Toward Holistic COPD Management: The Case for Mental Health Integration

TL;DR

This paper argues for integrating mental health care into COPD management to improve patients' quality of life and overall outcomes.

Contribution

The paper highlights the need for integrated mental health and COPD care and reviews non-pharmacological interventions for psychological distress.

Findings

COPD patients have higher rates of anxiety and depression, which impact their quality of life and healthcare outcomes.

Non-pharmacological interventions like pulmonary rehabilitation and cognitive behavioral therapy show promise in reducing distress.

Telerehabilitation and peer support are effective alternatives to increase access and improve psychological well-being.

Abstract

Chronic obstructive pulmonary disease (COPD) is a growing global public health concern, not only due to its physical effects but also because of the significant psychological distress it causes, including anxiety and depression. This perspective stresses the importance of addressing mental health issues in the management of COPD, discussing current treatment options, which include non‐pharmacological interventions.

This perspective synthesizes current literature on psychological distress in COPD and reviews evidence for non‐pharmacological approaches, including pulmonary rehabilitation, cognitive behavioral therapy, self‐management programs, telerehabilitation, education, and peer support. It draws on recent literature and guidelines to identify gaps and opportunities for integrated care.

Individuals with COPD experience substantially higher rates of anxiety and depression compared to the general population, and this can negatively impact quality of life, disease progression, and healthcare outcomes. Despite this, mental health symptoms often remain undiagnosed and untreated due to limited awareness, training, and resources. Psychological and non‐pharmacological interventions reveal encouraging results in reducing distress and improving overall well‐being. Pulmonary rehabilitation, combined with psychological support, demonstrates particular benefits but is underutilized due to patient and systemic barriers. Alternative approaches such as telerehabilitation and remote therapies offer potential for increased access. Moreover, education and peer support play a crucial role in empowering patients, improving coping skills, and fostering social connectedness, which contribute positively to psychological well‐being. This perspective advocates for integrated COPD management, which prioritizes mental health literacy, collaborative care models, and patient engagement.

Addressing both the physical and psychological aspects of COPD is essential for holistic care and enhancing the quality of life of individuals with COPD. Further research and healthcare policy efforts are needed to close existing gaps and deliver comprehensive support for people living with COPD.

Full text

Introduction

1

Chronic obstructive pulmonary disease (COPD) poses a pressing global public health challenge, with its prevalence steadily increasing worldwide [1, 2]. While the physical toll of COPD is widely acknowledged, yet less is known about the psychological distress. This perspective considers often‐overlooked mental health issues in COPD, and it seeks to raise awareness and advocate for integrated approaches that address both physical and psychological aspects of COPD management. The following sections examine the bidirectional relationship between COPD and psychological distress, review current treatment approaches, and discuss the implications for integrating mental health into comprehensive COPD management.

Bidirectional Relationship Between COPD and Psychological Distress

2

While depression affects 4.4% and anxiety 3.6% of the global population [3], individuals with COPD face a higher burden of these mental health conditions. Their rates of depression and anxiety range from 15.9% to 51% and from 16.2% to 35.4%, respectively, while they have a higher incidence of acute exacerbation, mortality, and morbidity, as well as increased intake of antidepressants and lower quality of life [4, 5, 6, 7].

Because of this clear difference, COPD ought to be regarded as more than just a physical condition; its psychological and social aspects are equally significant [8]. Gonçalves et al. [9] highlight that the experience of advanced COPD elucidates the biopsychosocial model [10], where biological, psychological, and social factors are closely interlinked. Biologically, progressive breathlessness, fatigue, and comorbidities contribute to loss of physical function and independence as well as changes in lifestyle. Psychologically, these symptoms trigger anxiety, panic, and depressive feelings, often reinforcing each other through the “dyspnea–anxiety–dyspnea” cycle. Socially, restrictions in mobility and reliance on oxygen lead to social isolation, loss of roles, and diminished identity. Moreover, recent research has also begun to identify novel biomarkers and underlying pathophysiological mechanisms which may underpin the bidirectional relationship between COPD and poor mental health outcomes [11].

Regrettably, around two‐thirds of people with COPD have untreated depression and anxiety symptoms, despite recommendations for providing psychological support [12, 13]. A contributing factor may be the limited mental health training among healthcare professionals, coupled with insufficient resources to support people with COPD experiencing psychological distress. These barriers can impede timely diagnosis and referral to appropriate interventions [12, 14]. Consequently, neglecting mental health in COPD treatment plans could lead to worsened outcomes and increased healthcare utilization [15].

Treatments for Anxiety and Depression in COPD

3

Non‐pharmacological treatment options for anxiety and depression management for people with COPD have gained attention within the literature. A plethora of approaches has been explored, including cognitive behavioral therapy (CBT), self‐management programs, pulmonary rehabilitation, self‐help groups, telemonitoring, and more extensive disease management programs [16].

Psychological Interventions and Self‐Management Programs

3.1

Individual and group counseling for people with COPD at psychological risk can support positive mental health outcomes and enhance quality of life [17]. Psychological interventions such as CBT have emerged as promising options [18]. Notably, a randomized controlled trial in the United Kingdom demonstrated the effectiveness of CBT, delivered by respiratory nurses, in reducing anxiety symptoms, lowering rates of hospital admissions and emergency department visits among people with COPD [19]. Furthermore, UK clinical guidelines recommend integrating CBT and patient education into self‐management plans of people with COPD [20].

Self‐management programs for people with COPD aim to identify symptoms and equip them and their caregivers with the necessary skills to adhere to medical regimens. These programs seek to support health‐related behavioral, cognitive, and emotional adjustments, empowering patients to effectively manage both the physical and psychological aspects of their condition, assume control over their life roles, adapt to the fluctuating dynamics inherent in the progression of their illness, and ultimately fostering their overall well‐being [21, 22]. Self‐management interventions, alongside symptom treatment, have been evidenced to provide beneficial effects for individuals with COPD, including reductions in depression and anxiety, along with improvements in quality of life and decreased respiratory‐related hospital admissions [23, 24]. Traditionally, self‐management interventions have been primarily related to an approach centered on healthcare professionals providing patients with prepared action plans for disease exacerbations [25]. Educational interventions such as breathing exercises have been shown to optimize respiratory muscle strength and lung function, thereby improving exercise capacity by promoting more efficient breathing patterns and reducing dynamic hyperinflation [26]. These improvements, in turn, positively affect quality of life and reduce subsequent hospitalizations [27]. Likewise, research indicates that education and action plans in isolation limit in‐hospital healthcare utilization and offer efficacy in reducing depression or anxiety [27, 28].

Self‐Help Groups and Peer Support

3.2

Self‐help groups offer another avenue of support for people with COPD. These groups, formed for reciprocal help and peer support, serve as valuable platforms for sharing experiences and providing community connections [29]. Improved perceived social support and associated psychological assets have been recognized as key benefits of participation in self‐help groups for people with COPD [29, 30, 31]. Peer meetings have been reported to provide learning opportunities and encourage patients to expand networks, interact with peers, make friends, have the opportunity for social comparison, and therefore, validate their experience [32]. By fostering mutual encouragement, self‐help groups contribute to a sense of belonging and empowerment among people with COPD, complementing traditional medical interventions with psychosocial support [32].

Pulmonary Rehabilitation

3.3

Pulmonary rehabilitation, incorporating exercise training and education as well as giving opportunities for expanding peer network, helps individuals with COPD to maintain muscular strength and to promote self‐management, ultimately reducing anxiety and depression symptoms [33, 34, 35]. Moreover, combining pulmonary rehabilitation with psychological interventions has been shown to reduce depressive symptoms more effectively than pulmonary rehabilitation alone [36]. However, despite its demonstrated benefits, pulmonary rehabilitation remains underutilized as there is a low uptake of these programs among people with COPD [37]. In fact, a national audit of COPD care in Wales indicated that 16% of people with diagnosed COPD were referred to pulmonary rehabilitation from primary care and that lower odds of referral were attributed to those who were older, female, more deprived, or had comorbid conditions [38]. A subsequent audit covering England and Wales revealed that 66% of the referred individuals completed pulmonary rehabilitation, with various factors such as socioeconomic status, weight, and disease severity influencing completion rates [39]. Other barriers to completion include patients' lack of perceived benefits, particularly in advanced stages of COPD, with patients feeling tired and not expecting to see improvement [40, 41]. Therefore, despite the significant benefits of pulmonary rehabilitation for people with COPD, challenges persist in its uptake and completion.

Recent guidelines and toolkits have made significant advances in addressing barriers to pulmonary rehabilitation. They advocate integrating psychological support within multidisciplinary care, specifying protocols that encompass not only tailored exercise and structured educational components but also targeted modules for screening and managing anxiety and depression, which are often delivered by or in collaboration with mental health professionals [42, 43, 44]. This highlights the critical role of cognitive–behavioral strategies, peer support, and behavior change frameworks in enhancing both referral and completion rates. Moreover, recent research emphasizes that holistic models improve rehabilitation engagement and self‐management by combining physical, psychological, and social interventions [45]. Consequently, contemporary pulmonary rehabilitation recommendations call for systematic incorporation of mental health support to address persistent barriers, facilitating more equitable and effective care for people with COPD.

Building on the recognition of psychological and behavioral components in pulmonary rehabilitation, a recent qualitative study by Hill et al. [46] sheds a degree of light onto ways in which healthcare professionals can be employed to assist these challenges by focusing on the quality of their interactions with patients when recommending pulmonary rehabilitation. Patients were more likely to join pulmonary rehabilitation when healthcare professionals treated them holistically, using empathy, active listening, and trust‐building rather than focusing solely on the disease. Therefore, encouraging patients through clear, personalized communication and sharing success stories may help reduce their fears. According to Hill et al. [46], using simpler language ‐ for example, supported, individualized exercise and self‐care ‐ instead of clinical jargon such as “pulmonary rehabilitation,” may further increase uptake. Consequently, by engaging empathetically and supporting shared decision‐making, healthcare professionals can boost referrals and participation, improving outcomes for people with COPD.

Alternative and Remote Interventions

3.4

Alternative approaches such as telerehabilitation and neuromuscular electrical stimulation, improving exercise capacity, and quality of life and reducing depression, can offer promising options for patients unable or unwilling to engage in traditional pulmonary rehabilitation [47, 48, 49]. Additionally, the inability to leave home has been identified as a barrier to the provision of psychological interventions, suggesting that adapting and offering home visits could be a potential remedy, albeit financial constraints may pose challenges to its implementation [50]. Importantly, the rapid advancement and adoption of telemedicine during the COVID‐19 pandemic have catalyzed the growth of telerehabilitation programs, which offer comparable benefits to face‐to‐face pulmonary rehabilitation in enhancing physical and mental health outcomes [51]. Telehealth pulmonary rehabilitation is an effective and accessible alternative to center‐based programs, providing comparable improvements in exercise capacity, quality of life, and symptom control; however, challenges related to digital literacy, individualized supervision, and sustainability remain [52, 53]. In addition, Bhatt et al. [54] highlight heterogeneity in telehealth delivery models, the necessity for initial in‐person clinical evaluation for safety, and limited data on specific subgroups with severe comorbidities, pointing to areas for further research and optimization.

Conclusion

3.5

This perspective focuses on the importance of understanding the range of treatment options available for individuals with COPD, particularly their impact on psychological distress and quality of life. Moving forward, a concerted initiative to integrate physical and psychological care is essential for comprehensive COPD management. Multidisciplinary teams play a key role in delivering integrated approach that considers both physical and psychological needs. Recognizing that holistic healing encompasses body and mind, more dedicated research, alongside clear implementation strategies and actions, is needed to understand the impact of various treatments on the psychological well‐being and quality of life of people with COPD.

Author Contributions

Conceptualization: B.G., J.L., A.C., C.S., and E.H.‐M. Writing – original draft preparation: B.G. Writing – review and editing: B.G., J.L., A.C., C.S., and E.H.‐M.

Funding

The authors received no specific funding for this work.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author Barbara Gonçalves affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.