The effect of complex interventions on depression and anxiety in chronic obstructive pulmonary disease: systematic review and meta-analysis

Peter A Coventry, Peter Bower, Christopher Keyworth, Cassandra Kenning, Jasmin Knopp, Charlotte Garrett, Daniel Hind, Alice Malpass, Chris Dickens, Peter A Coventry, Peter Bower, Christopher Keyworth, Cassandra Kenning, Jasmin Knopp, Charlotte Garrett, Daniel Hind, Alice Malpass, Chris Dickens

Abstract

Background: Depression and anxiety are very common in people with chronic obstructive pulmonary disease (COPD) and are associated with excess morbidity and mortality. Patients prefer non-drug treatments and clinical guidelines promote non-pharmacological interventions as first line therapy for depression and anxiety in people with long term conditions. However the comparative effectiveness of psychological and lifestyle interventions among COPD patients is not known. We assessed whether complex psychological and/or lifestyle interventions are effective in reducing symptoms of anxiety and depression in patients with COPD. We then determined what types of psychological and lifestyle interventions are most effective.

Methods and findings: Systematic review of randomised controlled trials of psychological and/or lifestyle interventions for adults with COPD that measured symptoms of depression and/or anxiety. CENTRAL, Medline, Embase, PsychINFO, CINAHL, ISI Web of Science and Scopus were searched up to April 2012. Meta-analyses using random effects models were undertaken to estimate the average effect of interventions on depression and anxiety. Thirty independent comparisons from 29 randomised controlled trials (n = 2063) were included in the meta-analysis. Overall, psychological and/or lifestyle interventions were associated with small reductions in symptoms of depression (standardised mean difference -0.28, 95% confidence interval -0.41 to -0.14) and anxiety (standardised mean difference -0.23, 95% confidence interval -0.38 to -0.09). Multi-component exercise training was the only intervention subgroup associated with significant treatment effects for depression (standardised mean difference -0.47, 95% confidence interval -0.66 to -0.28), and for anxiety (standardised mean difference -0.45, 95% confidence interval -0.71 to -0.18).

Conclusions: Complex psychological and/or lifestyle interventions that include an exercise component significantly improve symptoms of depression and anxiety in people with COPD. Furthermore, multi-component exercise training effectively reduces symptoms of anxiety and depression in all people with COPD regardless of severity of depression or anxiety, highlighting the importance of promoting physical activity in this population.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Risk of bias summary: review…
Figure 1. Risk of bias summary: review authors’ judgements about each risk of bias item for each included study.
Figure 2. Effects of complex interventions on…
Figure 2. Effects of complex interventions on self-reported depression symptoms at post-treatment.
Note: Meta-analysis of Individual trial and pooled effects. Random effects model used. 95% CI = 95% confidence intervals; SMD = standardised mean difference.
Figure 3. Effects of complex interventions on…
Figure 3. Effects of complex interventions on self-reported anxiety symptoms at post-treatment.
Note: Meta-analysis of individual trial and pooled effects. Random effects model used. 95% CI = 95% confidence intervals; SMD = standardised mean difference.
Figure 4. Funnel plot of effect size…
Figure 4. Funnel plot of effect size versus standard error for depression outcomes.
Figure 5. Funnel plot of effect size…
Figure 5. Funnel plot of effect size versus standard error for anxiety outcomes.
Figure 6. Effects of complex interventions by…
Figure 6. Effects of complex interventions by sub-group on self-reported symptoms of depression at post-treatment.
Note: Random effects model used. 95% CI = 95% confidence interval; SMD = standardised mean difference.
Figure 7. Effects of complex interventions by…
Figure 7. Effects of complex interventions by sub-group on self-reported symptoms of anxiety at post-treatment.
Note: Random effects model used. 95% CI = 95% confidence interval; SMD = standardised mean difference.
Figure 8. Effects on self-reported symptoms of…
Figure 8. Effects on self-reported symptoms of depression in sub-group of non-exercise based complex interventions.
Note: Random effects model used. 95% CI = 95% confidence interval; SMD = standardised mean difference.
Figure 9. Effects on self-reported symptoms of…
Figure 9. Effects on self-reported symptoms of anxiety in sub-group of non-exercise based complex interventions.
Note: Random effects model used. 95% CI = 95% confidence interval; SMD = standardised mean difference.
Figure 10. Effects on self-reported symptoms of…
Figure 10. Effects on self-reported symptoms of depression in trials that included confirmed depressed samples or above threshold samples.
Note: Random effects model used. 95% CI = 95% confidence intervals; SMD = standardised mean difference.
Figure 11. Effects on self-reported symptoms of…
Figure 11. Effects on self-reported symptoms of anxiety in trials that included confirmed anxious samples or above threshold samples.
Note: Random effects model used. 95% CI = 95% confidence intervals; SMD = standardised mean difference.
Figure 12. Effects on self-reported symptoms of…
Figure 12. Effects on self-reported symptoms of depression in trials where severity of depression was unknown at baseline.
Note: Random effects model used. 95% CI = 95% confidence intervals; SMD = standardised mean difference.
Figure 13. Effects on self-reported symptoms of…
Figure 13. Effects on self-reported symptoms of anxiety in trials where severity of anxiety was unknown at baseline.
Note: Random effects model used. 95% CI = 95% confidence intervals; SMD = standardised mean difference.

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