lobby whom he had
grasp concepts easily and offering insight about other not seen for some time, but he was not able to go into the
participants' difficulties. Early on, A1 identified physical formal meetings. Later, he was able to join the group
symptoms related to depression (hypersomnia, lack of meetings. He also reported benefits of SLEEP skills for
energy), associated negative thoughts ("I cannot perform improving his sleep hygiene, including setting a regular
as efficiently as I used to"; "My aneurysm may rupture at wake time and eliminating naps. However, despite these ap-
any moment"; "I am worthless for not getting things done"), parent changes in coping strategies, Max failed to report
and lethargic behaviors (watching television all day). He benefits of the group on most posttreatment measures.
expressed a strong desire at the start of group to change
his behavior to accomplish goals related to his art restora-
Discussion
tion work. However, A1 had difficulty completing h o m e
practice exercises, despite significant attention to motiva- CBT-RADAR was developed to reduce anxiety and de-
tional exercises and ways m which he might schedule this pressive symptoms for patients with COPD. Case report
activity into his normal daily routine (e.g., while he drank data from five patients participating in an ongoing RCT
his m o r n i n g coffee). He also missed one session due to suggested significant variability in response and ability to
illness, had difficulty with the more complex cognitive use coping skills. O n e patient (Bill) reported meaningful
coping skills (e.g., identifying logical errors, substituting improvements in almost all variables over both treatment
alternative thoughts), and was unable to reach his initial and follow-up. A n o t h e r patient (Brady) demonstrated
identified goal of establishing a walking routine. How- meaningful improvements over the treatment interval,
ever, a group discussion o f REACT skills as they might be but not all gains were maintained over follow-up, poten-
useful for helping A1 change depressive-related thoughts tially due to declining physical health status. A third pa-
seemed particularly useful in increasing his motivation to tient (Tim) showed improvement with regard to anxiety
b e c o m e more active. Some of this discussion focused on and depressive symptoms, a result that is notable in light
reducing a l l / n o n e thinking and reestablishing work ex- of deteriorating physical quality of life. Two patients (A1,
pectations that were manageable in light of Al's medical Max) demonstrated improvement only in disease-specific
problems. Before b e c o m i n g medically ill, Al worked be- emotional quality of life. Qualitative data also suggested
tween 12 and 15 hours per daywithout tiring. This type of significant x-ariability in patient outcomes and abilities to
schedule no longer was possible. In response to this dis- use various coping skills. All patients were able to learn re-
cusslon, A1 decided that he would like to make a greater laxation and simple cognitive skills (i.e., coping statements;
c o m m i t m e n t to behavioral activation, and he modified thought stopping), but other skills (e.g., more complicated
his activity plan to involve playing the piano, a pleasur- cognitive interventions; problem-solving, behavioral acti-
able activity he had given up m a n y years prior. By the end vation; a n d s l e e p - m a n a g e m e n t skills) were difficult for
of group sessions, Al had begun to play the piano twice a some patients to u n d e r s t a n d a n d / o r i m p l e m e n t a n d
day. He also reported modification of his sleep schedule therefore not consistently useful for all individuals.
to incorporate a consistent wake time and to limit day- Although conclusions await examination o f data from
time naps to 1 h o u r in the early afternoon. the full clinical triM, one major strength o f the interven-
Max. Max's self-report data indicated meaningful im- tion is the breadth o f treatment, with coping skills repre-
provement in emotional quality of life (CRQ-Emotional), senting a wide range of skills with demonstrated efficacy
but deteriorating physical quahty of life (CRQ-Physical) for improving anxiety and depression (Barlow et al.,
at posttreatment. No changes occurred in anxiety or de- 2004). The large n u m b e r of coping skills in CBT-RADAR
pression. However, self-reported sattsfaction with the in- allows for the potential utility of the intervention a m o n g
tervention was high. Max was able to discuss in the group heterogeneous groups of patients with variable symptom
that his anxiety had worsened over the prior 6 months to presentations and abilities. The range of treatment tech-
the point where he rarely left his apartment. He de- niques vary in difficulty, as well as with regard to expected
scribed anxiety related to his financial situation; i.e., he outcomes related to anxiety, depression, or both. Coping
434 Stanley et al.

skills also r e p r e s e n t attention to a r a n g e of response mo- differences in p r e s e n c e o f COPD diagnosis, associated


dalities for b o t h anxiety a n d depressive symptoms (e.g., functional capacity, a n d t r e a t m e n t response for patients
cogniuve, somatic, behavioral). A n o t h e r strength o f the with b r e a t h i n g disorders ( C h a p m a n , Tashkin, & Pye,
i n t e r v e n t i o n is the e x p e c t e d utihty for m a n a g i n g m e n t a l 2001; Hankinson, O d e n c r a n t z , & Fedan, 1999; Leidy &
h e a l t h symptoms even in the absence o f formally diag- Traver, 1995; Rose et al., 2002; Vollmer et al., 2000), at-
nosed disorders, a l t h o u g h t h r e e o f the five l n c t u d e d pa- t e n t i o n to the i m p a c t o f CBT-RADAR across a diverse
taents h a d symptoms that m e t criteria for an anxiety a n d / sample o f patients is essential. In addition, m e d i c a l care
o r depressive disorder. Nevertheless, the t r e a t m e n t is not for patients in this r e p o r t was p r o v i d e d by o t h e r clinics
directed toward improving symptoms o f any specafic D S M - wathin the VA system, a n d no attention was given to this
/V diagnostic category; rather, the focus is on modifying issue in CBT-RADAR. This lack o f attention to medical
cognitions a n d behaviors c o m m o n to a range o f anxiety a d h e r e n c e may explain a n o t h e r significant s h o r t c o m i n g
a n d depressive disorders. In these domains, CBT-RADAR o f the i n t e r v e n t i o n - - i t s inability to have an i m p a c t on
is a novel a p p r o a c h , perhaps the first o f its type to target health-related quality o f hfe. In future studies, t r e a t m e n t
the needs o f patients with coexistent COPD a n d m e n t a l p r o c e d u r e s will n e e d to be m o d i f i e d to i n c o r p o r a t e an
h e a l t h symptoms. Finally, despite variability in t r e a t m e n t i m p r o v e d m a i n t e n a n c e phase a n d increased attention to
response, self-reported p a u e n t satisfaction was uniformly medical care m a n a g e m e n t . I n c o r p o r a t i o n of specific strat-
high at p o s t t r e a t m e n t a n d over long-term follow-up. egies from p u l m o n a r y rehabilitation programs a i m e d at
Nevertheless, limitations of the interventaon can be i m p r o v i n g physical o u t c o m e s would a p p e a r to be an-
identified in light o f variable p a t i e n t response, some o f o t h e r useful direction.
which may have resulted from insufficient flexibility an Despite these limitations a n d the n e e d for r e f i n e m e n t
t r e a t m e n t p r o c e d u r e s to m e e t individual p a t i e n t needs. o f t r e a t m e n t p r o c e d u r e s , CBT-RADAR appears to be a
A d m i n i s t r a t i o n o f CBT-RADAR in a g r o u p f o r m a t likely potentially useful intervention for treating anxiety a n d
c o n t r i b u t e d to this restricted flexibility. F o r example, depressive symptoms for patients with COPD. T h e pri-
even when a parUcular skill was n o t a p p r o p r i a t e for every m a r y goal o f r e d u c i n g m e n t a l h e a l t h symptoms in
p a t i e n t (e.g., n o t all patients h a d sleep difficulties a n d p a u e n t s with chronic illness was attained for t h r e e o f five
t h e r e f o r e d i d n o t n e e d SLEEP skills), the g r o u p f o r m a t patients, a n d the variable response across individuals was
called for reviewing the skill in some detail, thus limiting consistent with o u t c o m e s following the use o f o t h e r em-
time that m i g h t have b e e n used m o r e effecuvely to rein- pirically s u p p o r t e d i n t e r v e n u o n s (Chambless & Ollen-
force alternative skills that were m o r e relevant. In o t h e r dick, 2001). Data from the full clinical trial will evaluate
cases, even t h o u g h certain skills were too c o m p l e x to be m o r e fully the utility o f this intervention relative to an ed-
useful for all patients (e.g., adentifying logical errors a n d ucation control condition, a n d a d d i t i o n a l analyses will
substituting alternative thoughts), the g r o u p f o r m a t re- e x a m i n e the i m p a c t o f the intervention on service use
q m r e d u m e for reviewing a n d practicing these skills to a n d differential response for patients with a n d without
m a k e t h e m available for patients who were able to bene- psychiatric diagnoses o f anxiety a n d / o r depression. Fu-
fit. Lakewise, b r i e f mouvational exercises may have b e e n ture studies will e x a m i n e a d d i t i o n a l benefits that may re-
insufficient for some patients, a n d the assignment o f be- sult from an i m p r o v e d version o f CBT-RADAR, which al-
havioral activation tasks hkely r e q u i r e d a m o r e adiographic lows for increased flexibility a n d i d i o g r a p h i c attention to
a p p r o a c h than was feasible here given the complexity of p a t i e n t needs. T h e utility o f t r e a t m e n t variants for pa-
the m u l t i c o m p o n e n t intervention. I n c o r p o r a t i n g some- tients with o t h e r chronic medical illnesses also will be o f
what m o r e substantave motivataonal a p p r o a c h e s (Miller & interest, as will be investigations into the utility o f CBT-
Rollnick, 2002) a n d a m o r e t h o r o u g h functional analysas RADAR as p a r t o f a collaborative care m o d e l to provide
o f behavior, as suggested by Martelt et al. (2001), may i n t e g r a t e d care for patients with coexistent medical a n d
have b e e n useful in thas regard. Fmally, the g r o u p f o r m a t psychological difficulties.
limited flexibility with r e g a r d to scheduling appoint-
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disease Journal cf the A merzcan Med,cal Assoc, at~on, 290, 2301-2312 This work was supported by a Health Services Research and
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trahne effects on dyspnea in patients ruth obstructive mrways dis- and by a grant from the Nauonal Institute of Mental Health (R01-
ease Psyehosomat*cs, 39, 24-29 MH53932) to the first author
Stanley, M A , Beck,J G , Novy, D M , Avenll, P M , Swann, A C , Dlef- Address correspondence to Melmda A StanleTg Ph D., M e n m n g e r
enbach, G J , & Hopko. D R (2003) Cognitive behavmral treat- Department of Psychiatry and Behaworal Sciences, Baylor College of
m e n t of late-hfe generalized anxiety d~sorder Journal of Consultzng
Medicine, 2002 Holcombe Blvd (152), Houston, TX 77030; e-mail
and Chmcal Psychology, 71. 309-319
Stanley, M A , Diefenbach. G J , & Hopko, D R (2004) Cognitive mstanley@bcm tmc edu
behavioral treatment for older adults with generalized anxiety dis-
order A therapist manual for primary care settings Bebawoa Mod- Recezved June 10, 2004
*ficatzon, 28, 73-117. Accepted March 2, 2005