Limitations and Future Directions
Data on implementation was generated via self-report by Mental Health
Coordinators at these CF programs. There is always a potential for
self-report data to be biased, given its reliance on the perspectives of
the respondent. However, the perspective of those implementing the
mental health screening protocol was invaluable, and the alternatives,
which included collecting observational data or generating program-level
quality improvement evidence was not feasible at a national level.
Additionally, since patient-level data on screening scores were not
collected for this study, this analysis could not identify the potential
benefits of assessing and treating mental health symptoms on short- or
long-term health outcomes.
This suggests critical directions for future research. First, the impact
of the CF Mental Health Guidelines cannot be precisely measured without
collecting data on CF patient mental health. Currently the CFFPR only
collects data on whether screening occurred but not the results of that
screening. The addition of depression (PHQ-9) and anxiety (GAD-7)
screening scores would provide valuable data on the associations of
mental health with CF outcomes (frequency of hospitalizations,
health-related quality of life, mortality), adherence, and side effects
of medications such as modulators, and would also allow measurement of
the effects of mental health screening and interventions. Complex
questions about the long-term trajectories of depression/anxiety and
their impact could also be addressed. Second, the mental health
guidelines that served to direct this integration of mental health into
CF care, as well as these implementation efforts, may need to be
updated. Given the recent recommendation of the US Preventative Task
Force to implement anxiety screening in preadolescent
children,20-21 a consideration of mental health
screening in this age group of children with CF is timely and
appropriate.22,23 Lastly, elevated rates of depression
and anxiety have been consistently reported in other chronic respiratory
diseases (e.g., non-CF bronchiectasis, primary ciliary dyskinesia,
NTM).3-5 This model of mental health screening and
intervention implemented in CF could serve as a model for the
integration of mental and physical health in other respiratory
conditions.