Psychological therapies for the treatment of anxiety disorders in chronic obstructive pulmonary disease

Probably not a substantial claim: may not pass S3 (load-bearing).

Another systematic review and meta-analysis of complex interventions for depression and anxiety in COPD identified 28 studies for inclusion.

“Another systematic review and metaanalysis of complex interventions for depression and anxiety in COPD identified 28 studies for inclusion (Coventry 2013).”

• cites Coventry 2013 sourceDisputed

  The paper is a systematic review and meta-analysis of complex interventions for depression and anxiety in COPD, but its Characteristics of Populations section says 32 studies met the inclusion criteria, not 28. The Abstract reports that 29 trials were included in the meta-analysis. (LLM, conf=0.91)

  Checked by a reasoning model — may be wrong.

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing).

Prevalence rates for anxiety disorders in people with COPD are 28%-36%.

“Studies have suggested prevalence rates for anxiety disorders of 28%-36% in people with COPD (Di Marco 2006;Yohannnes 2006).”

• cites Di Marco 2006 sourceSupported
• cites Yohannnes 2006Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The severity of anxiety correlates with the severity of COPD and the presence of lower PaO.

“Moreover, the severity of anxiety has been shown to correlate with the severity of COPD and the presence of lower PaO (partial pressure of oxygen in the blood, an indicator of severity of COPD) (Elassal 2014).”

• cites Elassal 2014 sourceSupported

May combine two claims.

COPD is associated with a higher risk of anxiety, and co-morbid COPD and anxiety is related to poor health outcomes in terms of exercise tolerance, quality of life, COPD exacerbations, inappropriate use of medications and persistence of smoking as a coping strategy for anxiety management.

“COPD is associated with a higher risk of anxiety, and co morbid COPD and anxiety is related to poor health outcomes in terms of exercise tolerance, quality of life, COPD exacerbations (Eisner 2010), inappropriate use of medications and persistence of smoking as a coping strategy for anxiety management (Royal College of Physcians).”

• cites Eisner 2010 sourceSupported
• cites Royal College of PhysciansNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

By compromising health status, mood disorders lead to increased risk of hospitalisation and re-hospitalisation and hence also increase direct and indirect costs to the health system.

“By compromising health status, mood disorders lead to increased risk of hospitalisation and re-hospitalisation (Gudmundsson 2005) and hence also increase direct and indirect costs to the health system.”

• cites Gudmundsson 2005 sourcePartly supported

  The Abstract and Discussion report an increased risk of rehospitalisation among COPD patients with anxiety and low health status. They do not establish that mood disorders cause poor health status or increased hospitalisation generally; the Discussion explicitly reports no association between depression and readmission. The cost statement follows the citation as the citing authors’ inference, rather than a finding attributed to this source. (LLM, conf=0.89)

  Experimental — accuracy not yet measured

May combine two claims.

Co-morbid depression is a strong predictor of anxiety, which confounds anxiety symptoms making treatment more difficult.

“Indeed, co-morbid depression is known to be a strong predictor of anxiety (DiNicola 2013), which confounds anxiety symptoms making treatment more difficult (Atlantis 2013).”

• cites DiNicola 2013 sourceSupported
• cites Atlantis 2013 sourceNot checked — no full text of the source

May combine two claims.

Among people with COPD, anxiety is related to poorer health outcomes including worse submaximal exercise performance, greater risk of self-reported functional limitations and a higher longitudinal risk of COPD exacerbations.

“A recent study has shown that among people with COPD, anxiety is related to poorer health outcomes including worse submaximal exercise performance, greater risk of self-reported functional limitations and a higher longitudinal risk of COPD exacerbations (Eisner 2010).”

• cites Eisner 2010 sourceSupported

Classified as probably not a substantial claim.

We used the Chi2 and I2 statistics to quantify inconsistency across studies in combination with visual inspection of the data.

“We used the Chi 2 (Deeks 2011) and I 2 statistics (Higgins 2003) to quantify inconsistency across studies in combination with visual inspection of the data for differences between studies (e.g.types of interventions, participants etc.).”

• cites Deeks 2011Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Higgins 2003 sourceSupported

May combine two claims.

In Coventry 2013, subgroup analyses identified small but non-significant effects on self-reported anxiety symptoms post-treatment for cognitive and behavioural interventions (SMD -0.17; 95% CI -0.35 to 0.01; 7 studies) and relaxation (SMD -0.18; 95% CI -0.67 to 0.30; 3 studies), but no evidence of any effect for self-management education (SMD -0.00; 95% CI -0.17 to 0.16; 5 studies).

“Subgroup analyses identified small but non-significant effects on self-reported anxiety symptoms post-treatment for cognitive and behavioural interventions (SMD -0.17; 95% CI -0.35 to 0.01; 7 studies) and relaxation (SMD -0.18; 95% CI -0.67 to 0.30; 3 studies), but observed no evidence of any effect for selfmanagement education (SMD -0.00; 95% CI -0.17 to 0.16; 5 studies).”

• cites Coventry 2013 sourcePartly supported

  Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  Experimental — accuracy not yet measured

May combine two claims.

Coventry 2013 observed an improvement with the intervention for multi-component exercise training, though the sample included substantial heterogeneity (SMD -0.47; 95% CI -0.66 to -0.28; P = 0.002; 14 studies; I2 = 63.3%).

“This review observed an improvement with the intervention for multi-component exercise training, though the sample included substantial heterogeneity (SMD -0.47; 95% CI -0.66 to -0.28; P = 0.002; 14 studies; I 2 = 63.3%;Coventry 2013).”

• cites Coventry 2013 sourcePartly supported

  Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  Experimental — accuracy not yet measured

The quote only partly states this claim.

For quality of life - physical composite, the long-term follow-up SMD was -0.30 (95% CI -0.53 to -0.06; P = 0.01).

“long-term follow-up (6 to 12 months; SMD -0.30, 95% CI -0.53 to -0.06; P = 0.01)”

Probably not a substantial claim: may not pass S3 (load-bearing). The quote only partly states this claim.

The quality of life - physical composite analysis included 289 participants from 2 studies.

“289 (2 studies)”

Probably not a substantial claim: may not pass S3 (load-bearing).

The mean quality of life - emotional composite in the control groups was 52.3.

“The mean quality of life -emotional composite in the control groups was 52. 3”

Probably not a substantial claim: may not pass S3 (load-bearing).

The mean exercise capacity in the control groups was 839.

“The mean exercise capacity in the control groups was 839”

May combine two claims.

The Kunik 2008 study examined 6MWD at 8 weeks (post-intervention) and again at 12 months' follow-up with a difference in favour of the control arm at 12 months (P = 0.05).

“The Kunik 2008 study which examined 6MWD at 8 weeks (post-intervention) and again at 12 months' follow-up with a difference in favour of the control arm at 12 months (P = 0.05).”

• cites Kunik 2008 sourceNot checked — no full text of the source

May combine two claims.

Authors reported that group means at beginning of the follow-up period were not equal (P < 0.01), contributing to the spurious finding.

“However, authors reported that group means at beginning of the follow-up period were not equal (P < 0.01), contributing to the spurious finding.”

Probably not a substantial claim: may not pass S3 (load-bearing). The quote only partly states this claim.

The quality of life - emotional composite analysis included 289 participants from 2 studies.

“289 (2 studies)”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Two studies reported on quality of life, with one study (Kunik 2008) reporting both SF36 and CRQ.

“Two studies reported on quality of life with one study (Kunik 2008) reporting both SF36 and CRQ.”

• Also stated in: § Quality of life -emotional composite SGRQ and SF36 Follow-up: 6-12 months · plain

  “Two studies reported on quality of life with one study (Kunik 2008) reporting both SF36 and CRQ.”

• cites Kunik 2008 sourceNot checked — no full text of the source

May combine two claims.

Only one study (Kunik 2008) reported dyspnoea via CRQ, with an improvement in the CBT group over control at eight-week end-of-treatment follow-up (intervention mean 3.36 + 1.64; control mean 3.51 + 1.59; P = 0.02).

“Only one study (Kunik 2008) reported dyspnoea via CRQ, with an improvement in the CBT group over that of control at eight-week end-of-treatment follow-up (intervention group mean 3.36 + 1.64; control group mean 3.51 + 1.59; P = 0.02).”

May combine two claims.

Substantial heterogeneity was identified in all meta-analyses across studies, suggesting the possibility of true differences in the underlying treatment effect.

“Substantial heterogeneity was identified in all meta-analyses across studies, suggesting the possibility of these being true differences in the underlying treatment effect.”

May combine two claims.

There was substantial heterogeneity (I2 = 62%) in the anxiety meta-analysis, which limits the reliability of the findings.

“However, there was substantial heterogeneity (I 2 = 62%), which limits the reliability of the findings.”

May combine two claims.

Each included study reported difficulties with sample size, with two unable to meet target recruitment and the third not reporting a prespecified sample size calculation.

“Each study reported difficulties with sample size, two being unable to meet the target recruitment number (Kunik 2008;Hynninen 2010) and the third (de Godoy 2003) not reporting a prespecified sample size calculation.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Sample sizes ranged from n = 30 in de Godoy 2003, n = 51 in Hynninen 2010, and n = 238 in Kunik 2008.

“Samples sizes ranged from n = 30 in de Godoy 2003, n = 51 in Hynninen 2010 and the largest being n = 238 in Kunik 2008.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The majority of participants in this review were men.

“Also important to note is that the majority of the participants of this review were men.”

May combine two claims.

No studies provided data specifically on length of stay or hospital readmission rates; the Kunik 2008 study indirectly examined this and found no differences between groups in the ratio of pre-treatment to post-treatment outpatient visits, hospital admissions, mental health visits and emergency visits per month per participant.

“No studies provided data specifically on length of stay or hospital readmission rates.However the Kunik 2008 study did indirectly examine this by tracking the number of treatment visits pre and post study.No differences were observed for the ratio of pre treatment to post treatment between groups for outpatient visits, hospital admissions, mental health visits and emergency visits per month, per”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Seven studies were awaiting classification and two were ongoing at the time of review completion.

“Seven studies are awaiting classification and two were ongoing at the time of review completion (Figure 1).”

May combine two claims.

For anxiety, short-term (0 to 3 month follow-up) benefits favoured the intervention arm (MD -3.86; 95% CI -6.63 to -1.10; P = 0.006; I2 = 19%), while these findings were not maintained long-term (6 to 12 months; MD -4.30; 95% CI -10.57 to 1.97; P = 0.18; I2 = 80%).

“In the case of anxiety, short-term (0 to 3 month follow-up) benefits were seen in favour of the intervention arm with a MD of -3.86; 95% CI of -6.63 to -1.10 and P = 0.006 (I 2 = 19%), whilst these findings were not maintained long-term (6 to 12 months; MD -4.30 with 95% CI of -10.57 to 1.97 and P = 0.18; I 2 = 80%; Analysis 2.1).”

May combine two claims.

The quality of evidence in this review overall was low, with two of the three studies having prespecified protocols available for comparison to methods and outcomes reported in the final publications.

“The quality of evidence in this review overall was low, with two of the three studies having prespecified protocols available for comparison to methods, and outcomes reported on within the final publications.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Thirteen potentially eligible studies (15 full-text articles) were excluded from the review.

“We excluded 13 of the potentially eligible studies (15 full-text articles) from the review due to no diagnosis of anxiety at baseline”

Probably not a substantial claim: may not pass S3 (load-bearing).

All three included studies measured anxiety using the Beck Anxiety Inventory (BAI).

“All three studies measured anxiety using the Beck Anxiety Inventory (BAI).”

May combine two claims.

All three included studies were single-centre, parallel RCTs from Brazil, Norway and the USA.

“All three studies were single-centre, parallel RCTs coming from Brazil (de Godoy 2003), Norway (Hynninen 2010) and the USA (Kunik 2008).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In the Kunik 2008 study, of 256 eligible participants, 238 were randomised but only 181 attended their first session, a 24% attrition before the intervention commenced.

“Of the 256 eligible participants for the Kunik 2008 study, 238 were randomised but only 181 attended their first session (24% attrition before the intervention commenced).”

May combine two claims.

All three included studies recruited participants with both anxiety and depression, not just anxiety, and compared psychotherapy with co-intervention versus co-intervention alone.

“All three included studies recruited participants with both anxiety and depression, not just anxiety (which may confound the results) and compared psychotherapy with co-intervention versus co-intervention alone.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Anxiety can occur at any stage of COPD.

“Other studies suggest that anxiety can occur at any stage of COPD (Kim 2000;Heslop-Marshall 2014.”

• cites Kim 2000 sourceNot checked — no full text of the source
• cites Heslop-Marshall 2014Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

The lifetime prevalence of GAD amongst people with COPD is estimated at between 10% and 15.8%.

“The lifetime prevalence of GAD in particular amongst people with COPD is estimated at between 10% and 15.8% (Brenes 2003).”

• cites Brenes 2003 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Rates of anxiety symptoms in people with COPD range from 13% to 51% and are higher than the rates in people with heart failure, cancer, and other medical conditions.

“Rates of anxiety symptoms in people with COPD range from 13% to 51% and are higher than the rates in people with heart failure, cancer, and other medical conditions (Brenes 2003).”

• cites Brenes 2003 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The prevalence of panic disorder in the COPD population is estimated to be ten times higher than the general population.

“The prevalence of panic disorder in the COPD population is estimated to be ten times higher than the general population (Smoller 1996;Smoler 1999).”

• cites Smoller 1996 sourceNot checked — no full text of the source
• cites Smoler 1999Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

One model explains increased levels of anxiety and panic in people with COPD as catastrophic misinterpretations of ambiguous bodily sensations (such as shortness of breath, rapid heart rate) which increase arousal, creating a positive feedback loop that results in a panic attack.

“One model explains this relationship as catastrophic misinterpretations of ambiguous bodily sensations (such as shortness of breath, rapid heart rate) which increase arousal, creating a positive feedback loop that results in a panic attack (Clark 1986).”

• cites Clark 1986 sourceNot checked — no full text of the source

May combine two claims.

Current evidence examining quality of life suggests a reduction in satisfaction above and beyond what should be expected by COPD disease severity or co-morbid medical illnesses, indicating that psychological status plays an intrinsic role in overall well-being.

“Current evidence examining quality of life suggests a reduction in satisfaction above and beyond what should be expected by COPD disease severity or co-morbid medical illnesses (Coventry 2007), indicating that psychological status plays an intrinsic role in overall well-being.”

• cites Coventry 2007 sourceNot checked — no full text of the source

May combine two claims.

Dyspnoea is an ambiguous sensation open to catastrophic interpretation, leading to increased levels of anxiety and panic in people with COPD.

“Dyspnoea (shortness of breath) can be an unpleasant and potentially frightening experience at any time, and, as the key symptom of an eventually fatal illness like COPD, it is an ambiguous sensation open to catastrophic interpretation, leading to increased levels of anxiety and panic in people with COPD (Livermore 2010b).”

• cites Livermore 2010bNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

A recent study found that people with COPD and anxiety felt isolated and would avoid social occasions and usual daily activities.

“A recent study examining the impact of anxiety on the lives of people with COPD found that they felt isolated and would avoid social occasions and usual daily activities (Willgoss 2011).”

• cites Willgoss 2011Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

The evidence for treatment of anxiety disorders in COPD is limited, and there are limited data to support the efficacy of medication-only treatments.

“The evidence for treatment of anxiety disorders in COPD is limited, and there are limited data to support the efficacy of medicationonly treatments (Borson 1998).”

• cites Borson 1998Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Anxiety is common in COPD and is not correlated with COPD severity.

“Screening data from a large randomised controlled trial in the UK showed anxiety was common in COPD and was not correlated with COPD severity (Heslop-Marshall 2014).”

• cites Heslop-Marshall 2014Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Anxiety disorders in people with COPD increase disability and impair functional status, resulting in an overall reduction in their quality of life.

“Anxiety disorders in people with COPD have been shown to increase disability and impair functional status, resulting in an overall reduction in their quality of life (Beck 1988;Weaver 1997).”

• cites Beck 1988 sourceNot checked — no full text of the source
• cites Weaver 1997 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Two of three review authors retrieved and independently examined the full texts of studies identified as potentially relevant for final inclusion.

“Two of three review authors, as above, retrieved and independently examined the full texts of studies identified as potentially relevant for final inclusion.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Two independent review authors extracted data using a standardised and piloted data extraction form.

“Two independent review authors (a combination of ZU, KC and KHM) extracted the following data using a standardised and piloted data extraction form, for each included study.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Two of three review authors independently assessed all citations generated from the search strategies to determine whether they satisfied the inclusion criteria.

“Two of three review authors (either KC, ZU or KHM) independently assessed all citations generated from the search strategies to determine whether they satisfied the Criteria for considering studies for this review, through screening of the title, abstract and descriptors.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Two review authors independently assessed the risk of bias for all included studies using the Cochrane tool for assessing risk of bias.

“Two review authors independently assessed the risk of bias for all the included studies using the Cochrane tool for assessing risk of bias, which is a domain-based evaluation (Higgins 2011a).”

• cites Higgins 2011aNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Some evidence of improvement in anxiety was observed favouring the psychological therapy arm, but substantial heterogeneity and low quality of evidence limit the reliability of these findings.

“Some evidence of improvement in anxiety was observed with a benefit in favour of the psychological therapy arm, however, the presence of substantial heterogeneity and low quality of the evidence limits the reliability of these findings.”

Classified as probably not a substantial claim.

We extracted data from cross-over studies for the first phase only (pre-cross-over), due to the potential for a significant carry-over effect for psychological therapies.

“We extracted data from cross-over studies for the first phase only (pre-cross-over), due to the potential for a significant carry-over effect for psychological therapies.”

Classified as probably not a substantial claim.

For cluster-randomised studies, we performed analyses at the level of individuals, whilst accounting for the clustering in the data using a random-effects model for pooled meta-analysis.

“For cluster-randomised studies, we performed analyses at the level of individuals, whilst accounting for the clustering in the data using a random-effects model for pooled meta-analysis, as recommended in the Cochrane Handbook for Systematic Reviews of Interventions (chapter 16.3.3) (Higgins 2011b) (checked by a statistician (AE)).”

• cites Higgins 2011bNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Two included studies sufficiently reported allocation concealment, using an external statistician (Kunik 2008) and numbered identical containers (Hynninen 2010).

“Two studies sufficiently reported allocation concealment using an external statistician to provide treatment codes to the study coordinator once sufficient numbers of participants for two classes had been recruited (Kunik 2008) and by using numbered containers that were identical in appearance for the two groups (Hynninen 2010).”

Probably not a substantial claim: may not pass S3 (load-bearing).

The de Godoy 2003 study did not report any details of allocation concealment.

“The de Godoy 2003 study did not report any details of allocation concealment.”

May combine two claims.

The two remaining included studies reported randomisation as occurring but did not describe their methods in detail.

“The two remaining studies reported randomisation as occurring, however, they did not describe their methods in detail.”

May combine two claims.

Selective reporting was a low risk in two included studies due to available prespecified protocols, while de Godoy 2003 had unclear risk because no prespecified protocol could be reviewed.

“Selective reporting was a low risk in two studies due to the availability of prespecified published protocols, allowing adequate comparison of prespecified outcomes and those reported in the publications.We assessed the de Godoy 2003 study as having an unclear risk of bias due to the inability to review a prespecified protocol.”

Classified as probably not a substantial claim.

For studies that did not adjust for clustering, we replaced the actual sample size with the effective sample size (ESS), calculated using a rho = 0.02.

“For those studies that did not adjust for clustering, we replaced the actual sample size with the effective sample size (ESS), calculated using a rho = 0.02 (as per Campbell 2000).”

• cites Campbell 2000Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

The identification of six ongoing studies and one awaiting classification is reassuring, but there is a possibility of negative studies being missed before publication of protocols became mandatory.

“The identification of six ongoing studies and one awaiting classification is reassuring, however, there is the possibility of negative studies being missed before publication of protocols became mandatory.”

May combine two claims.

Outcome assessor blinding was unclear in two included studies and was assessed as low risk of bias in Kunik 2008.

“Outcome assessor blinding was unclear in two studies and assessed to be a low risk of bias in the Kunik 2008 study as authors reported that study personnel performing assessments were blinded to treatment condition.”

Classified as probably not a substantial claim.

For participants who dropped out after the second week or with unclear dropout time, we used the last observation carried forward (LOCF) as presented in the publications.

“For participants who dropped out a er the second week or with unclear dropout time, we used the last observation carried forward (LOCF) as presented in the publications, or had the data been missing we would have obtained raw data.”

May combine two claims.

Two included studies did not blind participants or personnel to treatment allocation, while de Godoy 2003 reported that group 1 was blinded in relation to the activities of group 2 and vice versa.

“Two studies did not blind participants or personnel to the treatment allocation, whilst the third study (de Godoy 2003) reported that group 1 was blinded in relation to the activities of group 2 and vice versa.”

Probably not a substantial claim: may not pass S3 (load-bearing).

We evaluated missing information regarding participants on an available case-analysis basis.

“We evaluated missing information regarding participants on an available case-analysis basis as described in chapter 16.2.2 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011b).”

• cites Higgins 2011bNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Findings from this review should be interpreted with caution and the questions posed in this review remain unanswered.

“As such, findings from this review should be interpreted with caution and the questions posed in this review remain unanswered.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

We performed a sensitivity analysis for studies which were at an unclear or high risk of bias for sequence generation and allocation concealment, and for studies involving participants who had significant co-morbidities.

“We assessed all the included studies for inclusion in the primary analyses, and performed a sensitivity analysis for studies which were at an unclear or high risk of bias for sequence generation and allocation concealment, and for studies involving participants who had significant co-morbidities, for example, dementia or severe heart failure.”

May combine two claims.

Because only three studies were included, it is difficult to examine consistency effectively, and the quality of results was downgraded due to inconsistency.

“However, as we only included three studies, it is difficult effectively to examine consistency.As such, the quality of results was downgraded due to inconsistency.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

Screening of online clinical trial registries allows identification of studies regardless of a positive or negative effect, which may reduce the possibility of publication bias.

“Screening of online clinical trial registries allows identification of studies regardless of a positive or negative effect for the treatment, which may reduce the possibility of publication bias.”

May combine two claims.

All three included studies had a low risk of bias for incomplete outcome data because they used intention-to-treat analyses.

“All three studies had a low risk of bias for incomplete outcome data as they used intention-to-treat analyses.”

Classified as probably not a substantial claim.

We pooled the extracted data in meta-analyses using the random-effects model to allow for expected heterogeneity.

“We pooled the extracted data in meta-analyses using the randomeffects model to allow for expected heterogeneity (due to expected differences in the interventions and populations).”

May combine two claims.

Meta-analyses attempting to examine the impact of psychological interventions for anxiety in people with COPD have consistently identified a lack of methodologically rigorous evidence to support treatment efficacy, resulting in the inability to draw reliable conclusions.

“Meta-analyses attempting to examine the impact of psychological interventions for anxiety in people with COPD have consistently identified a lack of methodologically rigorous evidence to support treatment efficacy (Rose 2002;Mikkelsen 2004;Baraniak 2011), resulting in the inability to draw reliable conclusions.”

• cites Rose 2002 sourceNot checked — no full text of the source
• cites Mikkelsen 2004 sourceNot checked — no full text of the source
• cites Baraniak 2011 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

A 2014 overview examining the prevalence, impact and management of depression and anxiety in COPD found that the quality of evidence underpinning treatment varied considerably.

“A 2014 overview examining the prevalence, impact and management of depression and anxiety in COPD also found that the quality of evidence underpinning treatment varied considerably (Panagioti 2014).”

• cites Panagioti 2014Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

An additional limitation is that risk of bias categories were deemed unclear by review authors because individual study authors were not contacted for clarification or further information.

“An additional limitation relates to risk of bias categories deemed to be unclear by review authors, as we did not contact individual study authors for clarification or to obtain further information.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Hynninen 2010, random sequence generation was at unclear risk of selection bias because randomisation was reported but methods were not described.

“Random sequence generation (selection bias) Unclear risk Randomisation reported however methods not described”

• cites Hynninen 2010 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

In Hynninen 2010, allocation concealment was at low risk of selection bias because numbered containers identical in appearance were used.

“Allocation concealment (selection bias) Low risk Allocation concealment was implemented using numbered containers that were identical in appearance for the two groups”

• cites Hynninen 2010 sourceNot checked — no full text of the source

May combine two claims.

Some evidence of improvement in anxiety was observed in the psychological therapy arm, but the low quality of evidence and substantial heterogeneity limit the ability to draw conclusions from these findings.

“Some evidence of improvement in anxiety was observed in the psychological therapy arm, however, the low quality of the evidence and presence of substantial heterogeneity limits our ability to draw any conclusions from these findings.”

Probably not a substantial claim: may not pass S3 (load-bearing).

For Kunik 2008, allocation concealment was at low risk of selection bias.

“Allocation concealment (selection bias) Low risk The statistician provided randomisation numbers and treatment codes to the study co-ordinator when sufficient participants for two classes had completed the baseline assessment and consented to participate; the instructor assigned the treatment to the code initially by flipping a coin”

Probably not a substantial claim: may not pass S3 (load-bearing).

For Kunik 2008, selective reporting was at low risk of reporting bias.

“Selective reporting (reporting bias) Low risk Pre-specified protocol available and no selective reporting identified”

Probably not a substantial claim: may not pass S3 (load-bearing).

For de Godoy 2003, incomplete outcome data was at low risk of attrition bias.

“Incomplete outcome data (attrition bias) All outcomes Low risk Reasons for choosing not to participate prior to randomisation (n = 6 participants) and attrition post recruitment (n = 3 intervention participants) were reported for all participants”

Probably not a substantial claim: may not pass S3 (load-bearing).

Sensitivity analyses were not conducted because the number of included studies in each meta-analysis was small.

“We did not conduct sensitivity analyses due to the small number of included studies reported within each meta-analysis.”

Probably not a substantial claim: may not pass S3 (load-bearing).

For de Godoy 2003, blinding of outcome assessment was at unclear risk of detection bias.

“Blinding of outcome assessment (detection bias) All outcomes Unclear risk No mention of blinding for outcome assessors”

Probably not a substantial claim: may not pass S3 (load-bearing).

For de Godoy 2003, blinding of participants and personnel was at unclear risk of performance bias.

“Blinding of participants and personnel (performance bias) All outcomes Unclear risk Group 1 was blinded in relation to the activities of Group 2 and vice versa”

Probably not a substantial claim: may not pass S3 (load-bearing).

For Hynninen 2010, outcome measures were validated, with the exception of service use outcomes.

“Outcome measures validated?: yes, with the exception of service use outcomes”

Probably not a substantial claim: may not pass S3 (load-bearing).

For de Godoy 2003, selective reporting was at unclear risk of reporting bias.

“Selective reporting (reporting bias) Unclear risk Insuffient information due to lack of prespecified study protocol”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Hynninen 2010, the target sample size from the power analysis (33 per arm) was not reached (25 in the intervention arm and 26 in the control arm).

“the target sample size identified as being necessary in the power analysis (33 in each arm) was not reached by the end of the study period (25 in the intervention arm and 26 in the control arm)”

• cites Hynninen 2010 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

For Kunik 2008, the sample size calculation required 120 participants per group, but this number was not met.

“Also, the sample size calculation in the statistical analysis section stated that 120 participants per group would be required yet this n-value was not met”

Probably not a substantial claim: may not pass S3 (load-bearing).

For Kunik 2008, blinding of participants and personnel was at high risk of performance bias.

“Blinding of participants and personnel (performance bias) All outcomes High risk Participants and staff performing the intervention were not blinded to treatment allocation”

Probably not a substantial claim: may not pass S3 (load-bearing).

For de Godoy 2003, other bias was at low risk.

“Other bias Low risk No other biases identified”

Probably not a substantial claim: may not pass S3 (load-bearing).

For Kunik 2008, other bias was at low risk.

“Other bias Low risk No other biases identified”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

For Hynninen 2010, missing data were addressed using intention-to-treat analysis, and missing data at one measurement point did not prevent including the individual in the analysis.

“Missing data addressed?: Yes, ITT analysis used and authors reported that missing data at one measurement point did not prevent including the individual in the analysis”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Hynninen 2010, blinding of outcome assessment was at unclear risk of detection bias because there was no mention of blinding for outcome assessors.

“Blinding of outcome assessment (detection bias) All outcomes Unclear risk No mention of blinding for outcome assessors”

• cites Hynninen 2010 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

For Kunik 2008, random sequence generation was at low risk of selection bias.

“Random sequence generation (selection bias) Low risk Randomisation list occurred via computer program (SAS) with blocks to provide appropriately equal numbers per class of COPD; instructor assigned treatment to the code initially by flip of coin”

Probably not a substantial claim: may not pass S3 (load-bearing).

For Kunik 2008, blinding of outcome assessment was at low risk of detection bias.

“Blinding of outcome assessment (detection bias) All outcomes Low risk Study personnel performing assessments were blinded to treatment condition”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Hynninen 2010, there was low risk of other bias because no other biases were identified.

“Other bias Low risk No other biases identified”

• cites Hynninen 2010 sourceNot checked — no full text of the source