Implementing psychological interventions delivered by respiratory professionals for people with COPD. A stakeholder interview study

The study addresses how to implement psychologically informed care for people with COPD by exploring NHS stakeholders’ views on barriers and facilitators to integrating such care within existing services. COPD frequently co-occurs with anxiety and depression, and access to psychological support is often fragmented from physical healthcare. Although IAPT has LTC pathways, people with COPD face barriers (mobility limits, exacerbations, scheduling) and show lower attendance and poorer outcomes compared with other LTCs. Respiratory professionals are increasingly encouraged to incorporate psychological approaches and have demonstrated feasibility in delivering CBT-informed support, yet many report lack of skills, training, supervision, and resources. Using TANDEM—a CBT-informed, COPD-tailored self-management intervention aiming to reduce anxiety/depression and improve PR uptake—as an exemplar, the study seeks to understand contextual factors, resources, partnerships, and potential barriers/facilitators to implementation.

Background literature highlights: high prevalence of anxiety and depression among people with COPD and other LTCs; challenges accessing psychological care when separated from physical services; policy emphasis on integrated, patient-centred care and IAPT LTC pathways; known barriers to IAPT engagement among COPD patients and relatively poorer outcomes; PR is a core, cost-effective COPD treatment that can improve mood but uptake/completion are suboptimal; CBT is effective for anxiety/depression, and specifically trained respiratory staff can deliver CBT-informed interventions; however, physical healthcare professionals cite insufficient training/supervision and resource constraints; implementation requires acceptance and integration by stakeholders (normalization process theory). TANDEM, a CBT-informed, COPD-tailored intervention delivered by trained respiratory professionals, was evaluated in a pragmatic RCT with high delivery fidelity and acceptability but did not show between-group differences at 6–12 months and was not cost-effective; this interview study’s data and analysis preceded trial outcome release.

Design: Qualitative interview study with NHS stakeholders to explore prospective implementation of TANDEM in routine COPD care in England and Wales. Sampling and participants: Purposive sampling targeting up to 20 stakeholders from primary care, secondary care respiratory services, PR services, commissioners/CCGs, and IAPT/psychological services. Inclusion: currently or recently (<12 months) providing care to people with COPD, referring to PR, or commissioning PR services; not involved in delivering TANDEM. Twenty participants consented (median healthcare experience 13 years; range 2–30) across diverse UK regions. Recruitment: Notices via social media and professional networks; additional identification via professional contacts and referrals. Data collection: Semi-structured telephone interviews conducted Nov 2019–Jan 2020 by experienced qualitative researchers (VW, VR). Average duration ~40 minutes (range 17–83). Interviews audio-recorded and transcribed verbatim by external services; transcripts checked for accuracy. Analysis: Inductive thematic analysis (Braun & Clarke) from a realist perspective using NVivo v12. Two researchers independently coded initial transcripts, developed and agreed a coding framework through iterative comparison, then applied it to remaining transcripts. Regular meetings ensured consistency; themes refined and supported by salient extracts. Reflexivity documented throughout. Ethical approval: London-Queen Square REC (17/LO/0095); written informed consent obtained.

- Sample and context: 20 stakeholders across primary/secondary care, PR, IAPT/psychology, and commissioning; median 13 years in healthcare; UK-wide settings. - Four overarching themes: 1) Living with COPD and emotional distress affects engagement with services: COPD-related breathlessness, loss of function, social isolation, and co-morbidities coexist with significant anxiety/depression, reducing ability to access and engage with PR and psychological services. Some patients resist discussing mood or have complex social issues that hinder engagement. 2) Resource limitations affect service provision: Time, staffing, training, and supervision needs were major obstacles to adding psychological care within existing workloads. Existing structures are hard to change under pressure; however, stakeholders anticipated psychological approaches could become routine with support. Cost and efficiency pressures favor modalities like phone/remote delivery, but suitability varies. IAPT LTC provision is valued yet overstretched; online/groups may not fit COPD populations. Commissioners may ask why not use IAPT; parallel provision in respiratory services faces funding scrutiny. Geographical dispersion challenges home visiting; community ‘hub’ models could improve access. Home visits can reduce barriers and reveal broader social needs influencing PR uptake. 3) Provision of integrated care is important: Stakeholders endorsed holistic, integrated models, noting delays and inflexibility in psychological services for COPD, and patient preference for known respiratory clinicians. Concern exists about delivering ‘too light’ psychological input; appropriate supervision and stepped referral pathways are essential. Respiratory professionals are seen as well placed to deliver psychologically informed care, though not all are suited; careful selection, training, competence assessment, and supervision are required. 4) Healthcare communication as enabler/barrier: Clear explanations to patients about the role of psychological approaches in managing breathlessness are crucial to avoid invalidating physical symptoms. Misunderstandings about PR terminology and purpose already hinder uptake; better communication and rebranding may help. Communication between providers and referrers also influences service uptake and commissioning perceptions. - Implementation facilitators: Commitment to integrated care; using respiratory professionals to deliver psychologically informed interventions; home-based options; potential to support and decongest PR/IAPT; holistic, person-centered benefits including addressing social determinants. - Implementation barriers: Limited resources and cost-effectiveness requirements (e.g., reducing admissions/GP visits); doubts about impact on admissions in complex COPD; supervision needs; not all staff suitable; concerns about home-visit costs in dispersed regions; risk of insufficient psychological dose; need for robust interprofessional communication and clear referral pathways.

Stakeholders largely support integrating psychological and physical care for COPD, viewing respiratory professionals as credible providers of psychologically informed support when appropriately trained and supervised. The findings reaffirm known barriers to IAPT engagement for LTCs and suggest that flexible, integrated models (including home-based options) may better meet COPD patients’ needs. However, successful implementation hinges on resources (staffing, time, training, supervision), fit with existing service structures, and demonstrable cost-effectiveness—metrics often focused on reduced admissions and service use, which may be difficult to achieve in a complex COPD population. Clear, acceptable patient-facing language is needed to explain psychological components without minimizing physical symptoms, and communication across services is essential to drive referrals and sustained uptake. Selecting suitable respiratory staff and establishing stepped pathways to higher-intensity psychological care address concerns about treatment sufficiency. Potential service models include multidisciplinary, co-located ‘COPD hubs’ to enhance integration and mutual understanding among professionals. Embedding psychologically informed skills into foundational training for respiratory teams could normalize and sustain these approaches.

Stakeholders expressed strong commitment to integrating psychological support within COPD care and endorsed trained respiratory professionals delivering psychologically informed interventions like TANDEM as part of holistic services. Nonetheless, significant implementation barriers exist—particularly limited resources, need for supervision structures, cost-efficiency requirements, and variable staff readiness. Future directions include piloting integrated COPD ‘treatment hubs’ that co-locate respiratory and psychological expertise, defining stepped-care referral pathways, optimizing communication strategies (including rebranding/explaining PR and psychological components), exploring remote delivery where appropriate, and embedding psychological skills training in respiratory workforce development. Addressing these factors can support scalable, sustainable implementation of psychologically informed COPD care.

- Limited representation per service type and potential selection bias from recruitment via professional networks and colleague referrals, possibly over-representing stakeholders favorable to psychological integration. - UK NHS-specific context may limit transferability to other health systems. - Interviewers (two authors) were employed on the TANDEM trial, introducing potential bias; mitigated through reflexivity, active search for barrier content, inclusion of psychology stakeholders, independence from intervention development and (for VW) trial management, and completion of analysis before trial outcomes were known. - Resource constraints limited sample size to 20 stakeholders.