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Addressing anxiety & depression in respiratory care. Are we missing a trick?

I had no aspirations to become a nurse until I was 21 when I was accepted for my Enrolled Nurse training. With further studies I qualified as a Registered Nurse in 1987. I worked in a respiratory ward and loved every minute of it. In 1990 I started my long career in the Chest Clinic in Newcastle becoming the first Sister ever to be appointed there. 

I completed various courses and gained a Degree in Nursing in 1997. I completed a dissertation about asthma education for in-patients.

My conclusion was that we needed to keep things simple and patients needed to know what asthma is, what medication to take (and why) and what to do if it doesn’t work.

I think these findings are still valid today.

Realising the importance of anxiety and depression

Over the years I progressed to a Nurse Specialist then Nurse Consultant. I thought it was best to do my MSc. I completed a small piece of qualitative research as part of my MSc in Health Sciences in 1998 and interviewed patients about their experience living with chronic obstructive pulmonary disease (COPD). Breathlessness was identified as a major symptom they had to contend with, but I became acutely aware that symptoms of anxiety and depression were commonly experienced. This was quite a revelation and I was extremely aware that I did not know what I could do to help.

A physiotherapy colleague and I decided to set up our pulmonary rehabilitation (PR) programme and hoped that this would help patients physically and psychologically. Indeed, it did, but unfortunately many patients decline to participate in PR programmes so we can’t rely on this intervention alone.

The course that changed my life

I was approached to participate in a research study to develop psychological skills so volunteered to participate in a foundation course in basic cognitive behavioural therapy skills (CBT) study. CBT is a treatment for addressing psychological difficulties such as anxiety and depression. It helps understand patients’ difficulties and identify their physical symptoms, thoughts, emotions (feelings) and what they do (their behaviours).

The CBT training provided by Dr Kath Mannix was part of a research trial to see if specialist nurses could learn basic CBT skills, use them in everyday practice and make a difference to patients. This course changed my life! I realised that CBT skills enabled me to provide holistic care to patients, addressing their psychological and physical needs. I decided to further enhance my knowledge and skills by completing a post-graduate diploma in CBT.


A steep learning curve to set up my own CBT clinic

The CBT post-graduate course was a steep learning curve for me. I was the only person from the physical health setting and the course was structured for people working in mental health settings. With help from a fantastic Clinical Psychologist supervisor, Dr Chris Baker and colleague psychiatrist called Dr Sanjay Rao, who provided mentorship during my training, I managed to qualify.

My dissertation helped me understand why CBT could be helpful for respiratory patients. The evidence was limited but it seemed to make complete sense to me that CBT would help. Once I qualified as a cognitive behavioural therapist, I set my skills to good use and set up my own CBT Clinic in the Chest Clinic, Newcastle. As I was finding my feet I slowly developed my own model of providing psychological support to patients with respiratory conditions who experienced symptoms of anxiety and depression and I called this ‘The Lung Manual’. Not very original I know but I am not that creative!

"It felt like I'd won the lottery"

Dr Karen Marshall

I am sure my colleagues were unsure about the benefit of CBT but over time my referrals increased. Dr Graham Burns very quickly became a great advocate for screening and treating anxiety and depression in respiratory patients and over time the service became embedded into our service. I had developed the CBT intervention bespoke to respiratory patients and felt having dual skills in respiratory and CBT was an ideal model to provide holistic care.

I was told that ‘people won’t use CBT unless there is a randomised controlled trial (RCT) to prove it works’. Dr Tony De Soyza, a Respiratory Consultant colleague, suggested that I might as well do a PhD to see if CBT works. Really, at my age! Well, after a while I decided he may be right, and I approached our Head of Nursing and Midwifery Research, Dr Debbie Carrick-Sen, who encouraged me apply for funding from the National Institute for Health Research. Amazingly I was successful and was awarded over £200,000 to do my PhD in 2011. It felt like I had won the lottery.

With a fantastic supervisory team, I conducted the RCT, completed my PhD and finally published the results in November 2018. I did struggle to publish it. Editors told me ‘this is not of interest to people working in respiratory medicine’. Most infuriating!  I tried submitting the paper again and it was accepted amid a flurry of press releases and radio interviews, as it had been identified as ‘an important piece of research’. Wow, I still haven’t got over the shock.

Looking back

When I think back on my career I find it quite ironic that mental health is now a very big component of my role. I would never have thought that would be where I would specialise. However, I can see through personal experience and research that providing CBT enhances my skills in so many ways. 

Nurses don’t need to be experts in CBT, but they can learn useful CBT skills to help patients who struggle with breathlessness, anxiety and depression and make a difference to patients psychological well-being and importantly, reduce admissions to hospital. On The Pivotal Foundation Training course nurses can learn how to approach patients with long term health conditions such as COPD, who may feel anxious or depressed and work with them to address these problems using basic CBT skills and techniques.  

"Providing CBT enhances my skills in so many ways"

Dr Karen Marshall

Our challenge

They say that it can be approximately 15 years before research findings finally get implemented into routine clinical care. The challenge now is to convince others that dual physical and psychological skills for front line staff working with long term conditions is the model to improve patient outcomes and I hope this will be incorporated into the NHS Ten Year Plan. If we don’t do it we will certainly be missing a trick!

Dr Karen Heslop-Marshall (PhD) has received an honorarium from GSK for developing this article/content.

PM-GB-CPU-WCNT-190015 - August 2019

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