Quittner AL, Abbott J, Georgiopoulos AM, et al. International Committee on Mental Health in Cystic Fibrosis: Cystic Fibrosis Foundation and European Cystic Fibrosis Society consensus statements for screening and treating depression and anxiety. Thorax. 2016 Jan;71(1):26-34. doi: 10.1136/thoraxjnl-2015-207488. Epub 2015 Oct 9.
Investigations examining depression and anxiety in individuals with cystic fibrosis and their caregivers indicate elevated symptoms of these mental health issues in this population. To address this concern, a multidisciplinary group of experts convened to develop consensus recommendations for identifying and treating depression and anxiety in the context of CF care. Fifteen guideline recommendations were proposed in the following areas:
- Psychological interventions
- Pharmacological treatments
- Future research
The committee noted that prior to the implementation of a screening program, care pathways and provisions for depression and/or anxiety should be in place.
Purpose and Background
The challenges of managing and living with a chronic medical illness, such as CF, place individuals at higher risk for mental health difficulties. Problems such as depression and anxiety can negatively impact adherence to prescribed treatments, physical health, role functioning, and quality of life. Early identification of depression and anxiety can help individuals obtain appropriate mental health services to prevent symptoms from worsening.
The Cystic Fibrosis Foundation and the European Cystic Fibrosis Society brought together a group of 22 experts in CF to develop specific recommendations to proactively screen, identify, and treat depression and anxiety in individuals with CF.
This International Committee on Mental Health in CF (ICMH) was divided into four workgroups and developed PICO questions to guide literature searches. The final recommendation statements were anonymously voted on by the committee. The statements that were included in the final guidelines reached at least 80 percent agreement.
|Recommendations||Evaluation of the Evidence|
|Provide developmentally appropriate education and preventive interventions for all individuals with CF and their caregivers.||100% consensus|
|For all individuals with CF, offer behavioral interventions to help alleviate distress associated with medical procedures.||100% consensus|
|Recommendations||Evaluation of the Evidence|
|It is recommended that all children with CF who are 7-11 years old be clinically assessed for depression and anxiety when a caregiver reports clinically elevated symptoms of depression or anxiety, or when there is a significant concern for the child exhibiting symptoms of depression or anxiety reported by the child, by his or her caregivers, and/or by a member of the CF care team.||100% consensus|
|Annual screening for depression and anxiety is recommended for all individuals with CF beginning at 12 years of age using the PHQ-9 and GAD-7.||100% consensus|
|Annual depression and anxiety screening is recommended for at least one primary caregiver for all children and adolescents with CF. The following measures can be used and chosen given the staff and resources available within the CF center: PHQ-9 and GAD-7; PHQ-8 and GAD-7; PHQ-2; and GAD-2.||100% consensus|
|Recommendations||Evaluation of the Evidence|
|Treatment for depression and anxiety for individuals with CF and for caregivers should be guided by clinical diagnosis. Elevated screening scores should be reviewed by health care professionals with the appropriate training in behavioral health and further clinical assessment be conducted as needed to recommend appropriate treatment.||100% consensus|
|For all individuals reporting elevated symptoms of depression and/or anxiety, it is recommended that they be referred for treatment to a primary care provider or a mental health provider following the completed assessment with a provider on the CF team.||100% consensus|
|Individuals with CF who report significant depression and/or anxiety should receive clinical intervention that reflects a flexible, stepped model of care that includes the patient, family, CF team, and primary care or mental health professionals. Each CF team should identify an individual with the appropriate mental health training to provide, coordinate, and monitor care.||100% consensus|
|Evidence-based psychological interventions for children with CF who are ages 7-11 are recommended as a first-line treatment for those who have clinically elevated depression or anxiety.||100% consensus|
|For individuals with CF who are 12 years or older and endorse mild symptoms of depression or anxiety, it is recommended that education about depression and/or anxiety be provided, preventive and supportive interventions be delivered, and re-screening take place at the next CF clinic visit.||100% consensus|
|Individuals endorsing moderate symptoms of depression and anxiety who are ages 12 and older should be provided with evidence-based psychological interventions, such as cognitive behavioral therapy (CBT) or interpersonal psychotherapy (IPT) or a referral for these interventions. If this treatment is not available or not effective in alleviating symptoms, psychotropic medication should be a consideration as a next step for treatment.||100% consensus|
|Individuals ages 12 years and older who endorse severe depression should receive a combination of an evidence-based psychological treatment and pharmacological intervention (i.e., antidepressant).||100% consensus|
|For individuals ages 12 years and older who endorse severe anxiety, it is recommended that exposure-based CBT be provided. If exposure-based CBT is not available or not fully effective, it is recommended that antidepressant medication be considered for treatment.||100% consensus|
|For most individuals with CF ages 12 and older who require antidepressant medication for treatment of depression and/or anxiety, the following first-line selective serotonin reuptake inhibitors (SSRIs) are recommended: citalopram, escitalopram, sertraline, and fluoxetine. It is recommended that each individual who is prescribed an antidepressant for treatment of depression and/or anxiety be closely monitored for appropriate dosing, therapeutic effects, and that any adverse effects or drug-drug interactions be promptly identified.||100% consensus|
|When a short-term pharmacological intervention is indicated for treatment of moderate to severe symptoms of anxiety related to medical procedures, and the individual has not shown a positive response to behavioral interventions alone, it is recommended that lorazepam be considered for treatment.||100% consensus|
The ICMH suggests that additional areas of research include the following:
- What are the clinical and psychosocial risk factors for depression and anxiety in individuals with CF and their caregivers?
- How do psychological factors, such as depression and anxiety, affect disease management and outcomes?
- In what ways do psychological and pharmacological interventions affect other outcomes beyond symptoms of depression and anxiety, such as adherence, health, and caregiver functioning?
- Which evidence-based psychological and psychopharmacological interventions treat depression and anxiety optimally in individuals with CF and caregivers?
- How do symptoms of depression and anxiety in individuals with CF impact health care utilization and cost?
- What model(s) of health care service delivery is most effective in treating depression and anxiety in individuals with CF and their caregivers?
Relevant manuscripts published after the original guidelines are listed below. These manuscripts have not been reviewed or endorsed by the guidelines committee.
Below are recent publications that address mental health in individuals with CF:
- Garcia G, Snell C, Sawicki G, Simons LE. Mental health screening of medically-admitted patients with cystic fibrosis. Psychosomatics. 2018 Mar - Apr;59(2):158-168. doi: 10.1016/j.psym.2017.08.010. Epub 2017 Aug 30.
- McKinzie CJ, Goralski JL, Noah TL, Retsch-Bogart GZ, Prieur MB. Worsening anxiety and depression after initiation of lumacaftor/ivacaftor combination therapy in adolescent females with cystic fibrosis. J Cyst Fibros. 2017 Jul;16(4):525-527. doi: 10.1016/j.jcf.2017.05.008. Epub 2017 Jun 8.
- Smith BA, Georgiopoulos AM, Quittner AL (2016). Maintaining mental health and function for the long run in cystic fibrosis. Pediatr Pulmonol. 2016 Oct;51(S44):S71-S78. doi: 10.1002/ppul.23522.
- Talwalkar JS, Koff JL, Hochang BL, Britto CJ, Mulenos AM, Georgiopoulos AM. Cystic fibrosis transmembrane regulator modulators: Implications for the management of depression and anxiety in cystic fibrosis. Psychosomatics. 2017 Jul - Aug;58(4):343-354. doi: 10.1016/j.psym.2017.04.001. Epub 2017 Apr 5.
- Goetz DM, Frederick C, Savant A, et al. Systematic depression and anxiety screening for patients and caregivers: implementation and process improvement in a cystic fibrosis clinic. BMJ Open Qual. 2021 May;10(2):e001333. doi: 10.1136/bmjoq-2020-001333.
Use of These Guidelines
The CF Foundation intends for this executive summary of its guideline to summarize the published guideline. The published guideline summarizes evidence, and provides reasonable clinical recommendations based on that evidence, to clinicians, patients, and other stakeholders. Care decisions regarding individual patients should be made using a combination of these recommendations, the associated benefit-risk assessment of treatment options from the clinical team, the patient's individual and unique circumstances, as well as the goals and preferences of the patients and families that the team serves, as a part of shared decision-making between the patient and clinician.
This executive summary was prepared by:
Jennifer Lindwall, PhD, Emily Muther, PhD, and Alexandra Quittner, PhD
The guidelines were published in January 2016, they were reviewed in July 2021 and it was determined that no update is needed at this time.