5. DISCUSSION
At the beginning of the COVID-19 crisis in Italy, rates of depression and anxiety were highly elevated in pwCF (71%) and parents (57% depression, 79% anxiety), with a large proportion scoring in the moderate to severe range. Ratings of stress were also highly elevated during this crisis. Importantly, these rates of psychological symptomatology were much higher during the COVID lockdown, than those obtained during routine CF care prior to COVID [12,27-28]. Twice the number of pwCF scored in the elevated range at baseline assessment in this study than prior published data [12].
Overall, the results of this Telehealth Psychological Support Intervention demonstrated positive effects, significantly reducing symptoms of stress and depression for both pwCF and caregivers. Decreases in ratings of stress and symptoms of depression and anxiety were substantial. For pwCF, 38% reported decreases in depression and 25% in anxiety, leading to a change in severity; for parents 21.4% and 28.6% reported less depression and anxiety, respectively. Two parents made a dramatic improvement, reporting severe symptoms at pre and mild symptoms at post, thus, improving by two categories of severity. This intervention may also have served to prevent a worsening of psychological symptoms. Although substantial decreases in symptomatology were observed, the majority of pwCF and caregivers remained stable within a particular category, with few showing a pattern of increased symptoms.
In considering how many participants achieved a clinically meaningful change in symptomatology, 17-37% of pwCF and 7-13% of parents, respectively. Although the overall results of this telehealth intervention were highly positive, decreases in anxiety did not meet the statistical threshold for significance for either pwCF or parents. Several possible reasons may account for this. First, COVID-19 is a novel coronavirus and there was no information about how this new virus might affect pwCF. Given that CF is a very serious, underlying pulmonary condition, there was considerable fear that pwCF would be more negatively affected than others, and the CF healthcare community did not know if pwCF were uniquely vulnerable. Second, during and after the intervention, people were still living with this crisis every day. Triggers for anxiety were ubiquitous (e.g., news, mortality rates) and the extreme social isolation in Italy may have also raised levels of anxiety. Finally, many people lost their jobs because all services and businesses were closed, and children and adolescents were not able to go to school. The pandemic caused a major economic recession in Italy, as in other parts of the world, and this might have limited reductions in anxiety.
The psychological support intervention was very brief, only 4 sessions, but was highly effective. It utilized basic skills derived from CBT, including relaxation training, cognitive reframing, exercises to increase positive emotions (e.g., music), good sleep hygiene, and physical exercises for home. It was delivered via telehealth with a clinical psychologist, which enabled pwCF and parents to access the intervention easily and efficiently. There were no technical difficulties because it utilized simple technology (videocall) and if necessary, could be conducted by phone.