INTRODUCTION
A growing body of evidence indicates that individuals with chronic
respiratory conditions, such as cystic fibrosis (CF), primary ciliary
dyskinesia (PCD), non-CF bronchiectasis, non-tuberculous mycobacteria
(NTM), and chronic obstructive pulmonary disease (COPD) have elevated
rates of depression and anxiety in comparison to community
samples.1-5 In addition, these psychological symptoms
have been linked to worse health outcomes, such as increased
inflammation, more frequent exacerbations and earlier
mortality.6 Additionally, they are associated with
worse adherence to prescribed treatments, worse health-related quality
of life and increased hospitalizations and healthcare
utilization.3,7-8 Thus, optimal health and functioning
require consideration of both mental and physical health. This study
focused on the integration of mental health screening and treatment into
the specialized care of individuals with CF, and measured its success in
a national cohort of CF programs.
In the largest mental health screening study conducted to date in a
chronic respiratory condition, over 6,000 people with CF (pwCF) and
4,200 caregivers were screened for depression and anxiety in 9 countries
(TIDES).1 This study showed that rates of depression
and anxiety were 2-3 times higher in this population than community
samples. Subsequent studies in the US and Europe have confirmed these
results, documenting clinical elevations in 30-45% of pwCF and
caregivers .2-5,9-10These findings led to the
development of international guidelines sponsored by the Cystic Fibrosis
Foundation (CFF) and the European Cystic Fibrosis Society (ECFS), which
recommended annual screening of adolescents and adults with CF for
symptoms of depression and anxiety, with follow-up treatment for those
scoring in the elevated range.12 These mental health
guidelines have been widely disseminated and adopted in the US and
Europe.13-14 This model of integrated care in CF could
promote facilitation of mental health screening and treatment in other
chronic respiratory conditions.
Although the development and publication of evidence-based guidelines
has been responsible for major advancements in medicine for the past 50
years,15 implementation of new clinical practices have
been relatively slow and inconsistent,16 with studies
showing it can take years for these practices to be adopted. To
facilitate implementation of the mental health guidelines, the CFF
launched a national competitive grant process to fund a Mental Health
Coordinator (MHC) at CF programs for 3 years and also sponsored an
international Mental Health Advisory Committee (MHAC), a
multidisciplinary committee consisting of healthcare professionals
representing multiple disciplines (psychology, psychiatry, social work,
pulmonology, nursing), CFF staff and members of the CF community.
Implementation of the mental health guidelines was accompanied by
intensive efforts to develop educational and training materials for
pwCF,17 families and healthcare providers, and to
disseminate continuing education programs to increase mental health
expertise among CF care team members (available at cff.org or
mentalhealth@cff.org).
The success of this implementation effort was evaluated, in its first
year, using the Consolidated Framework for Implementation Research
(CFIR) to identify the essential barriers and facilitators of mental
health screening and treatment.17 CFIR is considered
the “gold standard” for assessing implementation of new guidelines,
and measures key stakeholders’ perceptions of the primary barriers and
facilitators of implementation success. The central objective of this
study was to evaluate the longitudinal success of these implementation
efforts for 3 separate cohorts of CF programs over a period of 3 years.
The first aim was to identify the major barriers to implementation as
well as the successes that resulted from implementation of systematic
mental health screening and treatment. The second objective was to
evaluate the success of implementation in these cohorts over time. The
final aim was to identify predictors of implementation success,
including CF program characteristics (e.g., center size, pediatric
versus adult), and years of experience on a CF team.