Chronic obstructive pulmonary disease (COPD) is a highly prevalent, progressive condition causing significant morbidity and mortality globally. In Australia, it's the third leading contributor to disease burden and the fifth most common cause of death. The United States reports over 15.7 million diagnosed cases, with 96% of individuals having at least one other chronic condition. Depression is the second most frequently self-reported comorbidity among COPD patients, with estimated prevalence rates of depression and anxiety at 40% (8–80%) and 36% (6–74%), respectively. Panic disorder prevalence is about ten times higher in COPD patients than in the general population. These mental health issues negatively impact coping abilities, quality of life, pulmonary function, hospital admissions, medication adherence, and rehabilitation engagement. While global guidelines recommend screening for and managing psychological comorbidities in COPD, less than one-third of affected individuals receive adequate treatment. This under-treatment is likely due to a complex interplay of patient, provider, and health system barriers. Patient barriers include mental health stigma, inadequate self-appraisal, and access difficulties. Provider and health system barriers encompass clinicians' lack of confidence in mental health assessments, insufficient screening, poor inter-professional communication, and inadequate insurance coverage. Empirical data on these barriers' impact on mental health care uptake in COPD, particularly after respiratory clinician referrals, are limited. This study aimed to explore respiratory clinicians' perspectives on mental health illnesses in COPD, their attitudes towards mental health care provision, and their understanding of barriers and facilitators to patients' acceptance of psychological care.

Existing literature highlights the high prevalence of anxiety and depression in COPD patients, often exceeding that seen in other chronic illnesses. Studies consistently demonstrate the negative impact of these comorbid mental health conditions on various aspects of patients' lives, including physical function, quality of life, and treatment adherence. However, a significant gap exists in understanding the reasons for the under-treatment of mental health issues in this population. While some studies suggest a lack of recognition or prioritization of mental health concerns by clinicians, others point towards patient-related barriers, such as stigma, and systemic obstacles, such as limited access to mental health services. The current study addresses this gap by specifically focusing on clinicians' perspectives to identify and understand the complexities surrounding the provision and acceptance of mental health care for COPD patients. This qualitative approach allows for a nuanced exploration of the multifaceted challenges involved.

This study employed an exploratory qualitative design using purposive sampling to recruit a diverse group of 24 Australian respiratory health professionals (physicians, nurses, physiotherapists, social workers, and psychologists) from public and private hospitals and community health centers. Semi-structured interviews, lasting 40–45 minutes on average, were conducted via phone or in-person between February and May 2020 by a single interviewer. The interviews explored participants' perspectives on mental health care in COPD, including identifying and managing mental health issues, and barriers and facilitators to mental health care uptake. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis following Braun and Clarke's framework. The analysis involved line-by-line coding, iterative evaluation by multiple authors, and the identification of overarching themes. Intercoder reliability was ensured through independent coding by at least two researchers. Thematic saturation was achieved, indicating that no new concepts or themes emerged during data collection. All authors reviewed and discussed the themes to ensure transparency and consistency.

The overarching theme identified was "complexity," which manifested across five domains: (1) Physical and mental health illnesses: Clinicians recognized the high prevalence of mental health issues in COPD, often linked to disease severity, multi-morbidity, and hospital admissions. The interplay between physical and psychological symptoms sometimes made detection challenging. (2) Psychosocial circumstances: Complex psychosocial factors, including unemployment, addiction, financial hardship, and social isolation, hindered mental health care utilization. Substance use, particularly continued smoking, was associated with disengagement from healthcare. (3) Community views and stigma: Patients experienced a "double stigma"—shame related to smoking-related illness and stigma associated with mental illness and its treatments. Negative societal attitudes towards smoking contributed to psychological distress and reluctance to seek help. (4) Educational needs and knowledge gaps: Both patients and clinicians lacked adequate knowledge about mental health conditions, available treatments, and support services. Clinicians expressed limited confidence in managing mental health issues, highlighting a need for increased education and training. (5) Navigating the health system: System-level barriers such as fragmented care, limited service availability, long waiting lists, and a lack of integrated mental health services in respiratory clinics created challenges for both patients and providers. Time constraints in respiratory consultations further exacerbated these issues. The need for a standardized approach to mental health care and the integration of mental health clinicians into multidisciplinary respiratory services were repeatedly emphasized.

This study reveals respiratory clinicians' recognition of the complex mental health needs of COPD patients and their proactive attempts to manage these issues. This contrasts with some previous research suggesting under-recognition of emotional distress. The qualitative nature of this study allowed for a detailed exploration of clinical practices and the multifaceted barriers to care. Major barriers included time constraints, limited access to psychological services, navigating a complex mental health system, cost, and complex social circumstances. The "double stigma" related to COPD and mental illness represents a unique barrier to service utilization. The study underscores the need for increased patient education, clinician training, and inter-professional collaboration. Integrating mental health clinicians into routine respiratory care, particularly within pulmonary rehabilitation programs, is proposed as a key strategy to improve access to mental health treatments and address the identified complexities.

This qualitative study highlights the complex interplay of patient, provider, and health system factors that hinder the uptake of mental health care by individuals with COPD. While clinicians recognize the prevalence and impact of mental health issues, significant barriers impede access to appropriate treatment. The findings strongly advocate for increased patient education, enhanced clinician training, and the integration of mental health professionals within multidisciplinary respiratory teams to improve care and address the identified challenges. Future research should focus on evaluating the effectiveness and cost-effectiveness of integrated care models.

The study's findings may not be generalizable to other populations or geographical settings. Due to the COVID-19 pandemic, only health professionals' perspectives were obtained; future research should include the perspectives of patients and caregivers. The purposive sampling, while allowing for a diverse range of clinician views, may not fully represent the entire spectrum of clinicians' perspectives.