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.