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.