Running up that hill: How pulmonary rehabilitation can be enhanced by understanding patient perceptions of their condition

Abstract

The role of psychological factors in adjustment to and management of chronic respiratory disease has been increasingly elucidated over the last 50 years or so. Much of the impetus to understand psychological dimensions to care of the patient with COPD has been driven by recognition that the condition’s objective severity alone is insufficient to predict clinical outcomes. COPD is clearly associated with high levels of psychological morbidity; with prevalence of anxiety as much as 50% and figures for depression of similar magnitude– 2 to 3 times that of the general population. Such levels of psychological morbidity not only detrimentally affect quality of life but are correlated with compromised self-management, poorer physical outcomes and increased and often inappropriate health care utilization. In this context, Bratas and colleagues’ report of their intensive, inpatient rehabilitation programme with its explicit focus on alleviation of psychological distress, as well as exercise capacity and quality of life, is most welcome. With improvements in symptom and impact scores (on the St George’s Respiratory Questionnaire) and median HADS depression scores, this circumscribed multidisciplinary intervention reports clear benefit. However, as the authors note, the psychometrics used to assess anxiety may have been insufficiently specific to the type of anxiety (panic) that features more prominently in patients with respiratory disease, masking any alleviation. More importantly, the health gain achieved for patients were evident only for those with mild to moderate disease, which begs the question of how we might broaden benefit to all. Arguably, this requires rehabilitation programmes to become more tailored, by having a more nuanced understanding of participants’ psychological status, not only with regard to mood but the way they construe their condition and its management. Current rehabilitation programmes for COPD are increasingly sophisticated. Multidisciplinary approaches are explicitly informed by self-management, encouraging patients to collaborate in their own treatment, and are constructed to address salient psychological issues. Patients may have concerns about the effects of their symptoms, may need to modify behaviours to reduce risk factors and adhere to medication and prescribed exercise; they may struggle with the disease and its consequences, affecting both relationships with carers and families as well as daily activities and coping strategies. Programmes, such as the one described by Bratas, show awareness of these needs including an explicit psychosocial intervention. However, patients may also experience much more intense emotional reactions on diagnosis or exacerbations, find that disease progression heightens pre-existing psychological difficulties and be intensely fearful of their future, irrespective of their more objective functional status. So how can we further improve patient outcomes and, given the potential complexity of psychological issues, deliver tailored rehabilitation that is clinically feasible? An argument for the status quo is not very compelling since there is suspicion that those who