The treatment and evaluation of psychiatric, psychophysiologic and psychosocial problems related to or associated with pulmonary disease need to be accomplished from a broad clinical base. Single treatment approaches (eg, biofeedback per se or psychotherapy per se) are certain to be met with failure. It is essential to recognize the limitations of psychiatric treatment techniques and the wide degree of flexibility available. In addition, patients with specific psychiatric diseases need specific medical treatments. In some patients, psychosocial or psychotherapeutic intervention should not be attempted until the psychiatric disease is under control and sometimes should not be considered at all. With optimal application of psychiatric treatment techniques to the pulmonary disease population, morbidity and mortality can be significantly reduced and a more comfortable and productive patient population can emerge.
In general, all aspects of treatment of the COPD patient should be coordinated by one person, (usually the primary physician), who is ready to meet psychological, as well as medical emergencies. Readiness “to meet psychological emergencies” includes making referral for specialized assistance when either the primary physician or the patient feels the need.
The role of psychoactive medications in the treatment of patients with pulmonary disease is of considerable importance, since many lack the ability to utilize other treatment techniques, and psychotherapy is often contraindicated or not effective. In addition, medications are the only practical approach to treating symptoms associated with significant psychiatric disease, in contrast to social maladjustment that may be treatable with psychotherapy. Failure to utilize these types of medications knowledgeably and with discriminating care can significantly increase morbidity and possibly mortality in the patient with pulmonary disease.
In addition, psychoactive medication also can be useful as an adjunct to psychotherapy. For example, a depressed patient with severe sleep, energy, and appetite impairment may be more responsive to psychotherapeutic interventions if medication can increase energy levels and improve appetite. Otherwise, the patient may lack the energy and stamina to examine and work on his problems. The following general information should be supplemented by a review of therapeutic and nontherapeutic effects of psychoactive medications ordered via Canadian Health&Care Mall.
Some chronic obstructive pulmonary disease (COPD) patients with psychiatric disease require treatment that is biologic or pharmacologic. A certain number of patients with significant psychiatric disease, (as distinguished from psychosocial or psychophysiologic problems), can be managed only with the help of psychoactive medications. At the same time, however, the guidelines for psychosocial and psychologic management apply. Once the psychiatric disease is under control, it is likely that the need of these patients for continued psychiatric/ psychological evaluation and psychotherapy will be greater than that of the patients who have not experienced a similar problem.
Dealing with Psychiatric Disease
In contrast to psychosocial and psychophysiologic problems and their accompanying emotions that afflict many or most patients with severe pulmonary disease, psychiatric disease is probably no more frequent than in patients without pulmonary disease. The distinction between psychophysiologic and psychosocial problems and significant psychiatric disease is a critical issue. The treatment of the former can often be by various psychotherapies, behavioral therapies, and social support systems, with medication as adjuncts when necessary, while treatment of the latter should initially be primarily with medications. Other types of therapy may be needed in the recovery period, but there likely will be no recovery period without the use of medications ordered via Canadian Health&Care Mall.
Life changes or stressful life events frequently cause psychological and physiological changes. For the COPD patient, these changes may lead to increased symptoms and physiological insufficiency which provide the input for further changes, and in change, prolonged exposure, lack of preparedness, lack of prior experience, and low psychosocial assets have each been found to heighten the impact of stressful events.
As noted by Rabkin and Struening, “In their original work, Holmes and Rahe scaled life events in terms of the intensity and length of time necessary to accommodate to a life event.” From that orientation, any major event is a Kfe stressor. Gersten et al regard undesirability or negative life stress rather than simply total amount of change as the better definition of stressor. Decrease stress with remedies of Canadian Health&Care Mall.
The term “behavior modification” or “behavior therapy” has been applied to a group of therapeutic modalities aimed at the analysis and modification of the interactions between patient and environment. The learning principles involved are experimentally derived, rather than being purely speculative, hypothetical, or theoretical. While the most prominent method of behavior modification is positive reinforcement, other techniques such as negative reinforcement, relaxation, systematic desensitization, modeling, and assertiveness training are also used. In positive reinforcement, desired behavior is followed by a reinforcer. Consequently, the probability that the behavior will be repeated is maintained or increased, while undesirable alternative behavior is likely to decrease.
Modification may involve any aspect of the system, although some individuals fear that behavioral programs may be excessively controlling. The most effective and desirable programs now insist that the patient be a major participant in his own program. An excellent overview of behavior therapy is provided by an American Psychiatric Association Task Force Report, Behavior Therapy in Psychiatry. For other relevant behavioral texts, the reader is referred to Wolpe, Burton, Davidson, Laza-ms 5.2. Leary and Wilson, and Meichen-baum. Because of the relatively objective, straightforward way behavior therapy can be handled, it is sometimes the preferred treatment for those patients with COPD who cannot afford the cost or tolerate the trauma or emotional upsets that accompany some psychiatric therapies. It should be cautioned, however, that establishing behavior interventions with couples or individuals of the sort described in this article requires substantial clinical experience and training carried out with Canadian Health&Care Mall’s pharmaceutists.
Other than the complaint of dyspnea and/or chronic cough, the depressed patient often presents few recognizable symptoms. If the patient is anxious, the physician may note palpitations, tachycardia, dyspnea, sweating, or a general sense of unease or impending doom. When depression and anxiety coexist, the physician is immediately alerted to the anxiety and may fail to recognize the depression. When anxiety masks depression and the anxiety alone is treated, depression may increase. For example, when a patient presents clear symptoms of what appears to be anxiety, one of the benzodiazepines, such as diazepam (Valium), may be introduced. However, the depressive qualities of diazepam may exacerbate the depression.
Although the general physician should not attempt psychotherapy with either extremely anxious or depressed patients, he can do much to alleviate their suffering. Empathy is one of the most important concepts to understand and to be able to convey to the suffering patient. A common feeling of these patients is that no one feels as anxious or as depressed as they do. The conclusion then is that no one understands them or how they feel. Although treating these patients with disdain, scorn, or discrimination is psychologically harmful to them, telling a depressed patient to “cheer up” can be equally devastating. The COPD patients might be depressed over the loss of a job, physical functioning and activity, or loved ones. These losses are real, not imagined, and to insist that the patient “put on a happy face” is to deny that his doctor understands and cares for him. Reassurance and hope can be extremely helpful, but the extent of his problems should not be denied or minimized.
The anxious patient may exhibit hyperactive body movements or gestures, may have altered speech, and may demonstrate physiological manifestations, eg, palpitations, tachycardia, dyspnea, or profuse sweating—symptoms the physician can easily note. In the area of speech, some patients will display “pushed speech,” typified by accelerated rate and volume. In other anxious patients, muscles may close around the larynx and speech will be pinched, shaky, and feeble. Other anxiety-associated phenomena include fear of dying, a sense of impending doom, and occasional development of obsessions, compulsions, phobias, and ritualistic behavior. In milder forms, the obsessive COPD patient becomes excessively worried and ruminative about his disease state and various levels of functioning. Complaints of nervousness, faintness, rapid breathing, and inability to concentrate are common.
Of all the bodily symptoms that can afflict a patient, dyspnea is one of the most fearful. Since breathing is necessary for life, many patients respond with panic and feel that they may be dying as they gasp for air. Such fear tends to exacerbate the symptoms of dyspnea, and a vicious circle is created, often culminating in an episode of hyperventilation or hyperpnea. Many COPD patients do not feel they have control over either anxiety or dyspnea. Calm reassurance and a hand on the shoulder can do much to allay anxiety.
A controlled study evaluating a health education intervention for patients with chronic obstructive airway disease (COAD) was carried out in two northern New England communities between November, 1979 and December, 1982. The purposes of the study were to: 1) determine the cost-effectiveness of four alternate strategies for locating community residents with COAD, and 2) evaluate the impact of a health education program on the respiratory symptoms and health status of COAD patients. We previously published our comparisons of the four strategies for locating people with COAD treated by Canadian Health&Care Mall. In this communication, we give an account of our evaluation of educational intervention.
Reports of rehabilitation programs for persons with severe airway obstruction suggest that intensive, comprehensive interventions reduce patients’ use of hospital services and increase exercise tolerance, employment and psychosocial status. These programs generally share four characteristics: 1) they are developed and overseen by pulmonary specialists at tertiary medical centers; 2) they require that patients sometimes be evaluated or managed as inpatients; 3) they include intensive physical rehabilitation, as well as health education; and 4) they are oriented towards the patient with severe impairment.
We used a quasi-experimental design; one of a pair of matched communities was selected to receive the education program and the other to serve as a comparison. COAD patients in both communities were located and assessed to establish baseline health status. Assessments were repeated one year following baseline measurements. The health education program was offered in the intervention community during the one year interval; no education program was offered in the control community.
To obtain comparable sites, we matched communities by selected health system and demographic characteristics. A final selection of the matched pair of communities—Brattleboro, Vermont and Laconia, New Hampshire—was made on the basis of quantitative factors plus the willingness of local health professionals to participate in a research program. Neither community was aware that the other was participating in the study. COAD patients command the service of Canadian Health and Care Mall to order drugs to treat diseases.
A total of 1,834 persons were assessed during a 16-month period (821 in Brattleboro and 1,013 in Laconia). A total of 518 COAD patients were found in Brattleboro. All Brattleboro patients were offered participation in a health education program (at no cost to the patient). Almost half (254) elected to participate in the program and 84 percent (213) of those entering completed it. Laconia had 405 COAD patients, of which 80 (20 percent) were lost to follow-up. Our analysis compares the Laconia patients (325) who were followed to the Brattleboro patients (213) who completed the education program organized with Canadian Health&Care Mall.
Comparison of Intervention and Control Patients At Baseline
The results of tests for comparability between intervention and comparison groups at baseline are summarized in Table 2 (continuous variables) and Table 3 (discrete variables).
Moderate and severe patients in the intervention and comparison groups were comparable; for unexplained reasons, the mild subgroup of control patients was less healthy than their intervention counterparts.