Thomas G. Willgoss

Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: prevalence, relevance, clinical implications and management principles.

To review evidence regarding the prevalence, causation, clinical implications, aspects of healthcare utilisation and management of depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease.

Anxiety Disorders in Patients With COPD: A Systematic Review

BACKGROUND: There is a growing interest in the role of comorbid anxiety in patients with COPD. Comorbid anxiety has a major impact on physical functioning, health-related quality of life, and healthcare utilization. However, the prevalence of clinical anxiety, particularly specific anxiety diagnoses, in patients with COPD remains unclear. OBJECTIVE: We performed a systematic review of studies that report the prevalence of clinical anxiety and specific anxiety disorders in patients with COPD. METHODS: We searched for articles in CINAHL, EMBASE, MEDLINE, and PsycINFO, from 1966 to January 31, 2012, with a focus on studies that utilized clinical interviews for a robust psychiatric diagnosis in patients with COPD. RESULTS: Of 410 studies identified, 10 met the inclusion criteria for review. The studies had small to modest sample sizes (n = 20–204) and included mainly male COPD subjects (71% male). The prevalence of clinical anxiety ranged from 10–55% among in-patients and 13–46% among out-patients with COPD. The reported prevalence of specific anxiety disorders ranged considerably, and included generalized anxiety disorder (6–33%), panic disorder (with and without agoraphobia) (0–41%), specific phobia (10–27%), and social phobia (5–11%). Women were significantly more likely to have a clinical anxiety disorder, particularly specific phobia and panic disorder. CONCLUSIONS: There is a high prevalence of clinical anxiety in patients with COPD. Social phobia and specific phobia appear to be particularly prevalent, yet they have received little attention within existing literature. Further research into effective management and screening for clinical anxiety disorders is warranted.

Tiotropium for Treatment of Stable COPD: A Meta-analysis of Clinically Relevant Outcomes

OBJECTIVE: To systematically review recent evidence on the effectiveness of tiotropium versus placebo, ipratropium, and long-acting β2 agonists on outcomes relevant to patients with stable COPD, including health-related quality of life, dyspnea, exacerbations and hospitalizations. METHODS: Our inclusion criteria for trials were: ≥ 12 weeks; compared tiotropium to placebo, ipratropium, or long-acting β agonists; patients ≥ 40 y old and with stable COPD. Sixteen trials (16,301 patients) met the inclusion criteria. RESULTS: Tiotropium improved health-related quality of life (measured with St Georges Respiratory Questionnaire) compared to placebo (odds ratio [OR] 1.61, 95% CI 1.38–1.88, P < .001) and ipratropium (OR 2.03, 95% CI 1.34–3.07, P = .001). Tiotropium also improved dyspnea (measured with the Transitional Dyspnea Index) compared to placebo (OR 1.96, 95% CI 1.58–2.44, P < .001) and ipratropium (OR 2.10, 95% CI 1.28–3.44, P = .003). Tiotropium decreased the likelihood of an exacerbation (OR 0.83, 95% CI 0.72–0.94, P = .004) and related hospitalizations (OR 0.89, 95% CI 0.80–0.98, P = .02) but not serious adverse events (OR 1.06, 95% CI 0.97–1.17, P = .19), compared to placebo. The cumulative incidence of dry mouth was 7.4% with tiotropium, compared to 3.9% with ipratropium, 1.6% with salmeterol, and 2.0% with placebo. CONCLUSIONS: In stable COPD, tiotropium showed superior efficacy in improving quality of life and dyspnea, compared to placebo and ipratropium. However, tiotropiums differences with salmeterol were less clear.

Relationship Between Anxiety, Depression, and Quality of Life in Adult Patients With Cystic Fibrosis

BACKGROUND: The impact of anxiety and depression on quality of life (QOL) in adult patients with cystic fibrosis (CF) is fully unknown. We investigated the prevalence and factors associated with anxiety and depression, including QOL, in adult CF patients. METHODS: One hundred twenty-one adult CF subjects, age ≥ 18 years were recruited from our out-patient clinic. Participants self-completed the Hospital Anxiety Depression Scale and the Cystic Fibrosis Quality of Life Questionnaire (CF-QOL). Socio-demographic data and values for lung function were extracted from the medical notes. RESULTS: Mean ± SD age was 30 ± 8.8 years, and age ranged 18–70 years. Forty (33%) were identified with anxiety symptoms, 20 (17%) with depressive symptoms. Factors related with depression were impaired QOL and low lung function. Anxiety was associated with difficulty in interpersonal relationships and severity of chest symptoms. The CF-QOL sub-domains (physical functioning, social functioning, treatment issues, chest symptoms, emotional functioning, concerns for the future, interpersonal relationships, body image, future/career concerns, and total CF-QOL) were all significantly correlated with anxiety (P < .001) and with depression (P < .001), respectively. CONCLUSIONS: Anxiety and depressive symptoms are common in adult CF patients. They are associated with poorer QOL, low lung function, reduced physical functioning, and severity of chest symptoms. Therefore, routine screening for symptoms of anxiety and depression is a worthy endeavor, and those identified with elevated clinical symptoms should be referred to receive appropriate treatment.

“Everything was spiraling out of control”: Experiences of anxiety in people with chronic obstructive pulmonary disease

OBJECTIVE This study sought to elicit and describe the first-hand experiences of anxiety in community patients with stable chronic obstructive pulmonary disease (COPD). Anxiety is common among patients with COPD. Clinical anxiety affects up to two thirds of patients, leading to reduced quality of life and physical functioning. There has been little research exploring the experiences of anxiety in patients with COPD, particularly in individuals with stable respiratory symptoms. METHODS We interviewed 14 community patients with stable COPD and self-reported symptoms of anxiety. Data were analyzed using thematic network analysis to develop basic, organizing, and global themes. RESULTS Patients reported intense thoughts of fear, hopelessness, and confusion that were associated with the anxiety and panic attacks. Self-management was important, particularly self-talk coping strategies. CONCLUSIONS Unmanaged anxiety seems to be particularly distressing for patients with COPD. Self-management strategies can be highly effective in preventing and managing anxiety.

The Development and Validation of the Anxiety Inventory for Respiratory Disease

BACKGROUND Anxiety is a common comorbidity in patients with COPD, yet it remains underrecognized. Existing anxiety measures contain somatic items that can overlap with symptoms of COPD and side effects of medications. There is a need for a disease-specific nonsomatic anxiety scale to screen and measure anxiety in patients with COPD. METHODS In phase 1, 88 patients with COPD (mean age 71 years, 36% men) completed a 16-item scale developed with patients and clinicians. Six items were removed using item and factor analysis. In phase 2, 56 patients with COPD (mean age 70 years, 48% men) completed the 10-item scale and other self-report measures of anxiety, quality of life, and functional limitations. Of these, 41 patients completed the scale on a second occasion, 14 days later. Construct validity (using confirmatory factor analysis [CFA]), discriminant validity, convergent validity, and anxiety screening accuracy were explored. RESULTS The Anxiety Inventory for Respiratory Disease (AIR) had high internal consistency (Cronbach α = 0.92) and test-retest reliability (intraclass correlation coefficient = 0.81) and excellent convergent validity, correlating with the Hospital Anxiety and Depression-Anxiety subscale (r = 0.91, P < .001). The scale also discriminated between patients with clinical anxiety (measured using the Patient Health Questionnaire) and those without (U = 9, P < .001). A cutoff score of 14.5 yielded a sensitivity of 0.93 and specificity of 0.98 for detection of clinical anxiety. A two-factor model of general anxiety and panic symptoms had the best fit according to CFA. CONCLUSIONS The AIR is a short, user-friendly, reliable, and valid scale for measuring and screening anxiety in patients with COPD.

Mind the gaps – Health Professions students’ views of support systems

This paper reports on students’ views of support services identified through the findings of a study of health professions student attrition in the North West of England. Health professions programmes attract a diverse student population and their educational experience is dissimilar to the general student population in a number of ways, as they study for professional qualifications and undertake more work-based learning. Student support systems need to be mindful of these differences and ensure that services are accessible for all. A total of 1,080 students completed an online survey, one section of which investigated student awareness of support services and encouraged them to comment on how they believed services could be improved. Students identified a range of services although of potential concern, 72 students (8%) reported that there were no services available to them. Although some students were positive about provision, several problems were described and included: difficulties accessing services, lack of services at satellite campuses and placement sites and difficulties contacting personal tutors. 736 students (68%) also left comments in response to a follow up question ‘How do you think student support could be improved?’ A thematic analysis identified five themes: increased support on placement, improved communication with academic staff, flexible provision on campus, greater financial support and raising awareness of services.

The accuracy of the anxiety inventory respiratory disease scale for patients with chronic obstructive pulmonary disease.

Anxiety disorders are common in patients with chronic obstructive pulmonary disease (COPD). Studies have reported that the prevalence of anxiety symptoms range between 6% and 70% (Willgoss and Yohannes, 2013). There is no a valid disease-specific scale to measure anxiety for patients with COPD. In addition, very little evidence is available in studies that examined the occurrence of anxiety disorders using the psychiatric diagnostic tools even after the short-term follow-up. Our group developed the Anxiety Inventory Respiratory Disease scale (AIR) to assess and measure anxiety for patients with COPD (Willgoss et al., 2013). We explored prospectively the accuracy of the newly developed disease-specific the AIR scale in stable COPD patients using the diagnostic criteria the Mini-International Neuropsychiatric Interview (MINI) at three months in order to establish the diagnosis of psychiatric disorders.

Diagnostic Tools for Anxiety and Depression

The purpose of screening tools for anxiety and depression in patients with chronic obstructive pulmonary disease is to identify those patients with clinically relevant symptoms who are in need of further diagnostic psychiatric assessment. Identifying high numbers of false positives is costly, both financially, and in terms of wasted time for the clinician and the patient. A scale that can efficiently screen patients for anxiety and depression is characterised by a high sensitivity, specificity, which ensures that all individuals with anxiety and depression disorders are identified with the symptom. This section of the book examined the available screening tools for anxiety and depression and their suitability and psychometric properties for patients with COPD. It is clear that although all of the scales reviewed have promising reliability and validity in general medical populations or in the populations they were designed. However, few, with the exception of the Anxiety Inventory for Respiratory disease (AIR), Brief Assessment Schedule for Depression, Beck Anxiety and Depression Inventory, Generalised Anxiety Inventory and Hospital Anxiety and Depression Scale have been partially validated in patients with COPD. The AIR is the only scale that is specifically designed and validated to measure anxiety in patients with COPD. It is responsive to pulmonary rehabilitation. These screening anxiety and depression scales have been widely used in patients with COPD including with other chronic respiratory diseases. However, the efficacy of these scales in terms of their responsiveness to intervention requires further testing.

S93 THE DEVELOPMENT OF A NOVEL SCALE TO SCREEN AND MEASURE ANXIETY IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Introduction and objectives Comorbid anxiety disorders are common among patients with COPD, affecting up to half of all patients. Comorbid anxiety may be a significant factor in predicting quality of life, yet recognition and management of anxiety among this patient group is poor. Screening and measuring symptoms of anxiety can be challenging due to the overlap of physical symptoms and the lack of a validated disease-specific tool. The aim of this study was to develop a novel non-somatic scale (Anxiety Inventory for Respiratory disease (AIR)) to screen and measure anxiety in patients with COPD. Methods This study utilised a multi-method approach to scale development incorporating both qualitative and quantitative methods. An item pool was developed using in-depth interviews with COPD patients who exhibited symptoms of anxiety (n=14), and the analysis of existing anxiety scales. Item wording, content and user-friendliness were checked by an expert reference group (ERG) that included clinicians and patients. This item pool was tested on a group of COPD patients (n=82). The Likert-type scale has four consistent responses to statements (Not at all, Occasionally, Frequently, Almost all of the time) that are scored from 0 to 3. Item and factor analysis were carried out to aid in item reduction and to explore the factor structure. Results Sixteen items were selected for inclusion following development and approval from the ERG. Items were retained based on item-to-total correlation analysis and α-if-item-deleted analysis. One item was discarded as it had a corrected-item-to-total correlation of <0.55. Exploratory principal component factor analysis was performed and three further items were removed due to low communalities (<0.50). Secondary analysis indicated a single factor solution accounting for 66.67% of total variance with a mean communality of 0.67. Abstract S93 table 1 shows the factor loadings for the final items. The 12-item scale had a mean total score of 13.55 (SD=9.41, range=0–36), and a Cronbachs α of 0.95.Abstract S93 Table 1 Factor loadings for the 12-item Anxiety Inventory for Respiratory disease (AIR) Item Factor 1 loading 1 I have felt tense, restless or wound-up 0.71 2 I have found it difficult to concentrate on things, such as watching TV or reading 0.71 3 I have had worrying thoughts going through my mind 0.83 4 I have felt frightened or very panicky 0.85 5 I have felt worked up and/or upset 0.78 6 I have had a fear of losing control and/or falling apart 0.82 7 I have worried about experiencing panic 0.88 8 I have found it hard to relax 0.77 9 I have had sudden and intense feelings of fear and/or panic 0.86 10 I have felt generally anxious 0.85 11 I have had thoughts that something bad might happen 0.83 12 I have felt nervous or on-edge 0.89 Conclusions The AIR is a short self-report non-somatic anxiety scale with a clear uni-dimensional factor solution and high internal consistency. Additional studies are warranted to further explore the scales psychometric properties and to establish its ability to screen for clinical anxiety disorders.