| Abstract |
Introduction
There is currently a paucity in the literature regarding the psychosocial aspects of Chronic Obstructive
Pulmonary Disease (COPD); this is associated with the limited number of parameters examined, but
mainly with the lack of assessment of the effects of pulmonary rehabilitation programs on psychological
symptoms.
Hypothesis-Objectives
The aim of this research was to investigate the psychological characteristics of Greek patients with
COPD, and to evaluate the potential changes in their psychological characteristics after attending a
pulmonary rehabilitation program. Essentially, we investigated two primary assumptions:
*If patients with COPD have higher rates of psychopathology than the general population and
*If the psychological symptoms associated with the disease can be modified through a pulmonary
rehabilitation program.
Subjects and methods
The study was conducted at the Pulmonary Rehabilitation Section of the Third Department of
Pulmonary Medicine in "Sotiria" General Hospital of Athens in Greece, during the years 2008-2012.
The study sample comprised of patients who had been diagnosed with COPD, uncomplicated by any
other chronic disease.
We assessed psychological characteristics of patients upon enrollment and at completion of this
pulmonary rehabilitation program.
The total study sample comprised of 144 patients (112 men). 43 (29.9%) of them did not
complete the rehabilitation program.
The measurement of psychological and psychosocial characteristics of patients with COPD was done
using self-report scales and questionnaires validated and standardized in the general population.
More in detail, we used the following questionnaires:
1. Beck's depression questionnaire (Beck Depression Inventory, BDI).
2. Spielberger's anxiety questionnaire (STAI).
3. The Toronto Alexithymia Scale Questionnaire (TAS-20).
4. Antonovsky's Sense of Coherence questionnaire (SOC).
5. The Family Support Scale (which was standardized in Greek population for the purposes of this
study).
6. The Vital Exhaustion questionnaire (Maastricht questionnaire).
7. A general psychopathology questionnaire (SCL-90R).
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The following parameters were recorded: gender, age, years of education, disease severity (as
determined by pulmonary functions tests per GOLD consensus protocol) and disease duration.
Results
The sample was not statistically different compared to the population of greek COPD patients regarding
gender (x2&γτ 0.05) and age (t-test p΄&γτ 0.05).
Initial evaluation
The average BDI score was significantly higher compared to the average BDI score in general
population (11.61 versus 5.86, t-test p ΄&λτ0.01). The same was also noted regarding anxiety in both men
and women (39.81 versus 34.54 and 44.47 versus 37.47, respectively, t-test p ΄&λτ0.01).
Vital exhaustion in COPD patients was higher than the average score in general population
(19.55 versus 15.00, t-test p΄& &λτ0.01). The average family support of COPD patients was higher than in
the general male or female Greek population (55.31 versus 51.43, and 51.37 versus 47.21, respectively).
The sense of Coherence of patients was also higher than the average in the general population (64.3
versus 60.0). Almost 56% of patients had abnormal findings: depression (36.1%), somatization (33.3%),
obsession (30.65%) and anxiety (23.7%), psychotism (4.9%), phobic anxiety (12.9%) and paranoid
ideation (16.7%).
Women with COPD had higher anxiety and depression scores compared to men (STAI: t test p
΄&λτ0.05 and BDI: t test p ΄&λτ0.05 respectively) and expressed a lower sense of family support (FS: t test p
΄&λτ0.05).
Evaluation with ANOVA did not show the average values of psychological parameters to be
different among the groups according to severity (ANOVA p΄&γτ 0.05). Thus, all four groups were similar
in severity of depression, anxiety, perception of family support, sense of coherence and vital exhaustion.
There was no effect of FV1% upon Alexithymia, Vital Exhaustion, Depression, Anxiety, Sense of
Coherence (Pearson Correlation p΄&γτ 0.05) whereas it showed a mild negative correlation with the sense
of Family Support (Pearson Correlation p ΄&λτ0.05, r = -0,209).
Results of stepwise multiple regression analyses revealed that anxiety accounted for 65% of the
variance of depression, vital exhaustion for 9% and sense of coherence for 2%, whereas family support
and alexithymia were not involved significantly. The variation of anxiety could be attributed at a rate of
65.95% to depression, 3% to vital exhaustion and 1.7% to family support, while sense of coherence and
alexithymia were not involved significantly.
Final Evaluation
80 men and 21 women, who completed the rehabilitation program, were finally evaluated. The average
depression score was statistically lower at this stage: at baseline the mean BDI score for the patients
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who completed the program was 10.7, statistically greater (t-test p ΄&λτ0.05) than the corresponding (5.86)
score observed in the general population, whereas at the end of the program the actual BDI average was
6.33, statistically invariable from the corresponding in the general population (t-test p΄&γτ 0.05). Regarding
the percentage of patients who had depressive symptoms (BDI΄&γτ 9) at baseline this was 47.5% (48
patients) and finally 14.9% (15 patients), indicating a statistically significant reduction (x2 p ΄&λτ0.05).
The average anxiety score in patients who attended the program decreased statistically in the final
evaluation (paired t-test p ΄&λτ0.01). The same applies to patients’ subgroups (by disease stage; paired ttest
p ΄&λτ0.05). Checking changes in anxiety among groups of different disease severity no statistical
difference was noted (ANOVA p΄&γτ 0.05); furthermore there were no differences between men and
women (t-test p΄&γτ 0.05).
Regarding anxiety, we observed at baseline average scores higher than in the corresponding general
population. Specifically, women had mean anxiety score of 42.62 (versus 37.47 in the general female
population, t-test p ΄&λτ0.01), whereas men had an average of 38.87 (compared to 34.54 in the general
male population, t -test p ΄&λτ0.01). In the final assessment, the average anxiety in women fell to 36.29 and
in men to 33.4, values that do not differ statistically from those of the general population (t-test p΄&γτ
0.05). The percentage of women with clinically significant anxiety symptoms (STAI΄&γτ 45) at baseline
was 47.6%, which dropped to 19% at the end of the program (x2 p ΄&λτ0.05); in men the proportion of
patients with clinically significant anxiety symptoms (STAI΄&γτ 43) in the beginning of the program was
25% and decreased to 12.5% (x2 p ΄&λτ0.05) at the end of the program. Significant changes occurred in the
final assessment of the SCL-90R scale. Changes were noted in the average scores and in the proportion
of patients who had abnormal values. The average final measurements after rehabilitation were
statistically significant for all SCL-90R parameters (paired t-test, p ΄&λτ0.05) except for the scales of
paranoid ideation and psychotism, where no change were found (paired t-test, p΄&γτ 0.05).
In the final assessment statistically significant decreases were observed in vital exhaustion/alexithymia
scores (paired t-test, p ΄&λτ0.05) and increases in sense of coherence and family support (paired t-test, p
΄&λτ0.05), respectively.
Conclusions
• Patients with COPD have higher rates of depression, anxiety and vital exhaustion compared to
the general population.
• Only 44.4% of the study population had no psychopathology.
• Symptoms of depression, somatization, anxiety and compulsions were predominant.
• Only 25% of women had no abnormal value in at least one measured parameter versus 50% of
men. Women showed higher percentages in obsessive-compulsiveness, depression and anxiety
compared with men.
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• Disease severity stages as per the GOLD criteria do not appear to have different values in
psychological characteristics, although FEV1% showed a negative correlation with Family Support.
• Family Support and sense of coherence showed a negative correlation with the other
psychological factors; this might be protective against anxiety and depression.
• In most scales (and also in rates of abnormal values) significant changes were noted at the end
of the rehabilitation program: notable decreases were observed in depression, anxiety, vital exhaustion
and increases in family support and sense of coherence.
• A decrease was observed in psychopathology rates and average scores of SCL-90R scales, with
the exception of psychotism and paranoid ideation.
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Ψυχολογικά χαρακτηριστικά ασθενών με χρόνια αποφρακτική πνευμονοπάθεια και η μεταβολή τους σε πρόγραμμα πνευμονικής αποκατάστασης
