Anxiety and depression are common comorbidities of chronic obstructive pulmonary disease and have a negative impact on patients’ physical functioning, use of healthcare resources and mortality. Risk factors for and rates of psychological difficulties are currently higher due to the coronavirus pandemic. A recent trial demonstrated the clinical effectiveness of a cognitive behavioural therapy intervention delivered by respiratory nurses, and surveys have shown they feel psychological support is an important part of their role. Barriers remain to patients receiving mental health support; however, this intervention could provide an important step towards improving access

Heslop-Marshall, Karen

Kelly, Carol

Knighting, Katherine

Pilkington, Melissa

E-space: Manchester Metropolitan University's Research Repository

Heslop-Marshall, Karen and Pilkington, Melissa and Knighting, Katherineand Kelly, Carol (2021) Nurse-led cognitive behavioural therapy for respira-tory patients. Nursing Times, 117 (2). pp. 47-48. ISSN 0954-7762Downloaded from: http://e-space.mmu.ac.uk/627394/Publisher: EMAPPlease cite the published versionhttps://e-space.mmu.ac.ukMss no 58726 Author contact details HESLOP, Karen (THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST) <karen.heslop3@nhs.net> Pages 2 Figures  Boxes  Tables  Images required  Peer reviewed yes notes  Web navigation Category for analytics:  COPD Editorial zones and other subjects COPD Respiratory Holistic care Assessment skills Mental health nurses Team Pick? Specify category    Strap Review   Substrap Chronic obstructive pulmonary disease   Standfirst  Anxiety and depression are common comorbidities of chronic obstructive pulmonary disease. This article discusses research into respiratory nurse-led mental health support, including cognitive behavioural therapy   Keywords Anxiety/Depression/Comorbidities/Respiratory nursing  Head  Nurse-led cognitive behavioural therapy for respiratory patients  In this article…  • Impact and psychological comorbidities of chronic obstructive pulmonary disease • Research into support provided by respiratory nurses for anxiety and depression • Barriers to accessing mental health support and next steps for nurse-led care  Key points  People with chronic obstructive pulmonary disease commonly experience symptoms of anxiety and depression These comorbidities have a significant impact on physical functioning, quality of life and use of healthcare resources Respiratory nurses feel that addressing patients’ psychological comorbidities is important A trial demonstrated the benefits of an intervention in which respiratory nurses deliver cognitive behavioural therapy  The intervention may allow barriers to accessing mental healthcare to be more easily overcome  Authors Karen Heslop-Marshall is respiratory nurse consultant, The Newcastle upon Tyne Hospitals NHS Foundation Trust; Melissa Pilkington is a Lecturer, Manchester Metropolitan University; Katherine Knighting is senior research fellow and senior lecturer; Carol Kelly is reader in respiratory care and head of department, applied health and social care; both at Edge Hill University.   Abstract  Anxiety and depression are common comorbidities of chronic obstructive pulmonary disease and have a negative impact on patients’ physical functioning, use of healthcare resources and mortality. Risk factors for and rates of psychological difficulties are currently higher due to the coronavirus pandemic. A recent trial demonstrated the clinical effectiveness of a cognitive behavioural therapy intervention delivered by respiratory nurses, and surveys have shown they feel psychological support is an important part of their role. Barriers remain to patients receiving mental health support; however, this intervention could provide an important step towards improving access.  Citation Heslop-Marshall K et al (2021) Nurse-led cognitive behavioural therapy for respiratory patients. Nursing Times [online]; 117: 2, xx-yy.  Quickfact  37%  Elderly people who have experienced depression and anxiety during the pandemic   74% Respiratory nurses who screen patients for anxiety and depression  Pull quote  “COPD patients with psychological difficulties are less able to manage symptoms and less likely to be physically active”   [main article] Chronic obstructive pulmonary disease (COPD) is a term often used to describe two common conditions: chronic bronchitis and emphysema, which often occur together. The disease trajectory is one of progressive decline, punctuated by frequent acute exacerbations (Newham et al, 2018). COPD cannot be cured; treatment focuses on managing symptoms, improving quality of life and reducing hospital admissions (Global Initiative for Chronic Obstructive Lung Disease, 2020). Quality of life and health status are determined by a number of factors, including:  • Gender; • Disease severity; • Lung function; • Body mass index; • Smoking status;  • Frequency and severity of symptoms; • Comorbidity, including anxiety and depression  • Frequency and severity of exacerbations (Tsiligianni et al, 2011).  Anxiety and depression have a significant impact on people with COPD, in terms of physical functioning, breathlessness, quality of life, exacerbation rates, use of healthcare resources, length of hospital stays, readmission rates and mortality (Yohannes and Alexopoulos, 2014). Additionally, COPD patients with psychological difficulties are less able to manage symptoms and less likely to be physically active (Yohannes and Alexopoulos, 2014) or attend pulmonary rehabilitation, a key strategy for people with chronic respiratory conditions (Bolton et al, 2013). To effectively support individuals with COPD, it is therefore important that any psychological comorbidities are identified and treated appropriately (Newham et al, 2018).  The coronavirus pandemic has required many vulnerable people, especially those with respiratory problems such as COPD, to shield to protect themselves. This has resulted in social isolation for many; social distancing and the lack of interaction may well increase the risk of depression and anxiety, particularly in the elderly (Santini et al, 2020). In a study of elderly people among the general population in China, Meng et al (2020) found that 37% of the people they surveyed had experienced depression and anxiety during the pandemic; they recommend that health professionals address their psychological needs.   National Institute for Health and Care Excellence (NICE, 2011; 2009) guidelines for the treatment of anxiety and depression recommend:  • Psychological treatment, including cognitive behavioural therapy (CBT), counselling and self-help approaches; • Pharmacological treatment; • A combination of both.  Recent studies have demonstrated the value of psychological therapy for people with COPD, including promising results for CBT; however, they have recommended that further research is needed (Cully et al, 2017; Usmani et al, 2017).    [crosshead]CBT delivered by respiratory nurses A large, randomised controlled trial recently demonstrated that a brief CBT intervention delivered by respiratory nurses was clinically effective in reducing symptoms of anxiety in COPD patients (Heslop-Marshall et al, 2018). The intervention was also cost-effective due to the reduced healthcare resource use: there was a reduction in both hospital admissions and emergency department attendances. The study’s comprehensive health economic evaluation showed the CBT intervention was effective in gaining quality-adjusted life years within the NICE threshold of £30,000/€34,000 often applied in the UK to determine whether an intervention is acceptable. The study concluded that the intervention was therefore preferable to and more cost-effective than self-help leaflets.   This study has, for the first time, identified that respiratory nurses have an important role in addressing patients’ psychological needs, adding to the clinical value of respiratory nurse-led care and services. However, it remains unknown whether respiratory nurses feel that addressing psychological needs is a key component of their role.   [subhead]Literature review and surveys The Association of Respiratory Nurse Specialists commissioned a systematic literature review and a national Delphi survey of respiratory nurses’ research priorities (Kelly et al, 2018); the survey identified that a key research priority for respiratory nurses was managing psychological morbidity in COPD patients.   The study also included an online survey to gather respiratory nurses’ views about their role in screening and managing psychological comorbidities and to gauge their capacity to deliver CBT as part of their role. This survey identified that 92% of respiratory nurses felt that screening for symptoms of anxiety and depression was part of their role and 78% agreed that respiratory nurses should help patients manage these symptoms. However, of the 74% of respondents who reported that they currently screen patients, only 52% said they have made referrals to psychological services. An overwhelming 96% of respondents felt they should be trained to identify psychological difficulties experienced by respiratory patients, with 77% agreeing respiratory nurses should be trained to provide CBT.   [crosshead]Barriers to addressing psychological comorbidities Nurses are expected to address people’s physical, social and psychological wellbeing (Nursing and Midwifery Council, 2019); however, there are barriers to providing mental health support. Firstly, both patients and clinicians often fail to recognise the psychological complications of COPD, leading to their underdiagnosis and under-treatment (Maurer et al, 2008). Other barriers include:  • The perceived stigma around mental health; • Patients’ unwillingness to engage with mental health services; • A lack of political prioritisation compared with physical healthcare; • Increasing demand for mental health services; • Limited resources (British Medical Association, 2017).  The challenge for all respiratory services is to identify how to improve the psychological care of patients.    [crosshead]Discussion There are significant challenges to implementing respiratory nurse-led CBT for COPD patients with psychological comorbidities, including cost, capacity and training needs. However, the potential benefits of actively screening for comorbid anxiety and depression in clinical settings, and of having dual-skilled respiratory nurses, may mean that barriers to accessing mental healthcare can be more easily overcome; therefore respiratory nurse-led CBT may be a step towards reducing costs and improving patients’ quality of life. The difficulties are identifying how to scale up and roll out this model for the benefit of more patients and ascertaining whether respiratory nurses are willing to meet the challenge.   References Bolton CE et al (2013) British Thoracic Society guidelines on pulmonary rehabilitation in adults. Thorax; 68: 2, 1-30. British Medical Association (2017) Breaking Down Barriers – the Challenge of Improving Mental Health Outcomes.  https://unitementalhealth.files.wordpress.com/2018/02/breaking-down-barriers-mental-health-briefing-apr2017.pdf  Cully JA et al (2017) Brief cognitive behavioural therapy for medically ill patients in primary care: a pragmatic randomised clinical trial. Journal of General Internal Medicine; 32: 9, 1014-1024.  Global Initiative for Chronic Obstructive Lung Disease (2020) Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: 2020 Report.  https://goldcopd.org/wp-content/uploads/2019/11/GOLD-2020-REPORT-ver1.0wms.pdf Heslop-Marshall K et al (2018) Randomised controlled trial of cognitive behavioural therapy in chronic obstructive pulmonary disease. European Respiratory Society Open Research; 4: 4, 00094-2018. Kelly CA et al (2018) Research priorities for respiratory nursing: a UK-wide Delphi study. European Respiratory Journal Open Research; 4: 2, 00003-2018.  Maurer J et al (2008). Anxiety and depression in COPD: current understanding, unanswered questions, and research needs. Chest; 134: 4, 43S-56S. Meng H et al (2020) Analyze the psychological impact of COVID-19 among the elderly population in China and make corresponding suggestions. Psychiatry Research; 289, 112983. National Institute for Health and Care Excellence (2009) Depression in Adults with a Chronic Physical Health problem: Recognition and Management. https://www.nice.org.uk/guidance/cg91/resources/depression-in-adults-with-a-chronic-physical-health-problem-recognition-and-management-pdf-975744316357   National Institute for Health and Care Excellence (2011) Generalised anxiety disorder and panic disorder in adults: management.  https://www.nice.org.uk/guidance/cg113/resources/generalised-anxiety-disorder-and-panic-disorder-in-adults-management-pdf-35109387756997    Newham JJ et al (2017) Features of self-management interventions for people with COPD associated with improved health-related quality of life and reduced emergency department visits: a systematic review and meta-analysis. International Journal of Chronic Obstructive Pulmonary Disease; 12: 1705-1720.  Nursing and Midwifery Council (2019) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates.  https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf  Santini ZI et al (2020) Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): a longitudinal mediation analysis. Lancet Public Health; 5, e62-70.  Tsiligianni I et al (2011) Factors that influence disease-specific quality of life or health status in patients with COPD: a review and meta-analysis of Pearson correlations. Primary Care Respiratory Journal; 20: 3, 257-268.  Usmani ZA et al (2017) Psychological therapies for the treatment of anxiety disorders in chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews; 3, CD010673.  Yohannes AM, Alexopoulos GS (2014) Depression and anxiety in patients with COPD. European Respiratory Journal; 23: 133, 345-349. 

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