**4.4 Psychosocial**

Anxiety and depression affect significantly in COPD patients leading to worse patient centered outcomes. Tselebis et al. conducted study in 101 consecutive patients and noted that psychological morbidity was improved with participation in PR program irrespective of severity of the disease (COPD) [37]. This was confirmed in a meta-analysis of six RCTs which indicated that pulmonary rehabilitation was more effective than standard care for the reduction of anxiety and depression [38].

HRQoL was noted to be significantly improved in patients with COPD participating in PR as well [34, 39]. The St. Georges Respiratory Questionnaire Scores were used in a meta-analysis, which showed significant improvement in HRQoL following pulmonary rehabilitation [40]. An early RCT compared pulmonary rehabilitation with education alone and demonstrated that self-efficacy improved in the intervention group [41].
