Exploring the Clinical Psychology Service in a Community Respiratory Team

At the Belfast Health and Social Care Trust, our multi-disciplinary Community Respiratory Team includes a Clinical Psychology Service. This is an assessment and treatment pathway for those receiving respiratory care, and who are experiencing condition-related emotional distress.

The team provides care for adults who have breathing conditions such as chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, and bronchiectasis.

A key component of patient-centred, integrated care is ensuring that people receive the right care from the most appropriate professional, at the optimal time and in the best environment.^[1] The Department of Health Mental Health Strategy 2021-2031 has called for further ‘integration of psychology in multi-disciplinary teams, to ensure that psychological support is mainstreamed across physical health’.^[2]

The Clinical Psychology Service, which is the focus of this article, is fully embedded into the Community Respiratory Team – a multidisciplinary ‘team without walls’.^[1]

The link between respiratory conditions and mental health issues

It is widely recognised that individuals with long-term physical health conditions commonly experience co-morbid mental health problems.^[3] Such co-morbidity can negatively impact the prognosis of their long-term condition and the quality of life they experience.^[3]

This is particularly so for those patients with chronic respiratory disease. Anxiety and depression have been identified as important and common co-morbid difficulties within patient samples with COPD,^[4] idiopathic pulmonary fibrosis,^[5] and bronchiectasis.^[6]

However, the relationship between depression and anxiety in COPD is likely to be complex, and the exact mechanisms linking them requires further investigation.^[7] Patients with COPD may experience varying levels of psychological distress,^[8] alongside shame, guilt and self-blame.^[9]

The clinical implications of co-morbid mental health issues in respiratory conditions are far-reaching for the individual and the health service. A recent review has found that COPD patients with co-morbid depression and anxiety have a higher rehospitalisation incidence and carry a higher risk of mortality than COPD patients without these co-morbidities.^[10] In a recent observational study, depression was found to be an independent factor for acute exacerbations of COPD.^[11]

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Report highlights the need for co-morbid presenting difficulties (such as anxiety and depression) in COPD to be actively sought and treated when identified.^[12]

It is evident from these findings that services must assess and address the psychological needs of individuals with chronic respiratory conditions. Let’s now turn to look at how our service at Belfast Health and Social Care Trust endeavours to meet these needs.

The referral process

Any professional within the multi-disciplinary Community Respiratory Team can make an internal referral to the Clinical Psychology Service. Fortnightly referral meetings facilitate case discussions regarding the most appropriate source of psychological support for our patients.

Respiratory team members administer validated screening measures of mood and anxiety at the point of referral to inform the decision-making process. These include the Patient Health Questionnaire (PHQ)^[13] and the Generalized Anxiety Disorders Scale.^[14]

Some of the common reasons we see for referral include, but are not limited to:

• anxiety and panic
• frightening breathlessness
• low mood
• bereavement
• difficulties with adjustment to the respiratory condition
• concerns regarding health deterioration
• traumatic experiences
• transplantation and end of life concerns
• difficulties with self-management.

Model of care

This service is informed by a stepped care model. The psychological needs of patients accessing the Community Respiratory Team are met in many ways by the whole staff team.

Step 1

Key workers within the team routinely provide significant emotional support to patients and their families, and can also deliver lower intensity psychological interventions with training and supervision.

Step 2

Interventions here include anxiety and mood management via the Occupational Therapist, and pulmonary rehabilitation (PR) which has known beneficial effects on mental health in COPD.^[15] As the service evolves, group-based psychological therapy interventions, co-facilitated with other professionals should be offered.

Step 3

The Clinical Psychologist provides psychological assessment and intervention to individuals who are experiencing significant psychological distress and require specialist input. Outpatient appointments and home visits are available to ensure that the service is accessible. Individuals who are awaiting transplantation or assessment for the same, and those who are considered to have palliative needs, are prioritised.

For individuals with more complex mental health presentations unrelated to their respiratory condition or requiring higher intensity input, onwards referral to specialist services may be required. The Clinical Psychologist is available to provide consultation and advice on all patients accessing the service.

Digital Intervention

In addition to the above, we are about to embark on a collaboration with BreathTec. This is a digital program based on cognitive-behavioural therapy (CBT) approaches, to promote self-management and includes a focus on managing breathlessness, staying active, and mental wellbeing.^[16] It is intended that all professionals within our team will soon be able to refer patients to this program.

Individual formulation and intervention

The Clinical Psychology Service seeks to provide timely, evidence-based, and compassionate care. Intervention is based on a psychological formulation which is collaboratively developed with the person, and seeks to integrate the relevant biological, social, and psychological aspects of their experience. It is a shared understanding of the persons presenting difficulties, the factors that may have contributed to their development, and maintaining factors. It incorporates a person’s strengths and existing coping strategies and provides the direction for intervention.

An overarching aim is to empower patients to self-manage their physical and mental health, and to build self-efficacy. While intervention is always individualised, there are some common areas of focus including:

• identifying personally meaningful values and goals
• supporting adjustment to the respiratory condition and any associated physical limitations or role changes
• promoting engagement in optimal self-management (for example, smoking cessation, attending rehabilitation, remaining active)
• identifying existing coping strategies and the development of new skills.

The service is informed by the National Institute for Health and Care Excellence (NICE) guidelines,^[17],[18] which recommend CBT for the treatment of anxiety, and mild-to-moderate depression in adults with a chronic physical health problem. A recent review supports the use of CBT for a range of health outcomes in people with COPD.^[19]

The Clinical Psychology Service also offers ‘third wave’ cognitive-behavioural approaches such as Acceptance and Commitment Therapy (ACT). Research indicates that interdisciplinary programs including ACT-based components are promising treatments for the rehabilitation of patients with chronic airway diseases.^[20]

Additional investigation is required to determine the optimal approaches to address the mental health needs of people living with respiratory conditions. The Clinical Psychologist will often use an integrative approach, which is informed by various theoretical perspectives and draws on strategies from different approaches to best meet the needs of each individual patient.

Conclusion

This article has given a brief glimpse into how one Clinical Psychology Service operates within a Community Respiratory Team.

Psychological distress is common in respiratory populations and has significant implications for the individual and the health service overall. As such, services should be carefully designed to respond to the psychological needs of individuals with respiratory conditions, with a view to providing patient-centred, holistic care and ensuring optimum client outcomes.

Any advice given and opinions expressed in this article are those of the author and do not reflect the view of Chiesi Limited (Chiesi).  All content in this article is for informational and educational purposes only.  Although Chiesi strives to always provide accurate information, it is not responsible for and does not verify for accuracy any of the information contained within.

[1] Patel I. Integrated respiratory care. Clinics in Integrated Care. 2021; 6: 100053

[2] Department of Health. Mental Health Strategy 2021-2023. Available at: https://www.health-ni.gov.uk/sites/default/files/publications/health/doh-mhs-strategy-2021-2031.pdf

[3] The King’s Fund. Long-term conditions and mental health: The cost of co-morbidities. Available at: https://assets.kingsfund.org.uk/f/256914/x/a7a77f9f6b/long_term_conditions_and_mental_health_february_2012.pdf

[4] Pumar MI, Gray CR, Walsh JR, et al. Anxiety and depression-Important psychological comorbidities of COPD. J Thorac Dis. 2014; 6(11): 1615-1631

[5] Lee YJ, Choi SM, Lee YJ, et al. Clinical impact of depression and anxiety in patients with idiopathic pulmonary fibrosis. PLoS One. 2017; 12(9): e0184300

[6] Özgün Niksarlioglu EY, Özkan G, Günlüoğlu G, et al. Factors related to depression and anxiety in adults with bronchiectasis. Neuropsychiatr Dis Treat. 2016; 12: 3005-3010

[7] Yohannes AM, Alexopoulos GS. Depression and anxiety in patients with COPD. Eur Respir Rev. 2014; 23(133): 345-349

[8] Volpato E, Farver-Vestergaard I, Brighton LJ, et al. Nonpharmacological management of psychological distress in people with COPD. Eur Respir Rev. 2023; 32(167): 220170

[9] Jerpseth H, Knutsen IR, Jensen KT, et al. Mirror of shame: Patients experiences of late-stage COPD. A qualitative study. J Clin Nurs. 2021; 30(19-20): 2854-2862

[10] Rahi MS, Thilagar B, Balaji S, et al. The Impact of Anxiety and Depression in Chronic Obstructive Pulmonary Disease. Adv Respir Med. 2023; 91(2): 123-134

[11] Martínez-Gestoso S, García-Sanz MT, Carreira JM, et al. Impact of anxiety and depression on the prognosis of copd exacerbations. BMC Pulm Med. 2022; 22(1): 169

[12] Global Initiative for Chronic Obstructive Lung Disease. 2024 GOLD Report. Available at: https://goldcopd.org/2024-gold-report/

[13] Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001; 16(9): 606-613

[14] Spitzer RL, Kroenke K, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006; 166(10): 1092-1097

[15] Almdabgy EM, Qader A, Binjahlan AA, et al. The Impact of Pulmonary Rehabilitation on Mental Health and Quality of Life in Patients With Chronic Obstructive Pulmonary Disease (COPD): A Narrative Review. Cureus. 2023; 15(11): e49230

[16] BreathTec. Available at: https://www.breathtec.co.uk/

[17] NICE. Generalised anxiety disorder and panic disorder in adults: management. Clinical guideline [CG113].  Available at: https://www.nice.org.uk/guidance/cg113

[18] NICE. Depression in adults with a chronic physical health problem: recognition and management. Clinical guideline [CG91]. Available at: https://www.nice.org.uk/guidance/cg91

[19] Williams MT, Johnston KN, Paquet C. Cognitive Behavioral Therapy for People with Chronic Obstructive Pulmonary Disease: Rapid Review. Int J Chron Obstruct Pulmon Dis. 2020; 15: 903-919

[20] Giusti EM, Papazian B, Manna C, et al. The Effects of an Acceptance and Commitment-Informed Interdisciplinary Rehabilitation Program for Chronic Airway Diseases on Health Status and Psychological Symptoms. Front Psychol. 2022; 12: 818659