Anna Chudyba, Anna Hamerla, Anna Kaźmierska, Magdalena Bodera, Dariusz Jastrzębski, Szymon Skoczyński The undervalued role of psychology in pulmonary rehabilitation. Short review

Author's note:

Anna Chudyba¹, Anna Hamerla², Anna Kaźmierska³, Magdalena Bodera⁴, Dariusz Jastrzębski⁵, Szymon Skoczyński⁶

¹ Provincial Psychiatric Hospital in Andrychow, Andrychow, Poland

https://orcid.org/0009-0005-7287-3219

² Student Society of the Department of Lung Diseases and Tuberculosis, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Zabrze, Poland

https://orcid.org/0009-0006-4001-0256 

³ Student Society of the Department of Lung Diseases and Tuberculosis, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Zabrze, Poland

https://orcid.org/0009-0005-2625-6260 

⁴ Student Society of the Department of Lung Diseases and Tuberculosis, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Zabrze, Poland

https://orcid.org/0009-0002-8890-214X 

Corresponding Author: mag.bodera@gmail.com 

⁵ Department of Lung Diseases and Tuberculosis, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Zabrze, Poland

https://orcid.org/0000-0002-8598-1930 

⁶ Department of Lung Diseases and Tuberculosis, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Zabrze, Poland

https://orcid.org/0000-0003-1796-7659 

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Introduction

The European Respiratory Society and the American Thoracic Society define rehabilitation as „a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, which include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory diseases, and to promote the long-term adherence to health-enhancing behaviors” (Troosters et al., 2023).

Pulmonological rehabilitation is therefore aimed at addressing not only respiratory problems through a holistic approach, with particular emphasis on preventing further progression of respiratory diseases (by means of optimizing pharmacotherapy and adherence to treatment), and initiating a therapy that is designed to the improvement of the patient’s physical and mental health, and to ensure that the patient will maximize physical activity and other health-promoting behaviors, including the cessation of tobacco smoking and the cultivation of healthy nutrition habits (Ries et al., 2007; Volpato et al., 2021).

Pulmonological rehabilitation is applicable to individuals with medical conditions such as chronic obstructive pulmonary disease (COPD), interstitial lung diseases, bronchiectasis, cystic fibrosis, asthma, pulmonary hypertension, lung cancer, status post lung volume reduction surgery, or status post lung transplantation (World Health Organization, 2023).

Before starting rehabilitation, the following are of particular importance in the examination of the patient: assessment of the severity of symptoms and respiratory capacity; spirometric examination; assessment of body structure and composition; assessment of the ability to undertake physical effort, and examination of the patient’s physical activity and ability to undertake daily living activities; detection and assessment of risk factors for respiratory diseases; assessment of the mental state; the ability to cope with health problems; support received by the patient, and the motivation to participate in the rehabilitation program; determination of the patient’s individual preferences and expectations; examination of health-related quality of life (Hanania and O’Donnell, 2019; Jacob et al., 2024; Troosters et al., 2023; Zhu et al., 2021).

A psychological assessment in general consists of an interview, observation of the patient and the use of diagnostic tools. Just as important as a thorough interview with the patient and family is the observation of the person being examined and the proper identification and labelling of psychopathological symptoms. Only when this information is put together can
a picture of the symptom complex emerge, which should then undergo final analysis and, if necessary, differential diagnosis. A properly made diagnosis is the basis for implementing appropriate therapeutic interventions (Gałecki, 2022).

Psychological tests helpful in diagnosing depression, anxiety and other mental disorders, used for patients undergoing pulmonological rehabilitation

1. Depression: The Beck Depression Inventory® – Second Edition – A. T. Beck, R. A. Steer, G. K. Brown, E. Łojek, J. Stańczak

The BDI-II is a tool for measuring the severity of depression in psychiatrically diagnosed patients, both adolescents and adults. The BDI-II has been developed with the aim to obtain an index of the presence and the severity of depressive symptoms in accordance with the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders). This examination, however, should be applied with particular caution if it is the sole diagnostic tool, as depression may be accompanied by a variety of primary disorders. The test is carried out in a simple and user-friendly manner. Although it is not only psychologists who can use the BDI-II and calculate the scores, the interpretation of the scores should only be performed by appropriately trained professionals with clinical experience. The test takes an average of 5-10 minutes to complete, depending on the patient’s state. Patients with severe depression or obsessive disorders often take longer than average to perform this test. For individuals with reading or attention difficulties, the test can be conducted orally. The BDI-II score is calculated by adding up the scores for the 21 items. Each item is rated on a 4-point scale ranging from 0 to 3. If
a subject has selected more than one answer under a particular item, the one with the highest score is taken into account. The maximum overall score is 63. When assessing the BDI-II scores, practitioners should keep in mind that all self-report inventories are susceptible to response bias. This means that some individuals may indicate a greater number of symptoms than they actually present with, and thus obtain falsely high scores. Other patients may not acknowledge their symptoms, and thus obtain falsely low scores. The BDI-II score may reflect the severity of depressive symptoms, and not represent a diagnosis of depression. The determination of the severity of depression, and the establishment of a diagnosis of depression requires examination by a clinician. The overall BDI-II score only provides a general estimate of the severity of depression, but, from a clinical point of view, it is important to pay attention to the content of specific statements. Particular attention should be paid to the question concerning suicidal thoughts (Beck et al., 2019).

Among other tools, the Beck Depression Inventory-II (BDI-II) was used in studies to measure the severity of depressive symptoms before and after interventions such as controlled breathing techniques, supporting their therapeutic potential (Klasa, Sobański, Rutkowski, 2023). The inventory was also employed to assess treatment compliance among patients with COPD and asthma, showing that depressive symptoms and concerns regarding prescribed therapy were associated with poorer treatment adherence (Homętowska, 2015). In another study on patients with severe asthma, the BDI-II was used to assess depressive symptoms, which – along with other psychological factors – were found to influence asthma severity, with the worst outcomes observed in patients with difficult asthma (Potoczek, 2022). Additionally, the Polish adaptation of the BDI-II has been validated, confirming its reliability in clinical practice in Poland (Zawadzki, Popiel, Pragłowska, 2009).

Other suggested diagnostic tools: Depression Measurement Questionnaire (DMQ), Set of Questionnaires for Diagnosing Depression in Children and Adolescents (CDI 2).

2. Anxiety: The State-Trait Anxiety Inventory (STAI) – D. Spielberger, R.L. Gorsuch, R.E. Lushene, C.D. Spielberger, J. Strelau, M. Tysarczyk, K. Wrześniewski

The Polish adaptation of the STAI questionnaire, like its original version, is intended for examining individuals over the age of 15. A separate version of the questionnaire, the STAIC, is used for measuring anxiety in children (Jaworowska, 2005). The STAI questionnaire can be used in screening studies. It allows for the detection of individuals with distinctly low or distinctly high levels of anxiety, understood as a stable internal disposition – a trait. It is also
a tool for measuring changes in anxiety intensity, that is, anxiety as a state that arises in response to a specific external stimulus. The test is structured around the distinction between anxiety understood as a temporary, situational state and anxiety understood as a relatively stable personality trait. Ultimately, the STAI took the form of a questionnaire composed of two scales: Scale X1 is used to assess state anxiety, and Scale X2 is used to assess trait anxiety. Each scale consists of 20 statements. The task of the respondent is to select a number on a scale from 1 to 4 that best describes their subjective feelings. Both scales are placed on a single A4-sized sheet. State anxiety is characterised by high variability under the influence of various threatening factors. Trait anxiety refers to an acquired behavioural disposition that makes an individual prone to perceiving objectively non-threatening situations as threatening and responding to them with a state of anxiety. This behaviour reflects a learned pattern of anxiety. Childhood is considered a particularly important period influencing the development of an anxious personality (Wrześniewski, et al., 2011; Spielberger et al., 2012).

The State-Trait Anxiety Inventory (STAI) has been used extensively in pulmonary research to assess both state and trait anxiety. One study found a link between increased airway inflammation, cognitive dysfunction severity, and depressive and anxiety symptoms in the studied population (Zawada-Drozd, 2023). Another study demonstrated a clear association between STAI-assessed anxiety levels and dyspnoea severity in asthma patients, highlighting the need for psychotherapeutic interventions as an essential component of non-pharmacological therapy for these patients (Pietras, et al., 2010). STAI is also recommended in national guidelines for assessing psychological well-being in palliative care for chronic lung disease (Pneumonologia i Alergologia Polska, 2012).

Other suggested diagnostic tools: Personality Inventory (NEO-PI-R), Adjective Check List (ACL).

3. STRESS: PSS-10 (Perceived Stress Scale): Stress measurement and coping tools –
   Cohen, T. Kamarck, R. Mermelstein, Z. Juczyński, N. Ogińska-Bulik

This tool is used to assess the intensity of stress related to the patient’s life situation over the past month. It is important to consider one’s own thoughts and feelings in the assessment. The intensity of stress is not represented by the number of events, but by their assessment. The scale can be used for research and practical purposes in screening and prophylactic examinations. However, particular attention should be paid to the interpretation of the scores in terms of the respondents’ reliability. The PSS-10 scale is used to examine adult subjects, both healthy and ill. It is used as a self-assessment method, and as a form of an interview. The scale can also be used to predict health status. A combination of high stress intensity and its long duration generally leads to serious stress effects, including on health. Stress can be regarded as a mechanism mediating the etiopathogenesis of a variety of diseases. Psychological stress has been documented to be associated with somatic and mental health disorders. The PSS-10 scale can be used as a screening tool to identify individuals eligible for psychological or medical assistance (Cohen et al., 2016).

The PSS-10 has been widely applied to assess perceived stress in both general and clinical populations. During the COVID-19 crisis, the PSS-10 revealed high stress levels and highlighted the psychological toll of the pandemic (Dymecka, 2021). Among COPD patients, the PSS-10 was used to measure perceived stress and its effects on psychological well-being and quality of life, identifying stress as a significant factor affecting patient outcomes. The study also emphasized the importance of involving psychologists and psychotherapists in the therapeutic teams working with these patients (Zielazny, 2016).

Other suggested diagnostic tools: Perceived Stress Questionnaire (PSQ).

4. The Coping Inventory for Stressful Situations (CISS) – S. Endler, J. D. A. Parker, P. Szczepaniak, J. Strelau, K. Wrześniewski

The questionnaire contains 48 simple statements concerning different behaviors people undertake in stressful situations. Next to each statement, numbers from 1 to 5 are provided to indicate the frequency with which a particular activity is undertaken in difficult, stressful situations. As the scale comprises 16 items, respondents can score from 16 to 80 points in each of them. The questionnaire is designed for individuals over 18 years of age. (Endler et al., 2016).

Selected scales are described in detail below:

The TFS scale – Task-focused style, defines a style of coping with stress that involves taking on tasks. Individuals scoring high on this scale, when under stressful situations, tend to make efforts to solve a problem through cognitive transformations or attempts to change the situation.

The EFS scale – Emotion-focused style, a style characteristic of individuals who, under stressful situations, tend to focus on themselves and their own emotional experiences, e.g. anger, sense of guilt, or tension. These individuals also have a tendency towards wishful thinking and fantasizing.

The AFS scale – Avoidance-focused style, is a style focused on the avoidance of thinking about, going through, and experiencing a particular situation. This style can take on the form of getting involved in substitute activities (SA), e.g. watching television, sleeping, overeating or seeking social contacts (SSC). For the two forms of the Avoidance-focused style, two subscales have been respectively distinguished, namely SA and SSC (Beck et al., 2019).

The Coping Inventory for Stressful Situations (CISS) is a tool commonly referenced in the context of psychological support for patients with chronic pulmonary conditions, particularly when examining how coping styles influence stress regulation and treatment adaptation. One study emphasized the need to raise physicians’ awareness of the psychological consequences of chronic lung diseases and highlighted the importance of cooperation between medical professionals and mental health specialists to improve patient outcomes and quality of life (Andysz, Merecz, 2009). The CISS has also been referenced in research discussing proactive and preventive coping strategies in patients with chronic pulmonary conditions, highlighting their role in mobilizing health resources, setting goals, and improving quality of life (Zielazny, 2016).

Other suggested diagnostic tools: Multidimensional Inventory for Measuring Coping with Stress (COPE).

Mental disorders in pulmonary patients and rehabilitation and psychological support

Patients suffering from chronic respiratory diseases, such as COPD, or those who have undergone SARS-CoV-2 infection, often experience numerous physical and mental disorders that significantly reduce their quality of life. The elderly, in particular, are a group particularly vulnerable to such problems due to their reduced recovery capacity and a higher risk of complications. Studies show that patients with chronic obstructive pulmonary disease (COPD) frequently experience mental health disorders, particularly anxiety and depression. A meta-analysis of 13 randomized controlled trials demonstrated that mind–body exercises–such as tai chi, health qigong, and yoga–significantly reduced symptoms of anxiety (SMD = -.76) and depression (SMD = -.86) in COPD patients (Li et al., 2019). Another study investigated the prevalence of anxiety and depression in patients with chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA), a condition collectively referred to as overlap syndrome. The research revealed that individuals with overlap syndrome exhibited significantly higher rates of anxiety and depression compared to those with COPD alone. These mental health disorders were linked to a poorer quality of life and greater disease severity. The mechanisms of these disorders are complex and multifactorial. Anxiety often results from experiencing shortness of breath and a sense of lack of control over one’s body, which leads to stress and distress about the future (Zhao, et al. 2022).

Patients who have experienced a severe course of COVID-19 may suffer from the trauma associated with hospitalization, isolation or being subjected to invasive treatment methods, e.g. intubation. In turn, depression in these individuals results from the chronic burden of illness, reduced physical activity, loss of independence, and gradual withdrawal from social and family life (Harrison et al., 2017; Li et al., 2019; Liu et al., 2020).

In a randomized, elderly patients who underwent a 6-week respiratory rehabilitation program showed notable improvements in anxiety levels, as measured by the Self-Rating Anxiety Scale (SAS), compared to those who did not receive the intervention. However, the program had minimal impact on depression symptoms, as assessed by the Self-Rating Depression Scale (SDS) . Similarly, another a study focusing on patients hospitalized for severe COVID-19 pneumonia. Their findings indicated that an 8-week rehabilitation program incorporating exercise, education, dietary, and psychological support led to significant improvements in mental health outcomes. Notably, participants exhibited reduced anxiety and depression scores, as well as enhanced cognitive function and overall quality of life (Liu et al., 2020; Asimakos, A. et al. 2023).

These problems are further exacerbated by physical limitations resulting from the damage to the respiratory system, such as dyspnea, respiratory muscle weakness, reduced lung volume or residual fibrotic lesions in the lungs. Patients struggle to perform basic daily activities, which leads to lower self-esteem and frustration. These conditions often coexist with physical weakness and reduced mobility, which increase the risk of developing hypokinesia syndromes and secondary complications, such as cardiovascular or metabolic diseases. Therefore, a crucial element in the process of rehabilitation for patients with chronic respiratory diseases or post-COVID-19 is a comprehensive approach that combines physical interventions with psychological support (Asimakos et al., 2023; Troosters et al., 2023).

Psychological therapy in patients undergoing pulmonological rehabilitation

Psychological therapy for individuals suffering from mental disorders, including anxiety and depression, includes a variety of methods and approaches that can be adapted to the individual patient’s needs. Crucial elements of the therapy include psychotherapy, pharmacotherapy and complementary interventions, such as relaxation techniques, health education or social support. The aim of the therapy is not only to reduce symptoms, but also to improve the patient’s life quality, increase their ability to cope with challenges, and prevent the recurrence of symptoms (Harrison et al., 2017).

Psychotherapy is a fundamental part of the treatment of most mental disorders, and includes various forms that can be used either alone or in a combination with other interventions. Cognitive behavioral therapy (CBT) is one of the most tested and effective approaches, particularly in the treatment of anxiety and depression. CBT is focused on identifying and changing negative thinking patterns and maladaptive behaviors (Curtiss et al., 2021). Patients learn how to recognize the thoughts that contribute to their malaise, and replace them with more realistic and constructive ones. The therapy often incorporates exposure techniques that help patients gradually become accustomed to anxiety-provoking situations, and strategies to improve their ability to cope with everyday challenges. CBT can be applied in the form of individual sessions with a therapist, group therapy, and also as self-help supported by digital applications (Jacob et al., 2024; Li et al., 2019).

Another important approach is interpersonal therapy (IPT), which is focused on improving the patient’s interpersonal relationships and communication skills. IPT is particularly effective in the treatment of depression, where disturbed social relationships or emotional losses are often a key trigger for symptoms. Patients learn how to resolve interpersonal conflicts, improve their relationships, and cope with bereavement or changes in their lives. For patients experiencing severe trauma, a trauma-focused therapy, including EMDR (Eye Movement Desensitization and Reprocessing) therapy, which helps process painful memories and reduce their impact on daily life, can also be effective (Li et al., 2019).

Pharmacotherapy serves an important role in the treatment of mental disorders, particularly in cases of moderate to high severity, where psychotherapy alone may be insufficient. Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), or serotonin-norepinephrine reuptake inhibitors (SNRIs), are most commonly used in the treatment of depression and anxiety disorders. These drugs act by increasing the availability of neurotransmitters in the brain, which improves mood and reduces the sensation of anxiety. In cases of severe anxiety disorders or states of sudden anxiety (panic attacks), short-term benzodiazepines may be used, although their use is limited due to the risk of the development of dependence. In turn, antipsychotic drugs can be included in the treatment when mental disorders coexist with psychotic symptoms, such as hallucinations or delusions. Mood-stabilizing drugs, e.g. lithium salts or antiepileptic drugs, are used in the treatment of bipolar disorder. It is worth emphasizing that pharmacotherapy should always be monitored by a psychiatrist, and often combined with psychotherapy, which increases the effectiveness of treatment (Ortiz-Ortigosa et al., 2024; Zhao et al., 2022).

Supportive therapeutic methods, such as relaxation techniques, mindfulness and meditation, play an important role in reducing stress and improving overall mental wellbeing. These techniques help patients learn how to manage stress reactions by increasing the awareness of their body and breath, and developing the ability to be “here and now”. Modern mindfulness programs, such as MBSR (Mindfulness-Based Stress Reduction) or MBCT (Mindfulness-Based Cognitive Therapy), have been shown to be highly effective in reducing symptoms of anxiety and depression, and improving the quality of life of chronically ill patients (Legierski, 2018; Li et al., 2019; Yohannes et al., 2017).

An additional element of psychological therapy is psycho-educational programs, aimed at enhancing the patient’s knowledge about their illness, available treatment methods, and ways of coping with difficulties. Psycho-education often extends to the patient’s family, which enables the establishment of a supporting therapeutic environment. Support groups, both those organized in the local community and those available online, offer an opportunity to share experiences and motivate each other in the struggle against difficulties. A holistic approach to psychological therapy also involves social interventions, such as support in establishing and maintaining relationships, or assistance with professional integration. Occupational therapy can help patients develop the skills they need to perform daily activities, which directly contributes to an improvement in their wellbeing and self-esteem. In certain cases, interventions targeting physical activity, shown by research to have a positive effect on mood and cognitive function, may also be helpful (Legierski, 2018; Li et al., 2019; Yohannes et al., 2017).

In summary, a comprehensive psychological therapy combines different methods and approaches that are tailored to the specific nature of the patient’s problems. The combination of psychotherapy, pharmacotherapy and complementary support not only enables alleviation of symptoms, but also the formation of healthy habits and strategies for coping with future challenges, contributing to a long-term improvement in the patient’s quality of life (Legierski, 2018; Li et al., 2019; Yohannes et al., 2017).

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Receipt Date: 04.02.2025

Date after correction: 10.06.2025

Print Acceptance Date: 16.06.2025

The article is available under the terms International 4.0 license (CC BY-NC-ND 4.0)