Nearly one in two people with chronic obstructive pulmonary disease (COPD) also experience anxiety or depression. It can be a vicious cycle. When a person has a hard time breathing, it can make them anxious and depressed. And having anxiety and depression affects quality of life, makes it harder to breathe, making it more likely that people will end up in the hospital with a COPD flareup.
Deepshikha Ashana, MD, MBA, a critical care specialist and pulmonologist at Duke University and the Durham Veterans Affairs hospital in Durham, North Carolina, often sees patients with COPD, who also deal with anxiety and depression in her practice. “In my clinical experiences I’ve seen there’s a very strong connection between any type of lung disease that causes shortness of breath and anxiety. It’s really scary, not being able to breathe,” she said. “If you can’t treat COPD together with anxiety and depression, it’s difficult to help people feel better. It’s a common problem and a hard one to treat.”
At the VA hospital where Dr. Ashana works, she commonly sees veterans who have COPD from years of tobacco use. They also commonly report anxiety and depression due to their history of combat exposure. “My patients are fortunate in that they can access mental healthcare more easily than many people in America can,” she said. “In general, there is a lack of available mental health care in this country, which makes treating anxiety and depression in patients with COPD challenging.”
Teaching Healthy Coping Skills Through a Phone App
To address this problem, Dr. Ashana is using an ACRC Pilot Award from the American Lung Association Research Institute to adapt an existing phone app, developed by her mentor Dr. Christopher Cox. The original app helped survivors of critical illness who developed depression and anxiety after being in the ICU use cognitive behavioral therapy (CBT). Dr. Ashana hopes a similar approach will be helpful for patients with COPD.
CBT is a widely used psychological treatment that has been shown to be effective for a range of issues. These include depression, anxiety disorders, post-traumatic stress disorder (PTSD), eating disorders and substance use disorders. It is based on the premise that our thoughts, feelings and behaviors are interconnected, and that changing negative thought patterns can lead to changes in feelings and behaviors.
Unfortunately, though effective, CBT can be difficult to access for two reasons. First, there are not enough trained therapists in the United States, and second, attending regular appointments can be challenging when managing a chronic illness. “Through the app, people with COPD who also have anxiety or depression will be able to learn and practice CBT skills in the comfort of their own homes, when they want and as often as they want,” Dr. Ashana said.
“It centers on patients’ needs and convenience instead of them having to adhere to a therapist’s schedule.” Her hope is that using the app will result in fewer symptoms of anxiety and depression, as well as improved COPD outcomes.
The app consists of a four-week program that helps patients learn coping skills to help manage their anxiety and deal with stressors. Patients learn to move away from maladaptive responses —persistent patterns of thought, action or feeling that interfere with the ability to adapt to life situations. Instead, they learn to use adaptive behaviors, which help a person effectively respond to their environment and cope with stressors in a healthy way.
“For example, a maladaptive response is to catastrophize or think things will get worse, and there is nothing that can be done to make things better. It’s a destructive mental cycle,” Dr. Ashana said. “An adaptive coping response is to evaluate a bad situation and, when things aren’t going well, using tools, like their rescue inhaler or reaching out to their healthcare provider, that will likely help them feel better.”
Dr. Ashana believes that for many patients, learning these simple coping skills can make a big difference in their overall health. Some patients will need more specialized support and medication, however, which is why this is only a tool that should be used alongside regular check-ups with a healthcare provider.
She and her co-investigator, Chris Mosher, MD, MHS, will conduct focus groups with patients of COPD to better understand their specific needs for the app. Then, they will modify the app accordingly and conduct another focus group to test the app. From there, they can collect data on how easy it is for patients to use and then analyze whether using it improves their anxiety and depression. They hope to start with a group of 30 people with COPD, in preparation for a larger clinical trial.
The Importance of Early Research Awards
Dr. Ashana says pilot grants such as the ACRC grant she received play a critical role in providing early funding to researchers. “The National Institutes of Health (NIH) is not set up for seeding initial funding which is why these grants from the American Lung Association are crucial in helping good ideas grow into larger ones that then can seek larger federal funding,” she said.
“Federal funding for research is more challenging than usual at the moment. Once investigators leave research, it’s a big challenge to replace them. It’s critical to ensure that people can stay in the research work force, which is why the Lung Association funding is so important.”
