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

Chronic obstructive pulmonary disease (COPD) frequently co-occurs with anxiety and depression, impacting access to psychological support. Integrated care aims to coordinate patient-centered healthcare, but barriers remain, particularly for those with COPD, who often experience lower IAPT attendance and poorer outcomes. Physical healthcare professionals are increasingly encouraged to incorporate psychological approaches, but challenges include skill gaps, training needs, and resource limitations. Successful implementation requires stakeholder buy-in. This study uses the TANDEM intervention (a cognitive behavioral therapy-based self-management program) as an exemplar to explore barriers and facilitators to implementing psychological interventions within existing COPD services. TANDEM aims to improve anxiety and depression, and encourage pulmonary rehabilitation (PR) uptake, addressing issues such as poor PR attendance often linked to practical, organizational, and communication barriers, as well as comorbid mental health issues. The study aims to understand resource needs, inter-service partnerships, existing psychological care provision, and potential barriers to implementing psychological interventions for COPD within the NHS.

Existing literature highlights the high prevalence of anxiety and depression among individuals with COPD, emphasizing the need for integrated care models that address both physical and mental health needs. Studies reveal significant barriers to accessing psychological support, including separate physical and mental healthcare systems and patient-level challenges like mobility limitations and competing appointments. While there's growing recognition of the benefits of integrating psychological approaches into physical healthcare, delivered by existing professionals like nurses and physiotherapists, significant challenges remain regarding skill development, training, and resource allocation. Previous research has demonstrated the effectiveness of interventions like CBT in managing anxiety and depression associated with COPD, but uptake and successful implementation remain inconsistent.

This qualitative study employed semi-structured interviews with 20 UK NHS stakeholders (primary/secondary care, commissioning organizations) purposively sampled based on their roles and experience in COPD care. Participants were recruited via professional networks and referrals. Interviews (average 40 minutes) were audio-recorded, transcribed verbatim, and analyzed using thematic analysis following Braun and Clarke's guidelines. The analysis involved independent coding of transcripts, comparison of themes, development of a coding framework, and iterative refinement through team discussions. A realist epistemological perspective was adopted, interpreting participants' words at face value. Ethical approval was obtained, and written informed consent was secured from all participants.

Four main themes emerged from the data analysis: 1. **Living with COPD and emotional distress affects engagement with physical and psychological services:** Participants highlighted the complex interplay between physical and psychological symptoms, with emotional distress impacting engagement with services. Many individuals struggle with breathlessness, reduced activity, and social isolation. The difficulty of accessing services, combined with anxiety and depression, often hindered individuals from seeking necessary support. 2. **Resource limitations affect service provision in COPD:** Significant resource constraints were identified as a major barrier. These constraints included limited time for healthcare professionals, inadequate funding for new initiatives, difficulties integrating psychological interventions into existing service structures, and geographical challenges in providing home visits. The cost-effectiveness of home visits was questioned, and the perceived additional workload caused concern. 3. **Provision of integrated care is important for patient well-being:** Stakeholders strongly advocated for integrated care, recognizing the need for holistic approaches addressing both physical and psychological needs. They highlighted delays in accessing psychological services and expressed a preference for psychological support delivered by familiar respiratory healthcare professionals. The study revealed support for a multidisciplinary approach, but emphasized the importance of delivering evidence-based treatments, ensuring referral pathways are clearly defined for those who require specialist support. 4. **Healthcare communication can be an enabler or a barrier to patient engagement:** Effective communication was seen as crucial. The study revealed challenges in explaining psychological interventions, especially concerns about patients misinterpreting them as implying their physical symptoms are not real. Poor communication between healthcare professionals also impacted service uptake. Issues around terminology, such as the use of ‘pulmonary rehabilitation’, created communication barriers between healthcare providers and patients.

This study reveals a commitment to improving psychological care for COPD patients, with support for integrated interventions delivered by respiratory professionals. However, significant organizational barriers were identified, particularly concerning resource limitations and the need for additional training and supervision. The study highlights the complexities of integrating psychological interventions into existing COPD services, emphasizing the need for careful consideration of both cost-effectiveness and the specific skills and training required. The findings support previous research on barriers to IAPT access for individuals with long-term conditions. The value of home visits is acknowledged, providing an alternative approach, but financial constraints limit their feasibility, especially in geographically dispersed areas. The study emphasizes the importance of improving communication between healthcare professionals and with patients, using clear and patient-centered language. The study points towards a multidisciplinary model of care, recognizing the potential for collaboration between respiratory professionals and psychologists specialized in COPD.

This study underscores the need for a multi-faceted approach to improve psychological care for COPD patients. While stakeholders are supportive of integrating psychological interventions into routine care, delivering this effectively will require addressing resource limitations, providing appropriate training and supervision for respiratory healthcare professionals, and improving communication strategies. Future research should explore models of integrated care, such as ‘COPD treatment hubs’, where respiratory professionals and psychologists collaborate, and consider embedding psychological approaches into healthcare foundation training.

The study's reliance on a purposive sample from the UK NHS might limit the generalizability of the findings to other healthcare systems. The recruitment methods, including professional colleague referrals, may have attracted participants more enthusiastic about psychological support in COPD than the broader population. The relatively small number of representatives from each service type limits the depth of perspectives from certain stakeholders.