Figures
- FIGURE 1
Patient flow diagram. HADS: Hospital Anxiety and Depression Scale; FEV1: forced expiratory volume in 1 s; FVC: forced vital capacity; COPD: chronic obstructive pulmonary disease; CBT: cognitive behavioural therapy.
- FIGURE 2
Cost-effectiveness plane. Quadrant 1: more costly/less effective; quadrant 2: more costly/more effective; quadrant 3: less costly/less effective; quadrant 4: less costly/more effective; CBT: cognitive behavioural therapy; QALYs: quality-adjusted life-years.
Tables
- TABLE 1
Inclusion and exclusion criteria
Inclusion criteria Exclusion criteria A confirmed diagnosis of COPD (FEV1/FVC ratio <70% [5]
All levels of COPD disease severity (mild–very severe)
HADS-Anxiety Subscale score of ≥8
Consent to 2–6 sessions of CBT [23]
A HADS-Anxiety Subscale score of <8
Known psychiatric history such as psychosis
Patients currently receiving psychological talking therapy including CBT treatment
Patients with cognitive impairment (e.g. dementia)
Patients involved in any other interventional clinical trial
COPD: chronic obstructive pulmonary disease; FEV1: forced expiratory volume in 1 s; FVC: forced vital capacity; HADS: Hospital Anxiety and Depression Scale; CBT: cognitive behavioural therapy.
- TABLE 2
Content of cognitive behavioural therapy (CBT) nurse training
Day 1 Day 2 Day 3 Course aims Revision Feedback from homework Basic introduction to CBT Feedback from homework Revision Using CBT in physical health setting Goal setting Case presentations Anxiety Cognitive techniques Supervision Panic Behavioural techniques Course evaluation Depression Case study Screening for anxiety and depression Practical session (theory into practice) Risk management (suicide assessment) Summary Formulation of patients difficulties Homework Socratic questioning and guided discovery Unhelpful thinking Practical session - TABLE 3
Baseline characteristics
CBT group Leaflet group Total patients Subjects n 139 140 279 Mean±sd age years 66±10.2 67±9.6 66.5±9.9 Males/females 61 (44)/78 (56) 67 (48)/73 (52) 128 (46)/151 (54) Ethnic group, Caucasian 139 (100) 140 (100) 279 (100) Mean±sd HADS-Anxiety Subscale 12.3±3.19 12.0±2.94 12.2±3.06 HADS-Anxiety Subscale 8–10 51 (37) 49 (35) 100 (36) HADS-Anxiety Subscale 11–14 52 (37) 63 (45) 115 (41) HADS-Anxiety Subscale 15–21 36 (26) 28 (20) 64 (23) Mean±sd HADS-Depression Subscale 9.2±4.0 8.8±3.7 9.0±3.85 Severity of airflow obstruction based on GOLD criteria Mild 16 (11) 13 (9) 29 (10) Moderate 44 (32) 47 (34) 91 (33) Severe 50 (36) 49 (35) 99 (35) Very Severe 29 (21) 31 (22) 60 (22) MRC Breathlessness score 0–2 8 (6) 12 (9) 20 (7) 3 25 (18) 19 (14) 44 (16) 4 39 (28) 44 (31) 83 (30) 5 67 (48) 65 (46) 132 (47) Current smoker 39 (28) 40 (29) 79 (28) Mean±sd BMI kg·m−2 26±6.4 27±6.0 26.5±6.22 No educational qualifications 100 (72) 103 (74) 203 (73) Data are presented as n (%), unless otherwise stated. CBT: cognitive behavioural therapy; HADS: Hospital Anxiety and Depression Scale; GOLD: Global Initiative for Chronic Obstructive Lung Disease; MRC: Medical Research Council; BMI: body mass index.
- TABLE 4
Group mean Hospital Anxiety and Depression (HADS)-Anxiety Subscale at each time point
Group mean±sd HADS-Anxiety Subscores Baseline 3 months 6 months 12 months Cognitive behavioural therapy 12.3±3.19
(n=139)8.8±4.49
(n=115)8.6±4.02
(n=93)8.7±4.06
(n= 93)Leaflet 12.0±2.94
(n=140)10.0±4.42
(n=121)9.7±4.31
(n=99)10.2±4.33
(n=79) - TABLE 5
Differences in mean anxiety from baseline and between groups
Mean improvement from baseline Difference in mean improvement
(95% CI, p-value)CBT group Leaflet group HADS-Anxiety Subscale at 3 months 3.40 (n=115) 1.88 (n=121) 1.52# (0.49–2.54, p=0.003) HADS-Anxiety Subscale at 6 months 3.42 (n=101) 2.36 (n=99) 1.05 (−0.04–2.14, p=0.05) HADS-Anxiety Subscale at 12 months 3.35 (n=93) 1.89 (n=79) 1.43 (0.28–2.66, p=0.016) CBT: cognitive behavioural therapy; HADS: Hospital Anxiety and Depression Scale. #: the mean difference is higher than the HADS-Anxiety Score minimal clinically important difference of 1.50 [17].
- TABLE 6
Costs and QALYs of cognitive behavioural therapy (CBT) intervention and self-help leaflets
CBT intervention mean (95% CI) Leaflets mean (95% CI) Bootstrapped mean difference (95% CI, p-value) Intervention costs GBP 175 (165–185) 175 (165–185, p=0.001) Number of respiratory admissions 0.6 (0.35–0.85) 1.01 (0.61–1.4) Costs of respiratory admissions GBP 1601 (936–2267) 2689 (1632–3746) −1089 (−2370–227, p=0.076) Number of ED attendances 0.37 (0.16–0.59) 0.81 (0.48–1.14) Costs of ED attendances GBP 55 (23–86) 118 (70–166) −63 (−121– −7, p=0.036) Total mean cost GBP 1830 (1143–2517) 2807 (1706–3909) −997 (−2349–228, p=0.158) Mean difference in effect QALYs 0.079 (0.023–0.140, p=0.008) ED: emergency department; QALYs: quality-adjusted life-years.
- TABLE 7
Results from the cost-effectiveness acceptability curve
Probability of each management strategy being considered cost-effective at different threshold values for society's willingness to pay for a QALY GBP 0 GBP 5000 GBP 10 000 GBP 20 000 GBP 30 000 Cognitive behavioural therapy 0.94 0.98 1.00 1.00 1.00 Leaflets 0.06 0.02 0.00 0.00 0.00 QALY: quality-adjusted life-years.
Supplementary Material
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