Psychological screening guidelines
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New Zealand Cystic Fibrosis Guidelines for the Psychological Screening of Young People with Cystic Fibrosis (CF)
- The psychological status of children and parents of children with CF should be reviewed on an annual basis at the time of their annual review and documented accordingly
- Depression and anxiety are the most common mental health disorders affecting children and parents of children with Cystic Fibrosis
- Children with Cystic Fibrosis are also at higher risk of ADHD and learning difficulties. Clinicians should enquire about this on at least an annual basis and refer children with significant symptoms for specialist evaluation3.
- The current evidence base supports targeted annual screening for depression and anxiety in CF patients aged 12 years and above and parents of children aged 0 to 17 years
- Standardised validated questionnaires should be used as screening tools: PHQ-A for depression and GAD-7 for anxiety
- Children and family members identified at risk of mental health disorders should be referred to the local consult liaison psychiatry service (if available) / either the child and adolescent psychiatry team or adult psychiatry service (depending on their age) for further targeted investigation and interventions
- Treatment options are tailored to severity of the issue; in children psychological interventions are usually trialled before pharmacological therapies.
Children and caregivers of children with Cystic Fibrosis (CF) have higher rates of mental health disorders. If not identified and treated in a timely manner this has been shown to lead to poorer outcomes in terms of adherence to complex regimens, decline in lung function and body mass index. This eventually leads to more frequent hospitalisations for the child and increased health care costs. Prevention and screening then treatment of mental health issues has shown to lead to better outcomes and improved quality of life of patients with CF and caregivers.
Studies measuring psychological distress in individuals with CF have found high rates of depression and anxiety, particularly in adolescence (a time of great physical/environmental change and increased susceptibility to stress). Adolescents with CF are also more than two times likely to report elevated depression or anxiety if either parent is affected by these conditions. These are by no means the only mental health issue affecting those with CF but a starting point for screening and treatment to improve outcomes taking into account limitations on nationwide resources regarding psychological services.
Before initiating annual screening CF teams should:
- Identify a clinician with specialised expertise and interest in mental health (within the paediatric team, via the consult liaison psychiatry service or elsewhere).
- Develop educational material that can be easily disseminated to young people and families.
- Develop a list of referral sources within the hospital and surrounding community.
- Integrate psychological screening with existing clinical routines. Adding screening to annual CF reviews and regularly auditing psychosocial wellbeing are good ways of achieving this goal. As young people with CF are also more likely to develop anxiety or depression during an episode of worse physical illness, it may be worth considering screening at the time of admission to hospital for acute medical treatment.
- Identify local processes for dealing with acute risk issues (including suicidal ideation which can be associated with depression).
Given that availability of resources differs nationwide, it is difficult to specify the qualifications and training of team members who will assess and treat mental health issues. Most regions have access to child and adolescent psychiatry services (CAMHS). Auckland, Wellington and Christchurch also have specialist Consult Liaison Teams.
There are many different screening tools for depression and anxiety. These instruments have recently been evaluated by the Consult Liaison Team at Starship Hospital and by the Cystic Fibrosis Society in the United States.1 We recommend routinely using:
- The Patient Health Questionnaire - Adolescent version (PHQ-A)4 to screen for depression in children aged 12 years and above and
- The Generalized Anxiety Disorder - 7 item Scale (GAD-7)5 to screen for anxiety in children aged 12 years and above.
Both instruments are psychometrically reliable and valid, quick, free to use and available in all major languages.
If anxiety or depression is identified using the GAD-7 or PHQ-A, further clinical assessment will be required via the paediatric team, consult liaison team or the local CAMHS. Treatment may involve psychological interventions (such as cognitive behaviour therapy), Serotonin Specific Reuptake Inhibitor (SSRI) medication or other types of therapy. Occasionally, acute mental health assessment and/or hospitalisation may be required. Other causes of low mood or anxiety and co-morbid issues also need to be identified and managed. Specialist psychiatric input is usually required prior to the commencement of medication.
- Quittner AL, Abbot J, Georgiopoulos AM et al. Cystic Fibrosis Foundation and European Cystic Fibrosis Society Consensus Statements for Screening and treating Depression and Anxiety. Thorax 2015
- Goldbeck L, Fidika A, Herle M, Quittner AL. Psychological inteventions for individual with cystic fibrosis and their families. Cochrane Database of Systematic Reviews. 2014. Issue 6
- Cymerknoh M, Tanny T, Blau H, Prevalence and Characteristics of attention deficit hyperactivity disorder (ADHD) in patients with CF. Journal of Cystic Fibrosis 2015
Authors: Hiran Thabrew (Child Psychiatrist & Paediatrician, Starship Consult Liaison Team, Starship Hospital), Jan Tate (CF Nurse Specialist, Starship Hospital) Prerna Sehgal (Registrar, Starship Consult Liaison Team, Starship Hospital)
Date last reviewed: March 2019
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