The complexity of mental health care for people with COPD: a qualitative study of clinicians’ perspectives

COPD is a prevalent, progressive disease associated with substantial morbidity and mortality. Anxiety, depression and panic disorder occur at high rates among people with COPD and are linked to poorer quality of life, lower pulmonary function, more hospitalizations, and reduced adherence to treatments. Although guidelines recommend screening and managing psychological comorbidities, less than one-third of affected patients receive adequate care. Under-treatment reflects complex patient, provider and system-level barriers, including stigma, poor recognition, access difficulties, limited clinician confidence, and fragmented services. Empirical data on how these barriers influence uptake of mental health care, especially following referrals from respiratory clinicians, are limited. This study aimed to explore respiratory clinicians’ perspectives on mental health needs in COPD, their attitudes to providing mental health care, and perceived barriers and facilitators to patients’ acceptance of psychological care.

Prior work shows high prevalence of depression and anxiety in COPD and their adverse impacts on disease outcomes. Guidelines advocate active screening and management of psychological comorbidities, yet standardized approaches to assessment and treatment are lacking. Reported barriers span patient-level (stigma, low recognition, access), provider-level (limited confidence, failure to screen, communication gaps), and health system-level (coverage and access constraints). Clinicians’ perceptions of patients’ psychological needs may influence referrals to ancillary services and patients’ willingness to accept support. However, there are limited empirical data on the effects of these barriers on mental health care uptake when initiated within respiratory care, motivating a qualitative inquiry into clinicians’ views.

An exploratory qualitative study using in-depth semi-structured interviews was conducted with purposively sampled respiratory clinicians and allied health professionals working in public/private hospital respiratory departments and community services in Victoria and South Australia. Recruitment occurred via email from the lead investigator; informed consent was obtained. Interviews (mean 40–45 minutes; a few 20–22 minutes) were conducted by phone or face-to-face between February and May 2020, audio-recorded, de-identified, transcribed verbatim, and supplemented with field notes. Demographic data (occupation, years in practice) were collected. Thematic analysis followed Braun and Clarke, with line-by-line coding, iterative refinement, independent coding by at least two researchers to encourage intercoder reliability, and analysis concurrent with data collection to achieve thematic saturation. Ethical approval: Melbourne Health Human Research Ethics Committee (Ref: 2019.281).

- Participants: 24 Australian respiratory health professionals (17 female, 7 male), aged 31–64. Median age 50.5 years (IQR 44.3–55.8); median years in practice 19.5 (IQR 12.5–25.8); occupations: respiratory physicians (n=12), nurses (n=5), physiotherapists (n=5), social worker (n=1), psychologist (n=1). Practice settings included public-only (n=9), private-only (n=1), public+private (n=7), and community centres (n=7). Median number of COPD patients seen per week: 15 (IQR 5–20). - Overarching theme: “Complexity” affecting mental health care engagement across five domains: 1) Physical and mental health illnesses: Mental health issues perceived as highly prevalent in COPD, increasing with disease severity and multimorbidity. Symptoms of breathlessness and anxiety are intertwined, complicating detection. Co-occurring chronic mental illnesses (e.g., schizophrenia, PTSD, substance use) are common. 2) Psychosocial circumstances: Financial strain, unemployment, trauma histories, addiction, social isolation, and low socioeconomic status reduce prioritization and uptake of mental health care; out-of-pocket costs are salient barriers. 3) Community views and stigma: A “double stigma” of smoking-related COPD and mental illness leads to shame, guilt, and reluctance to engage with psychological services; negative societal and some healthcare attitudes toward smoking exacerbate distress. 4) Educational needs and knowledge gaps: Patients have limited understanding of psychological symptoms and available treatments; clinicians recognize mental health struggles but many feel undertrained to manage them, relying on self-directed learning and therapeutic relationships to provide psychoeducation. 5) Navigating the health system: Fragmented care, lack of coordinated referral pathways, limited service availability, long waitlists, and short consultation times (e.g., 15-minute outpatient visits) hinder access. Participants advocate integrating mental health clinicians into multidisciplinary respiratory services and establishing standardized pathways/tools. - Clinicians reported routinely inquiring about mental health and sometimes using screening tools, indicating proactive engagement contrary to some prior assumptions. - Smoking is often used to regulate anxiety, perpetuating a vicious cycle that worsens COPD and undermines engagement with care.

Findings address the research aim by detailing clinicians’ recognition of complex, interlinked physical and psychological needs in COPD and by identifying multilevel barriers that impede patients’ acceptance of mental health care. Contrary to some prior studies, participants reported proactively screening and attempting to manage psychological issues, but were constrained by time, fragmented systems, limited access, and patient-level stigma and socioeconomic challenges. The identified “double stigma” (COPD as smoking-related plus mental illness) uniquely compounds disengagement from psychological services. Results support integrating mental health clinicians within respiratory outpatient clinics and pulmonary rehabilitation to streamline care, reduce stigma, and improve access. Standardized, collaborative care models, shared assessment tools, and workforce capacity-building (training for respiratory teams supported by psychologists/psychiatrists) are proposed to overcome current barriers. Embedding services may also improve equity for hard-to-reach patients and mitigate financial/logistical constraints.

Respiratory clinicians recognize substantial psychological comorbidity among people with COPD and attempt to address it, yet patient-, provider-, and system-level barriers limit uptake of recommended mental health treatments. The study underscores the need for targeted patient education, enhanced clinician training in mental health, standardized care pathways, and integration of mental health clinicians into routine respiratory outpatient services and pulmonary rehabilitation. Future research should evaluate the clinical and economic impacts of integrated models, and incorporate patient and caregiver perspectives to inform implementation.

Findings derive from clinicians in Australian settings (Victoria and South Australia) and may not generalize to other populations or health systems. Due to COVID-19, only clinicians’ perspectives were captured; patients’ and caregivers’ views were not directly collected. As with qualitative research, results reflect reported experiences and perceptions; however, purposive sampling and interdisciplinary analysis were used to enhance breadth and rigor.