"The experience of breathlessness can be distressing and difficult to understand and control. Psychological factors can create a vicious circle, with escalating breathlessness, physiological arousal and panic."

"There is evidence of disproportionately higher prevalence rates of generalised anxiety disorder, panic and depression. The rate of common mental health disorders is some three times greater than in the general population. The presence of psychological distress and mental health disorder results in restricted mobility, loss of energy, creates greater dependence on others, decreased levels of self-efficacy, less effective self-management of respiratory symptoms, and longer hospital stays."

Integrating psychological therapies into COPD care (and probably some other respiratory services) can

• Reduce anxiety and depression (which can drive demand for urgent care services)
• Reduce apprehension about exercise programmes and build confidence so that programmes such as pulmonary rehabilitation are taken up better and therefore have better outcomes
• Improve care of people with COPD by enabling more staff to support patients to cope with symptoms such as breathlessness

So says the latest Kings Fund report Long-term conditions and mental health: the cost of co-morbidities. 

The report gives case studies each of which shows the cost-benefit and value of integrating psychological support into COPD care programmes.  As well as the Hillingdon study, first reported in the DH guide to the IAPT programme (Improving Access to Psychological Therapies), there are reports from other parts of London, Bradford, Berkshire East and Lancashire.

The case for staff being trained in cognitive behavioural therapy  (CBT) is well made.  Perhaps very brief stop smoking support training and CBT training should be core skills for all those caring for people with COPD?

Perhaps we need to focus as much on integrating interventions for mind and body as vertical integration of services between primary and secondary care?

And then there's the case for addressing the needs of people receiving care from mental health services who are also at risk of, or have, chronic lung disease.  In London work is starting using a CQUIN for stop smoking in mental health trusts.   The case for the CQUIN explains the challenge clearly:

One of the key objectives of the Government’s mental health outcomes strategy is that more people with mental health problems will have good physical health and that fewer people with mental health problems will die prematurely, and more people with physical ill health will have better mental health[1]. The public health outcomes framework published in 2011 identified smoking cessation in mental health populations as an important public health intervention[2], while reduction in premature mortality amongst people with a severe mental illness is also a key objective in the public health outcomes framework, for 2013-2016[3].

As indicated in the mental health outcomes strategy, increased smoking is responsible for most of the excess mortality of people with severe mental health problems. Adults with mental health problems, including those who misuse alcohol or drugs, smoke 42% of all the tobacco used in England. Many wish to stop smoking, and can do so with appropriate support. Over 40% of children who smoke have conduct and emotional disorders. This is particularly important as most smoking starts before adulthood. People with mental health problems need good access to services aimed at improving health (for example, stop smoking services).

The CQUIN focuses on three evidence-based actions:

• Staff training
• Recording of smoking status
• Care planning for smoking cessation.

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And two more papers from end of 2012:

How Mental Illness Loses Out in the NHS by the London School of Economics

Investing in emotional and psychological wellbeing for patients with long-term conditions

by the NHS Confederation mental health network.

[1] HM Government (2011) No Health Without Mental Health: A cross government mental health outcomes strategy for people of all ages, available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124058.pdf

[2] Department of Health (2011) Healthy Lives, Healthy People: Transparency in Outcomes, proposals for a public health outcomes framework

[3] Department of Health (2012) Healthy lives, healthy people: Improving outcomes and supporting transparency, available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132358