Integrated Brief Cognitive Behavioral Therapy Improves Illness Intrusiveness in Veterans With Chronic Obstructive Pulmonary Disease

Integrated Brief Cognitive Behavioral Therapy Improves Illness Intrusiveness in Veterans With... Abstract Background Progressive illnesses such as chronic obstructive pulmonary disease (COPD) impart a high level of physical and psychological burden. Evidence-based psychotherapies hold the potential to improve perceptions of physical health impairment, yet few studies have documented these effects. Purpose To evaluate the effect of brief cognitive behavioral therapy (bCBT) on disease-related illness intrusiveness. Methods Participants were 175 Veterans with COPD and clinically elevated symptoms of depression and/or anxiety enrolled in a larger randomized trial (n = 99 randomized to bCBT, n = 76 to enhanced usual care; EUC). bCBT included up to six treatment sessions and optional booster sessions over a 4-month period. EUC entailed an assessment with documentation in the medical record. Primary outcomes focused on posttreatment changes on the Illness Intrusiveness Rating Scale (IIRS), an established measure of perceived impairment from a chronic health condition. Results Illness intrusiveness improved for bCBT participants relative to EUC, after controlling for baseline IIRS scores, depression, and anxiety (p = .03, partial η2 = .03). Specific improvement was observed in the Instrumental subscale (p = .02), encompassing improved intrusiveness of COPD on daily activities and daily functioning. IIRS scores improved in the absence of changes in physical functioning. Conclusions Illness intrusiveness was high among Veterans with COPD but improved over the course of bCBT. Integrated behavioral health interventions hold the potential to reduce disease intrusiveness. The IIRS may be a valuable tool to augment traditional assessment and measurement-based care approaches of behavioral health interventions for medically ill patients. Illness intrusiveness, Chronic obstructive pulmonary disease, Brief cognitive behavioral therapy, Veterans Introduction As chronic diseases continue to increase in prevalence and dominate the U.S. healthcare system, they contribute a high degree of individual and public health burden [1]. On an individual level, progressive and life-limiting chronic disease states raise existential issues related to uncertainty about one’s health and may impart negative perceptions about one’s future and sense of self [2, 3]. Individual reactions to chronic disease vary by patient and can range from resiliency to physical and emotional incapacitation [4, 5]. Although the severity of the physical illness often influences these reactions, mental health functioning and psychological constructs such as cognitive perceptions of the illness and perceived unpredictability and uncontrollability of the illness also play a pronounced role [6–8]. One such chronic disease that carries a high level of physical and psychological burden is chronic obstructive pulmonary disease (COPD), a progressive, debilitating lung disorder characterized by restricted airflow. COPD is a leading cause of death worldwide and carries an increased risk of morbidity, mortality, impaired functional status, and increased health service use [9, 10]. The focus of treatment for COPD is often on symptom management, as disease exacerbations disrupt daily life and punctuate the progressive decline associated with the illness. As such, chronic respiratory conditions deleteriously affect multiple outcomes, including functional ability [11], mental health [12], and quality of life (QoL) [11]. The expression of depression and anxiety may range in severity from mild, short-term symptoms to more severe, diagnosable chronic disorders. When present, these mental health difficulties can adversely affect disease self-management and further worsen functional outcomes and QoL—above and beyond the effects of the physical illness [13]. An emerging literature demonstrates the efficacy of behavioral health interventions on concomitant depression and anxiety outcomes in cardiopulmonary disease [14–17]. Preliminary data suggest the potential for these interventions to impact perceptions of health-related QoL (HRQoL) [17]. HRQoL refers to the impact of physical health on QoL, including well-being in domains of physical, psychological, and social functioning. To best measure HRQoL, clinicians and researchers often rely on disease-specific HRQoL measures, which are more sensitive to change than global QoL assessments (e.g. the Medical Outcomes Study 36-Item Short-Form Health Survey [SF-36]) [18]. However, disease-specific instruments limit inference to other medically ill populations because of their reliance on specific symptoms (e.g. dyspnea in respiratory conditions; glycemic control among patients with diabetes mellitus). Similarly, disease-specific measures have limited applicability and utility in multimorbid populations. Thus, while assessing HRQoL is important to understand an individual’s view of his/her own health and well-being, disease-specific measures may be deficient among complex or multimorbid patient populations. Illness intrusiveness is a transdiagnostic facet of chronic disease management that represents a commonality across disease conditions [19, 20]. Devins and colleagues [19] introduced the construct of illness intrusiveness to encapsulate one’s perception of interference related to a chronic illness on valued activities and daily living. Perceptions of intrusiveness may arise from both the symptoms of the disease (e.g. pain, functional limitations) as well as its treatment (e.g. time, side-effects). This disruption in lifestyle, or intrusiveness, of the illness contributes to reduced QoL and subjective well-being. Illness intrusiveness is commonly assessed using the Illness Intrusiveness Rating Scale (IIRS) [20, 21], an established self-report instrument with which individuals rate the extent to which “one’s illness and/or its treatment interfere” with 13 activities and domains that are thought to contribute to QoL [22]. The concept of illness intrusiveness might represent an important target in COPD assessment and treatment, given the significant lifestyle disruptions imparted by the respiratory condition. Illness intrusiveness is also associated with the presence of mental health symptoms, such as depression [23, 24] and anxiety [25]. Among individuals with cardiopulmonary disease, illness intrusiveness has been associated with poor internal health locus of control and avoidant coping strategies [26]. As such, illness intrusiveness likely presents an additional barrier to disease self-management and may be a worthy target of behavioral medicine assessment and interventions. Indeed, previous research substantiates that illness intrusiveness is amenable to treatment. For example, illness intrusiveness improved after a 6-week course of an online self-management program among medically ill patients (25% with lung disease, including COPD) [27], as well as after a 6-month self-management program for patients with COPD and their families [28]. However, despite the increasing integration of behavioral and physical health care, no published studies to date have examined the effect of psychotherapy on illness intrusiveness in medically ill patients. Results from our prior work demonstrated that a course of brief cognitive behavioral therapy (bCBT) improved symptoms of depression, anxiety, and disease-specific QoL in medically ill Veterans with cardiopulmonary disease [17]. Understanding illness intrusiveness as a potential treatment target may identify further opportunities for interventions for chronic disease management to maximize both physical and mental health. Thus, the present study examined whether bCBT could improve illness intrusiveness among Veterans with COPD. Given the results of the parent trial and the demonstrated efficacy of cognitive behavioral therapies for numerous psychological and medical conditions [29], we hypothesized that individuals receiving bCBT would evidence lower levels of posttreatment illness intrusiveness than the control group. Method Participants Participants were recruited from two large U.S. Veterans Affairs (VA) medical centers in the context of a randomized controlled investigation of bCBT for clinically significant symptoms of depression and/or anxiety among medically ill Veterans [30]. Design, procedures, and primary outcomes (including intent-to-treat analyses) of the parent study are detailed elsewhere [17]. Although the parent study targeted patient-participants with COPD and/or heart failure, the small sample size and complex physical health responses found for heart failure participants required that secondary analyses address these patient groups separately. In brief, potential COPD participants were extracted from Veterans Health Administration (VHA) patient databases, using International Classification of Diseases—Ninth Revision (ICD-9) diagnostic codes for COPD (ICD-9 codes 490, 491, 492, 493, 496, 508). ICD-9 codes were identified in collaboration with a pulmonologist to encompass commonly used codes in frontline practice for patients with COPD. Participants had their COPD confirmed by chart review and had to report mildly to severely disabling dyspnea (modified Medical Research Council dyspnea scale [mMRC] score ≥ 3) [31, 32]. In addition to these COPD-related criteria, participants had to endorse clinically significant symptoms of depression (Patient Health Questionnaire [PHQ-9] ≥ 10) [33, 34] and/or anxiety (Beck Anxiety Inventory [BAI] ≥ 16) [35]. Participants were excluded if they had a cognitive, bipolar, psychotic, or substance use disorder or if they had current suicidal intent or plan as assessed by a structured diagnostic interview (Mini International Neuropsychiatric Inventory [MINI]) [36]. Participants were also excluded if they were receiving other psychotherapy services at baseline, to avoid treatment overlap. Measures Illness Intrusiveness The IIRS [21] is a 13-item self-report instrument assessing the extent of illness intrusiveness on a 7-point scale (1 = not very much, 7 = very much; responses of “not applicable” coded as 1), with higher sum scores indicating greater illness intrusiveness. For this study, participants were directed to answer how much COPD and/or its treatment interferes with valued life domains, including items related to health, recreation, social relationships, family interaction, work and finances, intimacy, and religious and community involvement. In addition to a continuous illness intrusiveness total score (possible score range 13–91), the IIRS has three validated subscales: (a) Relationships and Personal Development (Relationship subscale), encompassing items related to engagement in passive recreation, family and other social relationships, civic and community involvement, religious expression, and self-expression; (b) Intimacy, based on relationship with spouse/significant other and sexual functioning; and (c) Instrumental, which assesses instrumental daily activities and daily functioning, such as health, work, active recreation, and finances [37]. Each subscale comprises the mean of individual items scores (range 1–7). The IIRS has good test–retest reliability [20]. Internal consistency of the IIRS in this sample was good (Cronbach’s α = .85). Psychological Symptoms Depressive symptoms were assessed using the PHQ-9 [33], a widely used self-report screening measure for depression that corresponds to the nine diagnostic symptoms of a major depressive episode. Items are scored on a 4-point scale (0 = not at all, 3 = nearly every day; total scores range from 0 to 27), with higher scores indicating greater symptom severity and frequency. A cut score ≥10 suggests the presence of clinically significant depression with favorable specificity and sensitivity [34]. As such, PHQ-9 total score was both treated as a continuous variable and dichotomized into clinical symptoms of depression (≥10) and no depression (<10). The BAI [35] is a psychometrically strong self-report measure of anxiety symptoms. The 21 items are scored on a 4-point scale (0 = not at all, 3 = severely; total scores range from 0 to 63), with higher scores indicative of more severe anxiety. BAI total score was both treated as a continuous variable and dichotomized into clinical symptoms of anxiety (≥16) and no anxiety (<16). COPD Severity, Functional Impairment, and QoL The mMRC [31, 32] assessed dyspnea severity using a grading system of the degree of breathlessness and resulting disability. A 5-point classification system staged the degree of dyspnea from a grade of 1 (not troubled with breathlessness) to 5 (too breathless to leave the house, or breathless when dressing or undressing). This self-rated scale is validated in COPD samples [31] and correlates with pulmonary function, walking disability, and survival [38, 39]. The Chronic Respiratory Questionnaire (CRQ) [40] is a disease-specific QoL instrument that measures the physical and emotional aspects of COPD. This 20-item, interviewer-administered instrument yields four component scores: dyspnea, fatigue, emotional functioning, and mastery. Total scores range from 20 to 140, with higher scores indicating better HRQoL. Although there are no established cut scores, a change of 0.5 points on any of the 7-point subscale scores represents the minimal clinically important difference [41]. Finally, the Medical Outcomes Study 12-item Short Form Health Survey (SF-12) [42] assessed general HRQoL. This instrument yields two subscales, the physical component summary (PCS) and the mental component summary (MCS), in which higher scores represent better HRQoL. Procedures Potential participants were contacted by research assistants for initial telephone screening and baseline assessment as part of the parent study. A total of 302 participants were randomized to receive either enhanced usual care (EUC) or the investigational bCBT intervention for the parent study. Unequal block randomization (60% to bCBT and 40% to EUC) was used in the parent study to increase statistical power for the intervention arm and to improve the study’s ability to better understand intervention delivery elements (e.g. secondary treatment analyses). Of those randomized, 226 participants had COPD (mMRC score ≥3), and 175 participants completed posttreatment assessment (Fig. 1 summarizes participant flow). EUC supplemented a participant’s usual VHA care with an assessment for depression and anxiety, documentation of these symptoms in the medical record, and printed psychoeducational materials on COPD and depression and anxiety. The integrated bCBT intervention was a manualized modular psychotherapy protocol that allowed patients and providers to select foci of treatment pertaining to the most pressing physical and emotional health concerns of the participant [43]. For example, modules consisted of psychoeducation, chronic disease self-management, goal setting, behavioral activation, cognitive restructuring, relaxation, and coping with physical health symptoms. Treatment was delivered in-person or by telephone by mental health providers in VHA primary care clinics and typically consisted of six weekly or biweekly treatment sessions (30 to 45 min) and two brief follow-up “booster” sessions (10 to 15 min) over a 4-month timeframe. Assessments were conducted at baseline and the 4-month posttreatment time points. Fig. 1. View largeDownload slide View largeDownload slide Flowchart of participants through each phase of the study. Fig. 1. View largeDownload slide View largeDownload slide Flowchart of participants through each phase of the study. The current study was approved by the relevant Institutional Review Boards and VA Research and Development review committees. All participants provided informed consent. The parent trial was registered on clinicaltrials.gov (NCT01149772). Statistical Analyses The present study analyzed a completer sample of participants who were randomized to one of two treatment conditions (bCBT or EUC) and completed posttreatment assessment. IBM SPSS version 22 was used for all analyses. Preliminary checks were conducted to assure no violation of assumptions of normality, linearity, multicollinearity, homogeneity of variances, homogeneity of regression slopes; and reliable measurement of the covariates. Pulmonary functional impairment was categorized by mMRC criteria: mild (mMRC score = 3), moderate (mMRC score = 4), and severe (mMRC score = 5). Three severity groups of illness intrusiveness were calculated, based on sample distribution: low intrusiveness (<1 SD below the group mean for the sample [possible score range 13–40]), high intrusiveness (>1 SD above the group mean [possible score range 72–91]), and normal intrusiveness (−1 to +1 SD from group mean [possible score range 41–71]) to describe the sample. Descriptive analyses provided demographics, clinical characteristics, and baseline levels of illness intrusiveness in the present sample. Univariate analyses assessed differences in baseline characteristics between treatment and EUC groups, using t-test for continuous variables and chi-square for categorical variables. Any significant covariates were included in adjusted analyses. To test the primary hypothesis that IIRS scores improved during the course of bCBT relative to EUC, a one-way analysis of covariance (ANCOVA) assessed posttreatment illness intrusiveness (adjusted for baseline IIRS score, PHQ-9, and BAI) of individuals receiving bCBT and EUC. The effect size of this test is reported as partial η2. Given the dearth of literature examining illness intrusiveness in COPD, a series of exploratory analyses supplemented the primary analysis. First, an IIRS change score was calculated for each individual’s difference in IIRS total score between baseline and posttreatment (4-month) assessment. Individual linear regression models explored possible predictors of change in IIRS scores among participants randomized to bCBT, consisting of age (continuous), baseline depressive symptoms (PHQ-9), baseline anxiety (BAI), and treatment engagement (number of sessions attended). A one-way ANOVA with the Greenhouse-Geisser correction analyzed the mean difference in IIRS change scores in bCBT participants between the remaining categorical demographic variables (gender, education level, race/ethnicity category, living status, marital status, and income group) and mMRC functional status severity groups. Subsequent exploratory within-group analyses were conducted to describe and characterize changes in illness intrusiveness during treatment. A series of paired sample t-tests assessed change between baseline and posttreatment (4-month assessment) in IIRS total score, IIRS subscales, physical health QoL (SF-12 PCS), mental health QoL (SF-12 MCS), and functional impairment (mMRC), using a split file (bCBT vs. EUC). The size of the treatment effect (Cohen’s d; reported as an absolute value) was computed for the bCBT group only, which can be interpreted as a small (0.2), medium (0.5), or large (0.8) effect. Results Demographics and Preliminary Analyses Data for the present completer analyses were available from the subset of 175 participants with COPD (n = 99 randomized to the bCBT treatment, n = 76 EUC) who completed both baseline and posttreatment assessments. The sample largely comprised older non-Hispanic White male Veterans who were married. Those in the bCBT arm completed a median of six (IQR = 2) treatment sessions and two (IQR = 1) booster sessions. Treatment groups did not differ on relevant demographic characteristics; however, the EUC group endorsed higher levels of depressive symptomatology and anxiety at baseline. Therefore, these two variables (PHQ-9 and BAI, respectively) were entered into subsequent adjusted models as covariates. See Table 1 for participant characteristics. Table 1 Baseline Sociodemographic and Clinical Characteristics by Intervention Status Overall (N = 175) bCBT (n = 99) EUC (n = 76) p-value Age, M (SD), years 66.5 (8.3) 65.8 (8.4) 67.4 (8.1) .21 Male gender n (%) 161 (92.0%) 90 (90.9%) 71 (93.4%) .92 Education n (%) .80  High School or less 77 (44.0%) 44 (44.4%) 33 (43.4%)  Some college 76 (43.4%) 44 (44.4%) 32 (42.1%)  College graduate 22 (12.6%) 11 (11.1%) 11 (14.5%) Race/ethnicity n (%) .21  Non-Hispanic White 117 (66.9%) 65 (65.7%) 52 (68.4%)  African American 39 (22.3%) 21 (21.2%) 18 (23.7%)  Hispanic 4 (2.3%) 1 (1.0%) 3 (3.9%)  Other 14 (8.0%) 11 (11.1%) 3 (3.9%) Living status n (%) .07  Alone 44 (25.1%) 20 (20.2%) 24 (31.6%)  Spouse 100 (57.1%) 64 (64.6%) 36 (47.4%)  Family/ other 31 (17.7%) 15 (15.2%) 16 (21.1%) Marital status n (%) .13  Married 109 (62.3%) 67 (67.7%) 42 (55.3%)  Not married 66 (37.7%) 32 (32.3%) 34 (44.7%) Income n (%) .66  Less than $20k 65 (37.1%) 36 (36.4%) 29 (38.2%)  $20–$39k 55 (31.4%) 34 (34.3%) 21 (27.6%)  $40k+ 54 (30.9%) 29 (29.3%) 25 (32.9%) Cardiopulmonary functional .28 Impairmentan (%)  Mild 40 (22.9%) 27 (27.3%) 13 (17.1%)  Moderate 91 (52.0%) 49 (49.5%) 42 (55.3%)  Severe 44 (25.1%) 23 (23.2%) 21 (27.6%) PHQ-9, total score, M(SD) 14.2 (4.7) 13.4 (4.2) 15.1 (5.2) .02  Above cutoff n (%)b 154 (88.0%) 85 (85.9%) 69 (90.8%) BAI, total score, M(SD) 22.5 (9.8) 21.2 (8.6) 24.1 (10.9) .05  Above cutoff n (%)b 134 (76.6%) 77 (77.8%) 57 (75.0%) Meeting both PHQ-9 and BAI criteria n (%)b 113 (64.6%) 63 (63.6%) 50 (65.8%) .89 Overall (N = 175) bCBT (n = 99) EUC (n = 76) p-value Age, M (SD), years 66.5 (8.3) 65.8 (8.4) 67.4 (8.1) .21 Male gender n (%) 161 (92.0%) 90 (90.9%) 71 (93.4%) .92 Education n (%) .80  High School or less 77 (44.0%) 44 (44.4%) 33 (43.4%)  Some college 76 (43.4%) 44 (44.4%) 32 (42.1%)  College graduate 22 (12.6%) 11 (11.1%) 11 (14.5%) Race/ethnicity n (%) .21  Non-Hispanic White 117 (66.9%) 65 (65.7%) 52 (68.4%)  African American 39 (22.3%) 21 (21.2%) 18 (23.7%)  Hispanic 4 (2.3%) 1 (1.0%) 3 (3.9%)  Other 14 (8.0%) 11 (11.1%) 3 (3.9%) Living status n (%) .07  Alone 44 (25.1%) 20 (20.2%) 24 (31.6%)  Spouse 100 (57.1%) 64 (64.6%) 36 (47.4%)  Family/ other 31 (17.7%) 15 (15.2%) 16 (21.1%) Marital status n (%) .13  Married 109 (62.3%) 67 (67.7%) 42 (55.3%)  Not married 66 (37.7%) 32 (32.3%) 34 (44.7%) Income n (%) .66  Less than $20k 65 (37.1%) 36 (36.4%) 29 (38.2%)  $20–$39k 55 (31.4%) 34 (34.3%) 21 (27.6%)  $40k+ 54 (30.9%) 29 (29.3%) 25 (32.9%) Cardiopulmonary functional .28 Impairmentan (%)  Mild 40 (22.9%) 27 (27.3%) 13 (17.1%)  Moderate 91 (52.0%) 49 (49.5%) 42 (55.3%)  Severe 44 (25.1%) 23 (23.2%) 21 (27.6%) PHQ-9, total score, M(SD) 14.2 (4.7) 13.4 (4.2) 15.1 (5.2) .02  Above cutoff n (%)b 154 (88.0%) 85 (85.9%) 69 (90.8%) BAI, total score, M(SD) 22.5 (9.8) 21.2 (8.6) 24.1 (10.9) .05  Above cutoff n (%)b 134 (76.6%) 77 (77.8%) 57 (75.0%) Meeting both PHQ-9 and BAI criteria n (%)b 113 (64.6%) 63 (63.6%) 50 (65.8%) .89 BAI Beck Anxiety Inventory; bCBT brief cognitive behavioral therapy; EUC enhanced usual care; scale; mMRC modified Medical Research Council dyspnea scale; PHQ-9 Patient Health Questionnaire. p-values are based on t-test for age, PHQ-9 total score, and BAI total score and chi-square for remaining items. aFunctional impairment defined by mMRC criteria. Mild = mMRC scores of 3; Moderate = mMRC score of 4; Severe = mMRC score of 5. bCutoff score is 10 for PHQ-9 and 16 for BAI. View Large Table 1 Baseline Sociodemographic and Clinical Characteristics by Intervention Status Overall (N = 175) bCBT (n = 99) EUC (n = 76) p-value Age, M (SD), years 66.5 (8.3) 65.8 (8.4) 67.4 (8.1) .21 Male gender n (%) 161 (92.0%) 90 (90.9%) 71 (93.4%) .92 Education n (%) .80  High School or less 77 (44.0%) 44 (44.4%) 33 (43.4%)  Some college 76 (43.4%) 44 (44.4%) 32 (42.1%)  College graduate 22 (12.6%) 11 (11.1%) 11 (14.5%) Race/ethnicity n (%) .21  Non-Hispanic White 117 (66.9%) 65 (65.7%) 52 (68.4%)  African American 39 (22.3%) 21 (21.2%) 18 (23.7%)  Hispanic 4 (2.3%) 1 (1.0%) 3 (3.9%)  Other 14 (8.0%) 11 (11.1%) 3 (3.9%) Living status n (%) .07  Alone 44 (25.1%) 20 (20.2%) 24 (31.6%)  Spouse 100 (57.1%) 64 (64.6%) 36 (47.4%)  Family/ other 31 (17.7%) 15 (15.2%) 16 (21.1%) Marital status n (%) .13  Married 109 (62.3%) 67 (67.7%) 42 (55.3%)  Not married 66 (37.7%) 32 (32.3%) 34 (44.7%) Income n (%) .66  Less than $20k 65 (37.1%) 36 (36.4%) 29 (38.2%)  $20–$39k 55 (31.4%) 34 (34.3%) 21 (27.6%)  $40k+ 54 (30.9%) 29 (29.3%) 25 (32.9%) Cardiopulmonary functional .28 Impairmentan (%)  Mild 40 (22.9%) 27 (27.3%) 13 (17.1%)  Moderate 91 (52.0%) 49 (49.5%) 42 (55.3%)  Severe 44 (25.1%) 23 (23.2%) 21 (27.6%) PHQ-9, total score, M(SD) 14.2 (4.7) 13.4 (4.2) 15.1 (5.2) .02  Above cutoff n (%)b 154 (88.0%) 85 (85.9%) 69 (90.8%) BAI, total score, M(SD) 22.5 (9.8) 21.2 (8.6) 24.1 (10.9) .05  Above cutoff n (%)b 134 (76.6%) 77 (77.8%) 57 (75.0%) Meeting both PHQ-9 and BAI criteria n (%)b 113 (64.6%) 63 (63.6%) 50 (65.8%) .89 Overall (N = 175) bCBT (n = 99) EUC (n = 76) p-value Age, M (SD), years 66.5 (8.3) 65.8 (8.4) 67.4 (8.1) .21 Male gender n (%) 161 (92.0%) 90 (90.9%) 71 (93.4%) .92 Education n (%) .80  High School or less 77 (44.0%) 44 (44.4%) 33 (43.4%)  Some college 76 (43.4%) 44 (44.4%) 32 (42.1%)  College graduate 22 (12.6%) 11 (11.1%) 11 (14.5%) Race/ethnicity n (%) .21  Non-Hispanic White 117 (66.9%) 65 (65.7%) 52 (68.4%)  African American 39 (22.3%) 21 (21.2%) 18 (23.7%)  Hispanic 4 (2.3%) 1 (1.0%) 3 (3.9%)  Other 14 (8.0%) 11 (11.1%) 3 (3.9%) Living status n (%) .07  Alone 44 (25.1%) 20 (20.2%) 24 (31.6%)  Spouse 100 (57.1%) 64 (64.6%) 36 (47.4%)  Family/ other 31 (17.7%) 15 (15.2%) 16 (21.1%) Marital status n (%) .13  Married 109 (62.3%) 67 (67.7%) 42 (55.3%)  Not married 66 (37.7%) 32 (32.3%) 34 (44.7%) Income n (%) .66  Less than $20k 65 (37.1%) 36 (36.4%) 29 (38.2%)  $20–$39k 55 (31.4%) 34 (34.3%) 21 (27.6%)  $40k+ 54 (30.9%) 29 (29.3%) 25 (32.9%) Cardiopulmonary functional .28 Impairmentan (%)  Mild 40 (22.9%) 27 (27.3%) 13 (17.1%)  Moderate 91 (52.0%) 49 (49.5%) 42 (55.3%)  Severe 44 (25.1%) 23 (23.2%) 21 (27.6%) PHQ-9, total score, M(SD) 14.2 (4.7) 13.4 (4.2) 15.1 (5.2) .02  Above cutoff n (%)b 154 (88.0%) 85 (85.9%) 69 (90.8%) BAI, total score, M(SD) 22.5 (9.8) 21.2 (8.6) 24.1 (10.9) .05  Above cutoff n (%)b 134 (76.6%) 77 (77.8%) 57 (75.0%) Meeting both PHQ-9 and BAI criteria n (%)b 113 (64.6%) 63 (63.6%) 50 (65.8%) .89 BAI Beck Anxiety Inventory; bCBT brief cognitive behavioral therapy; EUC enhanced usual care; scale; mMRC modified Medical Research Council dyspnea scale; PHQ-9 Patient Health Questionnaire. p-values are based on t-test for age, PHQ-9 total score, and BAI total score and chi-square for remaining items. aFunctional impairment defined by mMRC criteria. Mild = mMRC scores of 3; Moderate = mMRC score of 4; Severe = mMRC score of 5. bCutoff score is 10 for PHQ-9 and 16 for BAI. View Large Summary of Illness Intrusiveness in the Sample Baseline scores for illness intrusiveness were high among the entire sample (M = 55.9, SD = 15.8). These scores were normally distributed at baseline (skewness = −0.04, SE = 0.18; kurtosis = −0.48, SE = 0.37), with 15.4% (n = 27) of the sample classified as having low baseline illness intrusiveness, 63.4% (n = 111) as having average intrusiveness, and 21.1% (n = 37) as having high intrusiveness. Results of a one-way ANOVA indicated there was no difference in baseline illness intrusiveness between COPD severity groups, as measured by the mMRC [F(2, 172) = 2.09, p = .13]. After adjusting for baseline IIRS, PHQ-9, and BAI scores, participants who received bCBT treatment demonstrated reduced illness intrusiveness compared to EUC, F(1, 170) = 4.81, p = .03, partial η2 = .03. The bCBT treatment group evidenced lower intrusiveness on the Instrumental subscale (F(1, 170) = 4.01, p = .02) after treatment than the EUC group; however, the two groups did not differ significantly from one another on the IIRS Relationship (p = .37) or Intimacy (p = .09) subscales posttreatment. Demographic factors of age (β = −.04, SE = .18, p = .70), gender (F (1, 96) = 0.002, p = .96), education (F (2, 96) = 0.14, p = .87), race/ethnicity (F (3, 94) = 0.93, p = .43), living status (F (2, 96) = 1.41, p = .25), marital status (F (1, 97) = 0.26, p = .61), and income (F (2, 96) = 0.19, p = .83) were not associated with change in IIRS score. Neither baseline depression (PHQ-9; β = .06, SE = 0.37, p = .54) nor anxiety (BAI; β = −.04, SE = 0.18, p = .69) predicted IIRS change scores. Treatment engagement (number of treatment sessions attended) did not predict change in IIRS score (β = 0.12, SE = 0.78, p = .25). IIRS score change was not different between the three baseline mMRC severity groups, F (2, 96) = 0.86, p = .43. Treatment Effects on Illness Intrusiveness Table 2 presents exploratory within-group analyses of the change in IIRS scores and other outcome measures between baseline and 4-month assessments for both the bCBT and EUC groups. Consistent with our hypothesis, IIRS scores improved between baseline and posttreatment among participants in the bCBT group (t98 = 3.95, p < .001), even in the absence of treatment effects for physical health QoL (SF-12 PCS; t98 = −0.90, p = .37, d = 0.09). Among the IIRS subscales, the Intimacy (t94 = 4.08, p < .001, d = 0.39) and Instrumental (t94 = 4.97, p < .001, d = 0.49) subscales of intrusiveness evidenced improvement during bCBT treatment with small-to-medium effect sizes. There was a non-significant trend toward improvement in the Relationship subscale with a small effect size (t94 = 1.80, p = .08, d = 0.19). No treatment effects were realized for COPD severity (mMRC; t98 = −0.21, p = .84, d = 0.03). The small-to-medium treatment effect for the bCBT intervention on illness intrusiveness (d = 0.38) was comparable in magnitude to treatment effects for mental health QoL (SF-12 MCS; t98 = −4.26, p < .001, d = 0.44). Table 2 Within Group Change in Outcome Measures During Treatment Period Baseline M (SD) Posttreatment (4 months) M (SD) Within group change M (SD) Treatment effecta (Cohen’s d) bCBT EUC bCBT EUC bCBT EUC bCBT IIRS 57.0 (14.7) 54.3 (17.1) 51.0 (17.2) 55.0 (17.0) 6.02 (15.15)*** −0.67 (15.63) 0.38 t98 = 3.95 t75 = −0.37  Relationship 3.6 (1.4) 3.6 (1.6) 3.4 (1.5) 3.7 (1.5) 0.27 (1.47) −0.16 (1.44) 0.19 t94 = 1.80 t74 = −0.93  Intimacy 4.8 (2.1) 4.4 (2.0) 4.0 (2.3) 4.3 (2.1) 0.84 (2.01)*** 0.09 (1.84) 0.39 t94 = 4.08 t74 = 0.44  Instrumental 5.4 (1.2) 5.1 (1.3) 4.8 (1.4) 5.1 (1.5) 0.66 (1.28)*** −0.01 (1.40) 0.49 t94 = 4.97 T74 = −0.04 SF-12  MCS 42.6 (10.8) 37.8 (10.2) 47.4 (10.9) 38.4 (11.0) −4.78 (11.17)*** −0.59 (10.28) −0.44 t98 = −4.26 t75 = −0.50  PCS 25.1 (6.1) 27.4 (6.5) 25.6 (6.9) 27.9 (7.6) −0.58 (6.39) −0.46 (6.42) −0.09 t98 = −0.90 t75 = −0.63 mMRC 4.0 (0.7) 4.1 (0.7) 4.0 (0.8) 4.1 (0.7) −0.02 (0.98) 0.03 (0.85) −0.03 t98 = −0.21 t75 = 0.27 Baseline M (SD) Posttreatment (4 months) M (SD) Within group change M (SD) Treatment effecta (Cohen’s d) bCBT EUC bCBT EUC bCBT EUC bCBT IIRS 57.0 (14.7) 54.3 (17.1) 51.0 (17.2) 55.0 (17.0) 6.02 (15.15)*** −0.67 (15.63) 0.38 t98 = 3.95 t75 = −0.37  Relationship 3.6 (1.4) 3.6 (1.6) 3.4 (1.5) 3.7 (1.5) 0.27 (1.47) −0.16 (1.44) 0.19 t94 = 1.80 t74 = −0.93  Intimacy 4.8 (2.1) 4.4 (2.0) 4.0 (2.3) 4.3 (2.1) 0.84 (2.01)*** 0.09 (1.84) 0.39 t94 = 4.08 t74 = 0.44  Instrumental 5.4 (1.2) 5.1 (1.3) 4.8 (1.4) 5.1 (1.5) 0.66 (1.28)*** −0.01 (1.40) 0.49 t94 = 4.97 T74 = −0.04 SF-12  MCS 42.6 (10.8) 37.8 (10.2) 47.4 (10.9) 38.4 (11.0) −4.78 (11.17)*** −0.59 (10.28) −0.44 t98 = −4.26 t75 = −0.50  PCS 25.1 (6.1) 27.4 (6.5) 25.6 (6.9) 27.9 (7.6) −0.58 (6.39) −0.46 (6.42) −0.09 t98 = −0.90 t75 = −0.63 mMRC 4.0 (0.7) 4.1 (0.7) 4.0 (0.8) 4.1 (0.7) −0.02 (0.98) 0.03 (0.85) −0.03 t98 = −0.21 t75 = 0.27 bCBT brief cognitive behavioral therapy; EUC enhanced usual care; IIRS Illness Intrusiveness Rating Scale; SF-12 Medical Outcomes Study 36-Item Short-Form Health Survey; MCS mental component summary; PCS physical component summary; mMRC modified Medical Research Council dyspnea scale. Negative values on the change in MCS, PCS, and mMRC reflect a reduction in symptoms or functional limitations. aEffect sizes calculated for bCBT treatment group only. View Large Table 2 Within Group Change in Outcome Measures During Treatment Period Baseline M (SD) Posttreatment (4 months) M (SD) Within group change M (SD) Treatment effecta (Cohen’s d) bCBT EUC bCBT EUC bCBT EUC bCBT IIRS 57.0 (14.7) 54.3 (17.1) 51.0 (17.2) 55.0 (17.0) 6.02 (15.15)*** −0.67 (15.63) 0.38 t98 = 3.95 t75 = −0.37  Relationship 3.6 (1.4) 3.6 (1.6) 3.4 (1.5) 3.7 (1.5) 0.27 (1.47) −0.16 (1.44) 0.19 t94 = 1.80 t74 = −0.93  Intimacy 4.8 (2.1) 4.4 (2.0) 4.0 (2.3) 4.3 (2.1) 0.84 (2.01)*** 0.09 (1.84) 0.39 t94 = 4.08 t74 = 0.44  Instrumental 5.4 (1.2) 5.1 (1.3) 4.8 (1.4) 5.1 (1.5) 0.66 (1.28)*** −0.01 (1.40) 0.49 t94 = 4.97 T74 = −0.04 SF-12  MCS 42.6 (10.8) 37.8 (10.2) 47.4 (10.9) 38.4 (11.0) −4.78 (11.17)*** −0.59 (10.28) −0.44 t98 = −4.26 t75 = −0.50  PCS 25.1 (6.1) 27.4 (6.5) 25.6 (6.9) 27.9 (7.6) −0.58 (6.39) −0.46 (6.42) −0.09 t98 = −0.90 t75 = −0.63 mMRC 4.0 (0.7) 4.1 (0.7) 4.0 (0.8) 4.1 (0.7) −0.02 (0.98) 0.03 (0.85) −0.03 t98 = −0.21 t75 = 0.27 Baseline M (SD) Posttreatment (4 months) M (SD) Within group change M (SD) Treatment effecta (Cohen’s d) bCBT EUC bCBT EUC bCBT EUC bCBT IIRS 57.0 (14.7) 54.3 (17.1) 51.0 (17.2) 55.0 (17.0) 6.02 (15.15)*** −0.67 (15.63) 0.38 t98 = 3.95 t75 = −0.37  Relationship 3.6 (1.4) 3.6 (1.6) 3.4 (1.5) 3.7 (1.5) 0.27 (1.47) −0.16 (1.44) 0.19 t94 = 1.80 t74 = −0.93  Intimacy 4.8 (2.1) 4.4 (2.0) 4.0 (2.3) 4.3 (2.1) 0.84 (2.01)*** 0.09 (1.84) 0.39 t94 = 4.08 t74 = 0.44  Instrumental 5.4 (1.2) 5.1 (1.3) 4.8 (1.4) 5.1 (1.5) 0.66 (1.28)*** −0.01 (1.40) 0.49 t94 = 4.97 T74 = −0.04 SF-12  MCS 42.6 (10.8) 37.8 (10.2) 47.4 (10.9) 38.4 (11.0) −4.78 (11.17)*** −0.59 (10.28) −0.44 t98 = −4.26 t75 = −0.50  PCS 25.1 (6.1) 27.4 (6.5) 25.6 (6.9) 27.9 (7.6) −0.58 (6.39) −0.46 (6.42) −0.09 t98 = −0.90 t75 = −0.63 mMRC 4.0 (0.7) 4.1 (0.7) 4.0 (0.8) 4.1 (0.7) −0.02 (0.98) 0.03 (0.85) −0.03 t98 = −0.21 t75 = 0.27 bCBT brief cognitive behavioral therapy; EUC enhanced usual care; IIRS Illness Intrusiveness Rating Scale; SF-12 Medical Outcomes Study 36-Item Short-Form Health Survey; MCS mental component summary; PCS physical component summary; mMRC modified Medical Research Council dyspnea scale. Negative values on the change in MCS, PCS, and mMRC reflect a reduction in symptoms or functional limitations. aEffect sizes calculated for bCBT treatment group only. View Large Discussion Results from the current study demonstrate that illness intrusiveness was significantly improved following bCBT for Veterans with COPD. Illness intrusiveness was improved, relative to EUC, and independent of baseline depression or anxiety symptoms. Similarly, two specific domains of illness intrusiveness exhibited notable improvements within the bCBT treatment arm: instrumental aspects of life (i.e. work and finances, active recreation) and intimacy (i.e. perception of one’s sexual functioning and relationship with one’s spouse); however, only the Instrumental subscale evidenced between-group difference in bCBT participants relative to those receiving EUC. Notably, baseline levels of illness intrusiveness did not differ by dyspnea severity; and disease severity was not associated with change in IIRS scores. This independence between objective functional impairment and the perception of disease interference lends further support to illness intrusiveness as a psychosocial construct related to, but not dependent on, disease severity. Findings suggest that illness intrusiveness may be an important construct for behavioral medicine assessment and treatment. Data from our trial indicate that the IIRS is sensitive to change following a course of bCBT and has psychometric response characteristics that are consistent with other measures of physical and mental health functioning. Given that illness intrusiveness is thought to contribute to QoL through engagement in valued activities and perceived control [20], it is unsurprising that IIRS effect sizes were consistent with effect sizes found for mental health QoL. However, the treatment effect on illness intrusiveness was notably superior to changes on physical health QoL and disease-specific pulmonary functional limitations. Given the chronic and degenerative nature of COPD, one would not expect an improvement in physical health QoL or disease severity during this brief intervention. The present findings are consistent with a previous trial in which Veterans with COPD evidenced an improvement in mental health QoL, but not physical health QoL, over the course of an 8-week CBT intervention [15]. However, the significant improvements found for IIRS score, even in the absence of actual physical health improvements, suggest a potential avenue for improved treatment outcomes for medically ill patients such that behavioral medicine interventions may improve both illness perceptions as well as intrapersonal perceptions related to efficacy and identity. Moreover, merely assessing for mental health comorbidities (i.e. depression and anxiety) and encouraging patients and providers to follow-up on such care are not sufficient to affect change, as demonstrated by the findings in the EUC arm. Despite the prevalence and burden of COPD, behavioral medicine approaches for this disease have received little research or public interest relative to other chronic diseases [44]. A significant strength of the study was the clinical relevance imparted by a large, multisite sample of medically ill participants who engaged in treatment despite high levels of illness intrusiveness and dyspnea; this increases the applicability of these results to real-world behavioral medicine settings. However, the generalizability of these results must be considered in light of study limitations. First, it is unknown how these results will extend beyond our sample of older, predominantly non-Hispanic White male Veterans. Participants in this study also had elevated symptoms of depression and anxiety; while these comorbidities are common among those with COPD [12, 25, 45], they may have contributed to higher levels of illness intrusiveness and altered treatment response relative to COPD patients without mood and anxiety symptoms. A greater proportion of participants in the active treatment arm were lost to follow-up relative to those in EUC; of these, a greater number cited research burden and other stressors (health, family, or work) as the cause of their attrition. Although the parent study found no significant difference between completers and noncompleters [17], participants who completed bCBT may represent a curated subsample of individuals that are more likely to engage in treatment than other primary care patients with comorbid medical and mental illnesses. Regarding IIRS effects, exploratory analyses suggested that baseline illness intrusiveness did not differ by disease severity, and functional impairment did not predict change in IIRS score. Future studies should use prospective and potentially longitudinal study designs to assess the long-term trajectory of illness intrusiveness, taking into consideration changes in functional impairment and COPD disease progression. Furthermore, the treatment effects on illness intrusiveness, while promising, were measured after a 4-month intervention. Clinically speaking, this is a brief window of time in a chronic and variable disease course. While the intervention emphasized building a repertoire of skills that may be sustained by the participant after treatment cessation, future studies should assess maintenance of treatment effects and the most effective length of bCBT in a chronic disease course. Taken together, these results suggest that a bCBT intervention that integrates physical and emotional health was effective at reducing illness intrusiveness, even in the absence of actual physical health improvements (which might not be feasible or expected in a progressive chronic disease). Furthermore, illness intrusiveness may be an important construct to better assess and understand the bidirectionality between physical functioning and psychological impact of chronic disease, with more sensitivity to change than indices of HRQoL. This carries important implications for both researchers and clinicians. Future studies should investigate illness intrusiveness as a transdiagnostic construct that may have greater utility than disease-specific instruments in multimorbid patient samples. Of relevance for clinicians, illness intrusiveness represents a distinct clinical entity with implications for treatment. This construct may provide important information to better understand how and why patients have variable responses to medical diagnoses, ranging from resiliency to disengagement, distress, and even clinical disorders of depression and anxiety. Specifically, treatment aimed at facilitating engagement in psychologically meaningful activities may minimize the adverse psychosocial impact of chronic disease, independent of clinical symptoms of anxiety and depression. Incorporating illness intrusiveness into behavioral health treatment can guide intervention targets and improve HRQoL, particularly in the context of symptomatic depression and anxiety. Indeed, a skills-focused treatment approach such as bCBT may offer benefits particularly suitable for improving the activities most limited by COPD (e.g. active recreation, work). In conclusion, illness intrusiveness can help to elucidate the intersection of chronic disease limitations and psychological distress. Results from this study suggest that illness intrusiveness, particularly in instrumental and intimate domains of life, is amenable to treatment. The issue of how to augment current medical practices to best integrate mental health care remains critical for public health, and evidence-based psychotherapies have the potential to treat both mental health concerns and broader behavioral medicine issues. Interventions that incorporate illness intrusiveness provide opportunities to address not only psychological concerns but also lifestyle modifications important for chronic disease self-management. Conflict of Interest Authors Brenna N. Renn, Natalie E. Hundt, Shubhada Sansgiry, Nancy J. Petersen, Michael R. Kauth, Mark E. Kunik, and Jeffrey A. Cully declare that they have no conflict of interest. Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent The current study was approved by the relevant Institutional Review Boards and VA Research and Development review committees. All participants provided informed consent. The parent trial was registered on clinicaltrials.gov (NCT01149772). Acknowledgments This research was supported by a grant from the Department of Veterans Affairs HSR&D grant 09-088 (PI: J. A. Cully), partially supported by an HSR&D Career Development Award (#13–264) given to the second author, and the VA HSR&D Houston Center for Innovations in Quality, Effectiveness and Safety (CIN# 13–413), Michael E. DeBakey VA Medical Center, Houston, TX. 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Integrated Brief Cognitive Behavioral Therapy Improves Illness Intrusiveness in Veterans With Chronic Obstructive Pulmonary Disease

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1532-4796
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10.1093/abm/kax045
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Abstract

Abstract Background Progressive illnesses such as chronic obstructive pulmonary disease (COPD) impart a high level of physical and psychological burden. Evidence-based psychotherapies hold the potential to improve perceptions of physical health impairment, yet few studies have documented these effects. Purpose To evaluate the effect of brief cognitive behavioral therapy (bCBT) on disease-related illness intrusiveness. Methods Participants were 175 Veterans with COPD and clinically elevated symptoms of depression and/or anxiety enrolled in a larger randomized trial (n = 99 randomized to bCBT, n = 76 to enhanced usual care; EUC). bCBT included up to six treatment sessions and optional booster sessions over a 4-month period. EUC entailed an assessment with documentation in the medical record. Primary outcomes focused on posttreatment changes on the Illness Intrusiveness Rating Scale (IIRS), an established measure of perceived impairment from a chronic health condition. Results Illness intrusiveness improved for bCBT participants relative to EUC, after controlling for baseline IIRS scores, depression, and anxiety (p = .03, partial η2 = .03). Specific improvement was observed in the Instrumental subscale (p = .02), encompassing improved intrusiveness of COPD on daily activities and daily functioning. IIRS scores improved in the absence of changes in physical functioning. Conclusions Illness intrusiveness was high among Veterans with COPD but improved over the course of bCBT. Integrated behavioral health interventions hold the potential to reduce disease intrusiveness. The IIRS may be a valuable tool to augment traditional assessment and measurement-based care approaches of behavioral health interventions for medically ill patients. Illness intrusiveness, Chronic obstructive pulmonary disease, Brief cognitive behavioral therapy, Veterans Introduction As chronic diseases continue to increase in prevalence and dominate the U.S. healthcare system, they contribute a high degree of individual and public health burden [1]. On an individual level, progressive and life-limiting chronic disease states raise existential issues related to uncertainty about one’s health and may impart negative perceptions about one’s future and sense of self [2, 3]. Individual reactions to chronic disease vary by patient and can range from resiliency to physical and emotional incapacitation [4, 5]. Although the severity of the physical illness often influences these reactions, mental health functioning and psychological constructs such as cognitive perceptions of the illness and perceived unpredictability and uncontrollability of the illness also play a pronounced role [6–8]. One such chronic disease that carries a high level of physical and psychological burden is chronic obstructive pulmonary disease (COPD), a progressive, debilitating lung disorder characterized by restricted airflow. COPD is a leading cause of death worldwide and carries an increased risk of morbidity, mortality, impaired functional status, and increased health service use [9, 10]. The focus of treatment for COPD is often on symptom management, as disease exacerbations disrupt daily life and punctuate the progressive decline associated with the illness. As such, chronic respiratory conditions deleteriously affect multiple outcomes, including functional ability [11], mental health [12], and quality of life (QoL) [11]. The expression of depression and anxiety may range in severity from mild, short-term symptoms to more severe, diagnosable chronic disorders. When present, these mental health difficulties can adversely affect disease self-management and further worsen functional outcomes and QoL—above and beyond the effects of the physical illness [13]. An emerging literature demonstrates the efficacy of behavioral health interventions on concomitant depression and anxiety outcomes in cardiopulmonary disease [14–17]. Preliminary data suggest the potential for these interventions to impact perceptions of health-related QoL (HRQoL) [17]. HRQoL refers to the impact of physical health on QoL, including well-being in domains of physical, psychological, and social functioning. To best measure HRQoL, clinicians and researchers often rely on disease-specific HRQoL measures, which are more sensitive to change than global QoL assessments (e.g. the Medical Outcomes Study 36-Item Short-Form Health Survey [SF-36]) [18]. However, disease-specific instruments limit inference to other medically ill populations because of their reliance on specific symptoms (e.g. dyspnea in respiratory conditions; glycemic control among patients with diabetes mellitus). Similarly, disease-specific measures have limited applicability and utility in multimorbid populations. Thus, while assessing HRQoL is important to understand an individual’s view of his/her own health and well-being, disease-specific measures may be deficient among complex or multimorbid patient populations. Illness intrusiveness is a transdiagnostic facet of chronic disease management that represents a commonality across disease conditions [19, 20]. Devins and colleagues [19] introduced the construct of illness intrusiveness to encapsulate one’s perception of interference related to a chronic illness on valued activities and daily living. Perceptions of intrusiveness may arise from both the symptoms of the disease (e.g. pain, functional limitations) as well as its treatment (e.g. time, side-effects). This disruption in lifestyle, or intrusiveness, of the illness contributes to reduced QoL and subjective well-being. Illness intrusiveness is commonly assessed using the Illness Intrusiveness Rating Scale (IIRS) [20, 21], an established self-report instrument with which individuals rate the extent to which “one’s illness and/or its treatment interfere” with 13 activities and domains that are thought to contribute to QoL [22]. The concept of illness intrusiveness might represent an important target in COPD assessment and treatment, given the significant lifestyle disruptions imparted by the respiratory condition. Illness intrusiveness is also associated with the presence of mental health symptoms, such as depression [23, 24] and anxiety [25]. Among individuals with cardiopulmonary disease, illness intrusiveness has been associated with poor internal health locus of control and avoidant coping strategies [26]. As such, illness intrusiveness likely presents an additional barrier to disease self-management and may be a worthy target of behavioral medicine assessment and interventions. Indeed, previous research substantiates that illness intrusiveness is amenable to treatment. For example, illness intrusiveness improved after a 6-week course of an online self-management program among medically ill patients (25% with lung disease, including COPD) [27], as well as after a 6-month self-management program for patients with COPD and their families [28]. However, despite the increasing integration of behavioral and physical health care, no published studies to date have examined the effect of psychotherapy on illness intrusiveness in medically ill patients. Results from our prior work demonstrated that a course of brief cognitive behavioral therapy (bCBT) improved symptoms of depression, anxiety, and disease-specific QoL in medically ill Veterans with cardiopulmonary disease [17]. Understanding illness intrusiveness as a potential treatment target may identify further opportunities for interventions for chronic disease management to maximize both physical and mental health. Thus, the present study examined whether bCBT could improve illness intrusiveness among Veterans with COPD. Given the results of the parent trial and the demonstrated efficacy of cognitive behavioral therapies for numerous psychological and medical conditions [29], we hypothesized that individuals receiving bCBT would evidence lower levels of posttreatment illness intrusiveness than the control group. Method Participants Participants were recruited from two large U.S. Veterans Affairs (VA) medical centers in the context of a randomized controlled investigation of bCBT for clinically significant symptoms of depression and/or anxiety among medically ill Veterans [30]. Design, procedures, and primary outcomes (including intent-to-treat analyses) of the parent study are detailed elsewhere [17]. Although the parent study targeted patient-participants with COPD and/or heart failure, the small sample size and complex physical health responses found for heart failure participants required that secondary analyses address these patient groups separately. In brief, potential COPD participants were extracted from Veterans Health Administration (VHA) patient databases, using International Classification of Diseases—Ninth Revision (ICD-9) diagnostic codes for COPD (ICD-9 codes 490, 491, 492, 493, 496, 508). ICD-9 codes were identified in collaboration with a pulmonologist to encompass commonly used codes in frontline practice for patients with COPD. Participants had their COPD confirmed by chart review and had to report mildly to severely disabling dyspnea (modified Medical Research Council dyspnea scale [mMRC] score ≥ 3) [31, 32]. In addition to these COPD-related criteria, participants had to endorse clinically significant symptoms of depression (Patient Health Questionnaire [PHQ-9] ≥ 10) [33, 34] and/or anxiety (Beck Anxiety Inventory [BAI] ≥ 16) [35]. Participants were excluded if they had a cognitive, bipolar, psychotic, or substance use disorder or if they had current suicidal intent or plan as assessed by a structured diagnostic interview (Mini International Neuropsychiatric Inventory [MINI]) [36]. Participants were also excluded if they were receiving other psychotherapy services at baseline, to avoid treatment overlap. Measures Illness Intrusiveness The IIRS [21] is a 13-item self-report instrument assessing the extent of illness intrusiveness on a 7-point scale (1 = not very much, 7 = very much; responses of “not applicable” coded as 1), with higher sum scores indicating greater illness intrusiveness. For this study, participants were directed to answer how much COPD and/or its treatment interferes with valued life domains, including items related to health, recreation, social relationships, family interaction, work and finances, intimacy, and religious and community involvement. In addition to a continuous illness intrusiveness total score (possible score range 13–91), the IIRS has three validated subscales: (a) Relationships and Personal Development (Relationship subscale), encompassing items related to engagement in passive recreation, family and other social relationships, civic and community involvement, religious expression, and self-expression; (b) Intimacy, based on relationship with spouse/significant other and sexual functioning; and (c) Instrumental, which assesses instrumental daily activities and daily functioning, such as health, work, active recreation, and finances [37]. Each subscale comprises the mean of individual items scores (range 1–7). The IIRS has good test–retest reliability [20]. Internal consistency of the IIRS in this sample was good (Cronbach’s α = .85). Psychological Symptoms Depressive symptoms were assessed using the PHQ-9 [33], a widely used self-report screening measure for depression that corresponds to the nine diagnostic symptoms of a major depressive episode. Items are scored on a 4-point scale (0 = not at all, 3 = nearly every day; total scores range from 0 to 27), with higher scores indicating greater symptom severity and frequency. A cut score ≥10 suggests the presence of clinically significant depression with favorable specificity and sensitivity [34]. As such, PHQ-9 total score was both treated as a continuous variable and dichotomized into clinical symptoms of depression (≥10) and no depression (<10). The BAI [35] is a psychometrically strong self-report measure of anxiety symptoms. The 21 items are scored on a 4-point scale (0 = not at all, 3 = severely; total scores range from 0 to 63), with higher scores indicative of more severe anxiety. BAI total score was both treated as a continuous variable and dichotomized into clinical symptoms of anxiety (≥16) and no anxiety (<16). COPD Severity, Functional Impairment, and QoL The mMRC [31, 32] assessed dyspnea severity using a grading system of the degree of breathlessness and resulting disability. A 5-point classification system staged the degree of dyspnea from a grade of 1 (not troubled with breathlessness) to 5 (too breathless to leave the house, or breathless when dressing or undressing). This self-rated scale is validated in COPD samples [31] and correlates with pulmonary function, walking disability, and survival [38, 39]. The Chronic Respiratory Questionnaire (CRQ) [40] is a disease-specific QoL instrument that measures the physical and emotional aspects of COPD. This 20-item, interviewer-administered instrument yields four component scores: dyspnea, fatigue, emotional functioning, and mastery. Total scores range from 20 to 140, with higher scores indicating better HRQoL. Although there are no established cut scores, a change of 0.5 points on any of the 7-point subscale scores represents the minimal clinically important difference [41]. Finally, the Medical Outcomes Study 12-item Short Form Health Survey (SF-12) [42] assessed general HRQoL. This instrument yields two subscales, the physical component summary (PCS) and the mental component summary (MCS), in which higher scores represent better HRQoL. Procedures Potential participants were contacted by research assistants for initial telephone screening and baseline assessment as part of the parent study. A total of 302 participants were randomized to receive either enhanced usual care (EUC) or the investigational bCBT intervention for the parent study. Unequal block randomization (60% to bCBT and 40% to EUC) was used in the parent study to increase statistical power for the intervention arm and to improve the study’s ability to better understand intervention delivery elements (e.g. secondary treatment analyses). Of those randomized, 226 participants had COPD (mMRC score ≥3), and 175 participants completed posttreatment assessment (Fig. 1 summarizes participant flow). EUC supplemented a participant’s usual VHA care with an assessment for depression and anxiety, documentation of these symptoms in the medical record, and printed psychoeducational materials on COPD and depression and anxiety. The integrated bCBT intervention was a manualized modular psychotherapy protocol that allowed patients and providers to select foci of treatment pertaining to the most pressing physical and emotional health concerns of the participant [43]. For example, modules consisted of psychoeducation, chronic disease self-management, goal setting, behavioral activation, cognitive restructuring, relaxation, and coping with physical health symptoms. Treatment was delivered in-person or by telephone by mental health providers in VHA primary care clinics and typically consisted of six weekly or biweekly treatment sessions (30 to 45 min) and two brief follow-up “booster” sessions (10 to 15 min) over a 4-month timeframe. Assessments were conducted at baseline and the 4-month posttreatment time points. Fig. 1. View largeDownload slide View largeDownload slide Flowchart of participants through each phase of the study. Fig. 1. View largeDownload slide View largeDownload slide Flowchart of participants through each phase of the study. The current study was approved by the relevant Institutional Review Boards and VA Research and Development review committees. All participants provided informed consent. The parent trial was registered on clinicaltrials.gov (NCT01149772). Statistical Analyses The present study analyzed a completer sample of participants who were randomized to one of two treatment conditions (bCBT or EUC) and completed posttreatment assessment. IBM SPSS version 22 was used for all analyses. Preliminary checks were conducted to assure no violation of assumptions of normality, linearity, multicollinearity, homogeneity of variances, homogeneity of regression slopes; and reliable measurement of the covariates. Pulmonary functional impairment was categorized by mMRC criteria: mild (mMRC score = 3), moderate (mMRC score = 4), and severe (mMRC score = 5). Three severity groups of illness intrusiveness were calculated, based on sample distribution: low intrusiveness (<1 SD below the group mean for the sample [possible score range 13–40]), high intrusiveness (>1 SD above the group mean [possible score range 72–91]), and normal intrusiveness (−1 to +1 SD from group mean [possible score range 41–71]) to describe the sample. Descriptive analyses provided demographics, clinical characteristics, and baseline levels of illness intrusiveness in the present sample. Univariate analyses assessed differences in baseline characteristics between treatment and EUC groups, using t-test for continuous variables and chi-square for categorical variables. Any significant covariates were included in adjusted analyses. To test the primary hypothesis that IIRS scores improved during the course of bCBT relative to EUC, a one-way analysis of covariance (ANCOVA) assessed posttreatment illness intrusiveness (adjusted for baseline IIRS score, PHQ-9, and BAI) of individuals receiving bCBT and EUC. The effect size of this test is reported as partial η2. Given the dearth of literature examining illness intrusiveness in COPD, a series of exploratory analyses supplemented the primary analysis. First, an IIRS change score was calculated for each individual’s difference in IIRS total score between baseline and posttreatment (4-month) assessment. Individual linear regression models explored possible predictors of change in IIRS scores among participants randomized to bCBT, consisting of age (continuous), baseline depressive symptoms (PHQ-9), baseline anxiety (BAI), and treatment engagement (number of sessions attended). A one-way ANOVA with the Greenhouse-Geisser correction analyzed the mean difference in IIRS change scores in bCBT participants between the remaining categorical demographic variables (gender, education level, race/ethnicity category, living status, marital status, and income group) and mMRC functional status severity groups. Subsequent exploratory within-group analyses were conducted to describe and characterize changes in illness intrusiveness during treatment. A series of paired sample t-tests assessed change between baseline and posttreatment (4-month assessment) in IIRS total score, IIRS subscales, physical health QoL (SF-12 PCS), mental health QoL (SF-12 MCS), and functional impairment (mMRC), using a split file (bCBT vs. EUC). The size of the treatment effect (Cohen’s d; reported as an absolute value) was computed for the bCBT group only, which can be interpreted as a small (0.2), medium (0.5), or large (0.8) effect. Results Demographics and Preliminary Analyses Data for the present completer analyses were available from the subset of 175 participants with COPD (n = 99 randomized to the bCBT treatment, n = 76 EUC) who completed both baseline and posttreatment assessments. The sample largely comprised older non-Hispanic White male Veterans who were married. Those in the bCBT arm completed a median of six (IQR = 2) treatment sessions and two (IQR = 1) booster sessions. Treatment groups did not differ on relevant demographic characteristics; however, the EUC group endorsed higher levels of depressive symptomatology and anxiety at baseline. Therefore, these two variables (PHQ-9 and BAI, respectively) were entered into subsequent adjusted models as covariates. See Table 1 for participant characteristics. Table 1 Baseline Sociodemographic and Clinical Characteristics by Intervention Status Overall (N = 175) bCBT (n = 99) EUC (n = 76) p-value Age, M (SD), years 66.5 (8.3) 65.8 (8.4) 67.4 (8.1) .21 Male gender n (%) 161 (92.0%) 90 (90.9%) 71 (93.4%) .92 Education n (%) .80  High School or less 77 (44.0%) 44 (44.4%) 33 (43.4%)  Some college 76 (43.4%) 44 (44.4%) 32 (42.1%)  College graduate 22 (12.6%) 11 (11.1%) 11 (14.5%) Race/ethnicity n (%) .21  Non-Hispanic White 117 (66.9%) 65 (65.7%) 52 (68.4%)  African American 39 (22.3%) 21 (21.2%) 18 (23.7%)  Hispanic 4 (2.3%) 1 (1.0%) 3 (3.9%)  Other 14 (8.0%) 11 (11.1%) 3 (3.9%) Living status n (%) .07  Alone 44 (25.1%) 20 (20.2%) 24 (31.6%)  Spouse 100 (57.1%) 64 (64.6%) 36 (47.4%)  Family/ other 31 (17.7%) 15 (15.2%) 16 (21.1%) Marital status n (%) .13  Married 109 (62.3%) 67 (67.7%) 42 (55.3%)  Not married 66 (37.7%) 32 (32.3%) 34 (44.7%) Income n (%) .66  Less than $20k 65 (37.1%) 36 (36.4%) 29 (38.2%)  $20–$39k 55 (31.4%) 34 (34.3%) 21 (27.6%)  $40k+ 54 (30.9%) 29 (29.3%) 25 (32.9%) Cardiopulmonary functional .28 Impairmentan (%)  Mild 40 (22.9%) 27 (27.3%) 13 (17.1%)  Moderate 91 (52.0%) 49 (49.5%) 42 (55.3%)  Severe 44 (25.1%) 23 (23.2%) 21 (27.6%) PHQ-9, total score, M(SD) 14.2 (4.7) 13.4 (4.2) 15.1 (5.2) .02  Above cutoff n (%)b 154 (88.0%) 85 (85.9%) 69 (90.8%) BAI, total score, M(SD) 22.5 (9.8) 21.2 (8.6) 24.1 (10.9) .05  Above cutoff n (%)b 134 (76.6%) 77 (77.8%) 57 (75.0%) Meeting both PHQ-9 and BAI criteria n (%)b 113 (64.6%) 63 (63.6%) 50 (65.8%) .89 Overall (N = 175) bCBT (n = 99) EUC (n = 76) p-value Age, M (SD), years 66.5 (8.3) 65.8 (8.4) 67.4 (8.1) .21 Male gender n (%) 161 (92.0%) 90 (90.9%) 71 (93.4%) .92 Education n (%) .80  High School or less 77 (44.0%) 44 (44.4%) 33 (43.4%)  Some college 76 (43.4%) 44 (44.4%) 32 (42.1%)  College graduate 22 (12.6%) 11 (11.1%) 11 (14.5%) Race/ethnicity n (%) .21  Non-Hispanic White 117 (66.9%) 65 (65.7%) 52 (68.4%)  African American 39 (22.3%) 21 (21.2%) 18 (23.7%)  Hispanic 4 (2.3%) 1 (1.0%) 3 (3.9%)  Other 14 (8.0%) 11 (11.1%) 3 (3.9%) Living status n (%) .07  Alone 44 (25.1%) 20 (20.2%) 24 (31.6%)  Spouse 100 (57.1%) 64 (64.6%) 36 (47.4%)  Family/ other 31 (17.7%) 15 (15.2%) 16 (21.1%) Marital status n (%) .13  Married 109 (62.3%) 67 (67.7%) 42 (55.3%)  Not married 66 (37.7%) 32 (32.3%) 34 (44.7%) Income n (%) .66  Less than $20k 65 (37.1%) 36 (36.4%) 29 (38.2%)  $20–$39k 55 (31.4%) 34 (34.3%) 21 (27.6%)  $40k+ 54 (30.9%) 29 (29.3%) 25 (32.9%) Cardiopulmonary functional .28 Impairmentan (%)  Mild 40 (22.9%) 27 (27.3%) 13 (17.1%)  Moderate 91 (52.0%) 49 (49.5%) 42 (55.3%)  Severe 44 (25.1%) 23 (23.2%) 21 (27.6%) PHQ-9, total score, M(SD) 14.2 (4.7) 13.4 (4.2) 15.1 (5.2) .02  Above cutoff n (%)b 154 (88.0%) 85 (85.9%) 69 (90.8%) BAI, total score, M(SD) 22.5 (9.8) 21.2 (8.6) 24.1 (10.9) .05  Above cutoff n (%)b 134 (76.6%) 77 (77.8%) 57 (75.0%) Meeting both PHQ-9 and BAI criteria n (%)b 113 (64.6%) 63 (63.6%) 50 (65.8%) .89 BAI Beck Anxiety Inventory; bCBT brief cognitive behavioral therapy; EUC enhanced usual care; scale; mMRC modified Medical Research Council dyspnea scale; PHQ-9 Patient Health Questionnaire. p-values are based on t-test for age, PHQ-9 total score, and BAI total score and chi-square for remaining items. aFunctional impairment defined by mMRC criteria. Mild = mMRC scores of 3; Moderate = mMRC score of 4; Severe = mMRC score of 5. bCutoff score is 10 for PHQ-9 and 16 for BAI. View Large Table 1 Baseline Sociodemographic and Clinical Characteristics by Intervention Status Overall (N = 175) bCBT (n = 99) EUC (n = 76) p-value Age, M (SD), years 66.5 (8.3) 65.8 (8.4) 67.4 (8.1) .21 Male gender n (%) 161 (92.0%) 90 (90.9%) 71 (93.4%) .92 Education n (%) .80  High School or less 77 (44.0%) 44 (44.4%) 33 (43.4%)  Some college 76 (43.4%) 44 (44.4%) 32 (42.1%)  College graduate 22 (12.6%) 11 (11.1%) 11 (14.5%) Race/ethnicity n (%) .21  Non-Hispanic White 117 (66.9%) 65 (65.7%) 52 (68.4%)  African American 39 (22.3%) 21 (21.2%) 18 (23.7%)  Hispanic 4 (2.3%) 1 (1.0%) 3 (3.9%)  Other 14 (8.0%) 11 (11.1%) 3 (3.9%) Living status n (%) .07  Alone 44 (25.1%) 20 (20.2%) 24 (31.6%)  Spouse 100 (57.1%) 64 (64.6%) 36 (47.4%)  Family/ other 31 (17.7%) 15 (15.2%) 16 (21.1%) Marital status n (%) .13  Married 109 (62.3%) 67 (67.7%) 42 (55.3%)  Not married 66 (37.7%) 32 (32.3%) 34 (44.7%) Income n (%) .66  Less than $20k 65 (37.1%) 36 (36.4%) 29 (38.2%)  $20–$39k 55 (31.4%) 34 (34.3%) 21 (27.6%)  $40k+ 54 (30.9%) 29 (29.3%) 25 (32.9%) Cardiopulmonary functional .28 Impairmentan (%)  Mild 40 (22.9%) 27 (27.3%) 13 (17.1%)  Moderate 91 (52.0%) 49 (49.5%) 42 (55.3%)  Severe 44 (25.1%) 23 (23.2%) 21 (27.6%) PHQ-9, total score, M(SD) 14.2 (4.7) 13.4 (4.2) 15.1 (5.2) .02  Above cutoff n (%)b 154 (88.0%) 85 (85.9%) 69 (90.8%) BAI, total score, M(SD) 22.5 (9.8) 21.2 (8.6) 24.1 (10.9) .05  Above cutoff n (%)b 134 (76.6%) 77 (77.8%) 57 (75.0%) Meeting both PHQ-9 and BAI criteria n (%)b 113 (64.6%) 63 (63.6%) 50 (65.8%) .89 Overall (N = 175) bCBT (n = 99) EUC (n = 76) p-value Age, M (SD), years 66.5 (8.3) 65.8 (8.4) 67.4 (8.1) .21 Male gender n (%) 161 (92.0%) 90 (90.9%) 71 (93.4%) .92 Education n (%) .80  High School or less 77 (44.0%) 44 (44.4%) 33 (43.4%)  Some college 76 (43.4%) 44 (44.4%) 32 (42.1%)  College graduate 22 (12.6%) 11 (11.1%) 11 (14.5%) Race/ethnicity n (%) .21  Non-Hispanic White 117 (66.9%) 65 (65.7%) 52 (68.4%)  African American 39 (22.3%) 21 (21.2%) 18 (23.7%)  Hispanic 4 (2.3%) 1 (1.0%) 3 (3.9%)  Other 14 (8.0%) 11 (11.1%) 3 (3.9%) Living status n (%) .07  Alone 44 (25.1%) 20 (20.2%) 24 (31.6%)  Spouse 100 (57.1%) 64 (64.6%) 36 (47.4%)  Family/ other 31 (17.7%) 15 (15.2%) 16 (21.1%) Marital status n (%) .13  Married 109 (62.3%) 67 (67.7%) 42 (55.3%)  Not married 66 (37.7%) 32 (32.3%) 34 (44.7%) Income n (%) .66  Less than $20k 65 (37.1%) 36 (36.4%) 29 (38.2%)  $20–$39k 55 (31.4%) 34 (34.3%) 21 (27.6%)  $40k+ 54 (30.9%) 29 (29.3%) 25 (32.9%) Cardiopulmonary functional .28 Impairmentan (%)  Mild 40 (22.9%) 27 (27.3%) 13 (17.1%)  Moderate 91 (52.0%) 49 (49.5%) 42 (55.3%)  Severe 44 (25.1%) 23 (23.2%) 21 (27.6%) PHQ-9, total score, M(SD) 14.2 (4.7) 13.4 (4.2) 15.1 (5.2) .02  Above cutoff n (%)b 154 (88.0%) 85 (85.9%) 69 (90.8%) BAI, total score, M(SD) 22.5 (9.8) 21.2 (8.6) 24.1 (10.9) .05  Above cutoff n (%)b 134 (76.6%) 77 (77.8%) 57 (75.0%) Meeting both PHQ-9 and BAI criteria n (%)b 113 (64.6%) 63 (63.6%) 50 (65.8%) .89 BAI Beck Anxiety Inventory; bCBT brief cognitive behavioral therapy; EUC enhanced usual care; scale; mMRC modified Medical Research Council dyspnea scale; PHQ-9 Patient Health Questionnaire. p-values are based on t-test for age, PHQ-9 total score, and BAI total score and chi-square for remaining items. aFunctional impairment defined by mMRC criteria. Mild = mMRC scores of 3; Moderate = mMRC score of 4; Severe = mMRC score of 5. bCutoff score is 10 for PHQ-9 and 16 for BAI. View Large Summary of Illness Intrusiveness in the Sample Baseline scores for illness intrusiveness were high among the entire sample (M = 55.9, SD = 15.8). These scores were normally distributed at baseline (skewness = −0.04, SE = 0.18; kurtosis = −0.48, SE = 0.37), with 15.4% (n = 27) of the sample classified as having low baseline illness intrusiveness, 63.4% (n = 111) as having average intrusiveness, and 21.1% (n = 37) as having high intrusiveness. Results of a one-way ANOVA indicated there was no difference in baseline illness intrusiveness between COPD severity groups, as measured by the mMRC [F(2, 172) = 2.09, p = .13]. After adjusting for baseline IIRS, PHQ-9, and BAI scores, participants who received bCBT treatment demonstrated reduced illness intrusiveness compared to EUC, F(1, 170) = 4.81, p = .03, partial η2 = .03. The bCBT treatment group evidenced lower intrusiveness on the Instrumental subscale (F(1, 170) = 4.01, p = .02) after treatment than the EUC group; however, the two groups did not differ significantly from one another on the IIRS Relationship (p = .37) or Intimacy (p = .09) subscales posttreatment. Demographic factors of age (β = −.04, SE = .18, p = .70), gender (F (1, 96) = 0.002, p = .96), education (F (2, 96) = 0.14, p = .87), race/ethnicity (F (3, 94) = 0.93, p = .43), living status (F (2, 96) = 1.41, p = .25), marital status (F (1, 97) = 0.26, p = .61), and income (F (2, 96) = 0.19, p = .83) were not associated with change in IIRS score. Neither baseline depression (PHQ-9; β = .06, SE = 0.37, p = .54) nor anxiety (BAI; β = −.04, SE = 0.18, p = .69) predicted IIRS change scores. Treatment engagement (number of treatment sessions attended) did not predict change in IIRS score (β = 0.12, SE = 0.78, p = .25). IIRS score change was not different between the three baseline mMRC severity groups, F (2, 96) = 0.86, p = .43. Treatment Effects on Illness Intrusiveness Table 2 presents exploratory within-group analyses of the change in IIRS scores and other outcome measures between baseline and 4-month assessments for both the bCBT and EUC groups. Consistent with our hypothesis, IIRS scores improved between baseline and posttreatment among participants in the bCBT group (t98 = 3.95, p < .001), even in the absence of treatment effects for physical health QoL (SF-12 PCS; t98 = −0.90, p = .37, d = 0.09). Among the IIRS subscales, the Intimacy (t94 = 4.08, p < .001, d = 0.39) and Instrumental (t94 = 4.97, p < .001, d = 0.49) subscales of intrusiveness evidenced improvement during bCBT treatment with small-to-medium effect sizes. There was a non-significant trend toward improvement in the Relationship subscale with a small effect size (t94 = 1.80, p = .08, d = 0.19). No treatment effects were realized for COPD severity (mMRC; t98 = −0.21, p = .84, d = 0.03). The small-to-medium treatment effect for the bCBT intervention on illness intrusiveness (d = 0.38) was comparable in magnitude to treatment effects for mental health QoL (SF-12 MCS; t98 = −4.26, p < .001, d = 0.44). Table 2 Within Group Change in Outcome Measures During Treatment Period Baseline M (SD) Posttreatment (4 months) M (SD) Within group change M (SD) Treatment effecta (Cohen’s d) bCBT EUC bCBT EUC bCBT EUC bCBT IIRS 57.0 (14.7) 54.3 (17.1) 51.0 (17.2) 55.0 (17.0) 6.02 (15.15)*** −0.67 (15.63) 0.38 t98 = 3.95 t75 = −0.37  Relationship 3.6 (1.4) 3.6 (1.6) 3.4 (1.5) 3.7 (1.5) 0.27 (1.47) −0.16 (1.44) 0.19 t94 = 1.80 t74 = −0.93  Intimacy 4.8 (2.1) 4.4 (2.0) 4.0 (2.3) 4.3 (2.1) 0.84 (2.01)*** 0.09 (1.84) 0.39 t94 = 4.08 t74 = 0.44  Instrumental 5.4 (1.2) 5.1 (1.3) 4.8 (1.4) 5.1 (1.5) 0.66 (1.28)*** −0.01 (1.40) 0.49 t94 = 4.97 T74 = −0.04 SF-12  MCS 42.6 (10.8) 37.8 (10.2) 47.4 (10.9) 38.4 (11.0) −4.78 (11.17)*** −0.59 (10.28) −0.44 t98 = −4.26 t75 = −0.50  PCS 25.1 (6.1) 27.4 (6.5) 25.6 (6.9) 27.9 (7.6) −0.58 (6.39) −0.46 (6.42) −0.09 t98 = −0.90 t75 = −0.63 mMRC 4.0 (0.7) 4.1 (0.7) 4.0 (0.8) 4.1 (0.7) −0.02 (0.98) 0.03 (0.85) −0.03 t98 = −0.21 t75 = 0.27 Baseline M (SD) Posttreatment (4 months) M (SD) Within group change M (SD) Treatment effecta (Cohen’s d) bCBT EUC bCBT EUC bCBT EUC bCBT IIRS 57.0 (14.7) 54.3 (17.1) 51.0 (17.2) 55.0 (17.0) 6.02 (15.15)*** −0.67 (15.63) 0.38 t98 = 3.95 t75 = −0.37  Relationship 3.6 (1.4) 3.6 (1.6) 3.4 (1.5) 3.7 (1.5) 0.27 (1.47) −0.16 (1.44) 0.19 t94 = 1.80 t74 = −0.93  Intimacy 4.8 (2.1) 4.4 (2.0) 4.0 (2.3) 4.3 (2.1) 0.84 (2.01)*** 0.09 (1.84) 0.39 t94 = 4.08 t74 = 0.44  Instrumental 5.4 (1.2) 5.1 (1.3) 4.8 (1.4) 5.1 (1.5) 0.66 (1.28)*** −0.01 (1.40) 0.49 t94 = 4.97 T74 = −0.04 SF-12  MCS 42.6 (10.8) 37.8 (10.2) 47.4 (10.9) 38.4 (11.0) −4.78 (11.17)*** −0.59 (10.28) −0.44 t98 = −4.26 t75 = −0.50  PCS 25.1 (6.1) 27.4 (6.5) 25.6 (6.9) 27.9 (7.6) −0.58 (6.39) −0.46 (6.42) −0.09 t98 = −0.90 t75 = −0.63 mMRC 4.0 (0.7) 4.1 (0.7) 4.0 (0.8) 4.1 (0.7) −0.02 (0.98) 0.03 (0.85) −0.03 t98 = −0.21 t75 = 0.27 bCBT brief cognitive behavioral therapy; EUC enhanced usual care; IIRS Illness Intrusiveness Rating Scale; SF-12 Medical Outcomes Study 36-Item Short-Form Health Survey; MCS mental component summary; PCS physical component summary; mMRC modified Medical Research Council dyspnea scale. Negative values on the change in MCS, PCS, and mMRC reflect a reduction in symptoms or functional limitations. aEffect sizes calculated for bCBT treatment group only. View Large Table 2 Within Group Change in Outcome Measures During Treatment Period Baseline M (SD) Posttreatment (4 months) M (SD) Within group change M (SD) Treatment effecta (Cohen’s d) bCBT EUC bCBT EUC bCBT EUC bCBT IIRS 57.0 (14.7) 54.3 (17.1) 51.0 (17.2) 55.0 (17.0) 6.02 (15.15)*** −0.67 (15.63) 0.38 t98 = 3.95 t75 = −0.37  Relationship 3.6 (1.4) 3.6 (1.6) 3.4 (1.5) 3.7 (1.5) 0.27 (1.47) −0.16 (1.44) 0.19 t94 = 1.80 t74 = −0.93  Intimacy 4.8 (2.1) 4.4 (2.0) 4.0 (2.3) 4.3 (2.1) 0.84 (2.01)*** 0.09 (1.84) 0.39 t94 = 4.08 t74 = 0.44  Instrumental 5.4 (1.2) 5.1 (1.3) 4.8 (1.4) 5.1 (1.5) 0.66 (1.28)*** −0.01 (1.40) 0.49 t94 = 4.97 T74 = −0.04 SF-12  MCS 42.6 (10.8) 37.8 (10.2) 47.4 (10.9) 38.4 (11.0) −4.78 (11.17)*** −0.59 (10.28) −0.44 t98 = −4.26 t75 = −0.50  PCS 25.1 (6.1) 27.4 (6.5) 25.6 (6.9) 27.9 (7.6) −0.58 (6.39) −0.46 (6.42) −0.09 t98 = −0.90 t75 = −0.63 mMRC 4.0 (0.7) 4.1 (0.7) 4.0 (0.8) 4.1 (0.7) −0.02 (0.98) 0.03 (0.85) −0.03 t98 = −0.21 t75 = 0.27 Baseline M (SD) Posttreatment (4 months) M (SD) Within group change M (SD) Treatment effecta (Cohen’s d) bCBT EUC bCBT EUC bCBT EUC bCBT IIRS 57.0 (14.7) 54.3 (17.1) 51.0 (17.2) 55.0 (17.0) 6.02 (15.15)*** −0.67 (15.63) 0.38 t98 = 3.95 t75 = −0.37  Relationship 3.6 (1.4) 3.6 (1.6) 3.4 (1.5) 3.7 (1.5) 0.27 (1.47) −0.16 (1.44) 0.19 t94 = 1.80 t74 = −0.93  Intimacy 4.8 (2.1) 4.4 (2.0) 4.0 (2.3) 4.3 (2.1) 0.84 (2.01)*** 0.09 (1.84) 0.39 t94 = 4.08 t74 = 0.44  Instrumental 5.4 (1.2) 5.1 (1.3) 4.8 (1.4) 5.1 (1.5) 0.66 (1.28)*** −0.01 (1.40) 0.49 t94 = 4.97 T74 = −0.04 SF-12  MCS 42.6 (10.8) 37.8 (10.2) 47.4 (10.9) 38.4 (11.0) −4.78 (11.17)*** −0.59 (10.28) −0.44 t98 = −4.26 t75 = −0.50  PCS 25.1 (6.1) 27.4 (6.5) 25.6 (6.9) 27.9 (7.6) −0.58 (6.39) −0.46 (6.42) −0.09 t98 = −0.90 t75 = −0.63 mMRC 4.0 (0.7) 4.1 (0.7) 4.0 (0.8) 4.1 (0.7) −0.02 (0.98) 0.03 (0.85) −0.03 t98 = −0.21 t75 = 0.27 bCBT brief cognitive behavioral therapy; EUC enhanced usual care; IIRS Illness Intrusiveness Rating Scale; SF-12 Medical Outcomes Study 36-Item Short-Form Health Survey; MCS mental component summary; PCS physical component summary; mMRC modified Medical Research Council dyspnea scale. Negative values on the change in MCS, PCS, and mMRC reflect a reduction in symptoms or functional limitations. aEffect sizes calculated for bCBT treatment group only. View Large Discussion Results from the current study demonstrate that illness intrusiveness was significantly improved following bCBT for Veterans with COPD. Illness intrusiveness was improved, relative to EUC, and independent of baseline depression or anxiety symptoms. Similarly, two specific domains of illness intrusiveness exhibited notable improvements within the bCBT treatment arm: instrumental aspects of life (i.e. work and finances, active recreation) and intimacy (i.e. perception of one’s sexual functioning and relationship with one’s spouse); however, only the Instrumental subscale evidenced between-group difference in bCBT participants relative to those receiving EUC. Notably, baseline levels of illness intrusiveness did not differ by dyspnea severity; and disease severity was not associated with change in IIRS scores. This independence between objective functional impairment and the perception of disease interference lends further support to illness intrusiveness as a psychosocial construct related to, but not dependent on, disease severity. Findings suggest that illness intrusiveness may be an important construct for behavioral medicine assessment and treatment. Data from our trial indicate that the IIRS is sensitive to change following a course of bCBT and has psychometric response characteristics that are consistent with other measures of physical and mental health functioning. Given that illness intrusiveness is thought to contribute to QoL through engagement in valued activities and perceived control [20], it is unsurprising that IIRS effect sizes were consistent with effect sizes found for mental health QoL. However, the treatment effect on illness intrusiveness was notably superior to changes on physical health QoL and disease-specific pulmonary functional limitations. Given the chronic and degenerative nature of COPD, one would not expect an improvement in physical health QoL or disease severity during this brief intervention. The present findings are consistent with a previous trial in which Veterans with COPD evidenced an improvement in mental health QoL, but not physical health QoL, over the course of an 8-week CBT intervention [15]. However, the significant improvements found for IIRS score, even in the absence of actual physical health improvements, suggest a potential avenue for improved treatment outcomes for medically ill patients such that behavioral medicine interventions may improve both illness perceptions as well as intrapersonal perceptions related to efficacy and identity. Moreover, merely assessing for mental health comorbidities (i.e. depression and anxiety) and encouraging patients and providers to follow-up on such care are not sufficient to affect change, as demonstrated by the findings in the EUC arm. Despite the prevalence and burden of COPD, behavioral medicine approaches for this disease have received little research or public interest relative to other chronic diseases [44]. A significant strength of the study was the clinical relevance imparted by a large, multisite sample of medically ill participants who engaged in treatment despite high levels of illness intrusiveness and dyspnea; this increases the applicability of these results to real-world behavioral medicine settings. However, the generalizability of these results must be considered in light of study limitations. First, it is unknown how these results will extend beyond our sample of older, predominantly non-Hispanic White male Veterans. Participants in this study also had elevated symptoms of depression and anxiety; while these comorbidities are common among those with COPD [12, 25, 45], they may have contributed to higher levels of illness intrusiveness and altered treatment response relative to COPD patients without mood and anxiety symptoms. A greater proportion of participants in the active treatment arm were lost to follow-up relative to those in EUC; of these, a greater number cited research burden and other stressors (health, family, or work) as the cause of their attrition. Although the parent study found no significant difference between completers and noncompleters [17], participants who completed bCBT may represent a curated subsample of individuals that are more likely to engage in treatment than other primary care patients with comorbid medical and mental illnesses. Regarding IIRS effects, exploratory analyses suggested that baseline illness intrusiveness did not differ by disease severity, and functional impairment did not predict change in IIRS score. Future studies should use prospective and potentially longitudinal study designs to assess the long-term trajectory of illness intrusiveness, taking into consideration changes in functional impairment and COPD disease progression. Furthermore, the treatment effects on illness intrusiveness, while promising, were measured after a 4-month intervention. Clinically speaking, this is a brief window of time in a chronic and variable disease course. While the intervention emphasized building a repertoire of skills that may be sustained by the participant after treatment cessation, future studies should assess maintenance of treatment effects and the most effective length of bCBT in a chronic disease course. Taken together, these results suggest that a bCBT intervention that integrates physical and emotional health was effective at reducing illness intrusiveness, even in the absence of actual physical health improvements (which might not be feasible or expected in a progressive chronic disease). Furthermore, illness intrusiveness may be an important construct to better assess and understand the bidirectionality between physical functioning and psychological impact of chronic disease, with more sensitivity to change than indices of HRQoL. This carries important implications for both researchers and clinicians. Future studies should investigate illness intrusiveness as a transdiagnostic construct that may have greater utility than disease-specific instruments in multimorbid patient samples. Of relevance for clinicians, illness intrusiveness represents a distinct clinical entity with implications for treatment. This construct may provide important information to better understand how and why patients have variable responses to medical diagnoses, ranging from resiliency to disengagement, distress, and even clinical disorders of depression and anxiety. Specifically, treatment aimed at facilitating engagement in psychologically meaningful activities may minimize the adverse psychosocial impact of chronic disease, independent of clinical symptoms of anxiety and depression. Incorporating illness intrusiveness into behavioral health treatment can guide intervention targets and improve HRQoL, particularly in the context of symptomatic depression and anxiety. Indeed, a skills-focused treatment approach such as bCBT may offer benefits particularly suitable for improving the activities most limited by COPD (e.g. active recreation, work). In conclusion, illness intrusiveness can help to elucidate the intersection of chronic disease limitations and psychological distress. Results from this study suggest that illness intrusiveness, particularly in instrumental and intimate domains of life, is amenable to treatment. The issue of how to augment current medical practices to best integrate mental health care remains critical for public health, and evidence-based psychotherapies have the potential to treat both mental health concerns and broader behavioral medicine issues. Interventions that incorporate illness intrusiveness provide opportunities to address not only psychological concerns but also lifestyle modifications important for chronic disease self-management. Conflict of Interest Authors Brenna N. Renn, Natalie E. Hundt, Shubhada Sansgiry, Nancy J. Petersen, Michael R. Kauth, Mark E. Kunik, and Jeffrey A. Cully declare that they have no conflict of interest. Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent The current study was approved by the relevant Institutional Review Boards and VA Research and Development review committees. All participants provided informed consent. The parent trial was registered on clinicaltrials.gov (NCT01149772). Acknowledgments This research was supported by a grant from the Department of Veterans Affairs HSR&D grant 09-088 (PI: J. A. Cully), partially supported by an HSR&D Career Development Award (#13–264) given to the second author, and the VA HSR&D Houston Center for Innovations in Quality, Effectiveness and Safety (CIN# 13–413), Michael E. DeBakey VA Medical Center, Houston, TX. 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Annals of Behavioral MedicineOxford University Press

Published: May 31, 2018

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