Anxiety and Depression in Cystic Fibrosis

ABSTRACT

Symptoms of anxiety and depression have important consequences for patients with chronic disease, including lower rates of adherence and increased morbidity. This review discusses the prevalence of anxiety and depression in patients with cystic fibrosis (CF) across the life span and highlights current understanding of how these symptoms affect adherence, health outcomes, and health-related quality of life (HRQOL). Anxiety and depression appear to be more common in patients with CF than in the general population. Recent studies also indicate that symptoms of anxiety occur more frequently than depression in this population. Both anxiety and depression have been shown to be associated with poorer disease outcomes, including HRQOL. Depression, specifically, leads to lower adherence to recommended therapies. Given the prevalence and impact of anxiety and depression in CF, it seems appropriate to recommend annual screening using a validated approach, with referral for either pharmacotherapy or cognitive behavioral therapy of those with apparent symptoms. A large-scale epidemiological study of anxiety and depression in CF is under way and should provide better prevalence estimates and more information on the effects of these psychological symptoms.

Cystic fibrosis - anxiety - depression - psychological interventions - adherence

REFERENCES

• 1 Wells K B, Golding J M, Burnam M A. Chronic medical conditions in a sample of the general population with anxiety, affective, and substance use disorders.  Am J Psychiatry. 1989;  146 1440-1446
• 2 Herrmann C. International experiences with the Hospital Anxiety and Depression Scale: a review of validation data and clinical results.  J Psychosom Res. 1997;  42 17-41
• 3 Riolo S A, Nguyen T A, Greden J F, King C A. Prevalence of depression by race/ethnicity: findings from the National Health and Nutrition Examination Survey III.  Am J Public Health. 2005;  95 998-1000
• 4 Roy-Byrne P P, Davidson K W, Kessler R C et al.. Anxiety disorders and comorbid medical illness.  Gen Hosp Psychiatry. 2008;  30 208-225
• 5 DiMatteo M R, Lepper H S, Croghan T W. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence.  Arch Intern Med. 2000;  160 2101-2107
• 6 Gorman J M. Comorbid depression and anxiety spectrum disorders.  Depress Anxiety. 1996-1997;  4 160-168
• 7 Katon W, Ciechanowski P. Impact of major depression on chronic medical illness.  J Psychosom Res. 2002;  53 859-863
• 8 Sherbourne C D, Wells K B, Meredith L S, Jackson C A, Camp P. Comorbid anxiety disorder and the functioning and well-being of chronically ill patients of general medical providers.  Arch Gen Psychiatry. 1996;  53 889-895
• 9 Dowson C A, Kuijer R G, Mulder R T. Anxiety and self-management behavior in chronic obstructive pulmonary disease: what has been learned?.  Chron Respir Dis. 2004;  1 213-220
• 10 Whittemore R, Kanner S, Singleton S, Hamrin V, Chiu J, Grey M. Correlates of depressive symptoms in adolescents with type 1 diabetes.  Pediatr Diabetes. 2002;  3 135-143
• 11 Cystic Fibrosis Foundation .Patient Registry 2006 Annual Report. Bethesda, MD; Cystic Fibrosis Foundation 2008
• 12 Quittner A L, Barker D H, Marciel K K, Grimley M E. Cystic fibrosis: a model for drug discovery and patient care. In: Roberts MC, Steele RG Handbook of Pediatric Psychology. New York, NY; Guilford Press 2009: 271-286
• 13 Quittner A L, Barker D H, Snell C, Grimley M E, Marciel K, Cruz I. Prevalence and impact of depression in cystic fibrosis.  Curr Opin Pulm Med. 2008;  14 582-588
• 14 American Psychiatric Association .Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text rev. Washington, DC; American Psychiatric Association 2000
• 15 Chorpita B F, Daleiden E L, Moffitt C, Yim L, Umemoto L A. Assessment of tripartite factors of emotion in children and adolescents, I: Structural validity and normative data of an affect and arousal scale.  J Psychopathol Behav Assess. 2000;  22 141-160
• 16 Daleiden E, Chorpita B F, Lu W. Assessment of tripartite factors of emotion in children and adolescents: II. Concurrent validity of the affect and arousal scales for children.  J Psychopathol Behav Assess. 2000;  22 161-182
• 17 Weems C F, Costa N M, Watts S E, Taylor L K, Cannon M F. Cognitive errors, anxiety sensitivity, and anxiety control beliefs: their unique and specific associations with childhood anxiety symptoms.  Behav Modif. 2007;  31 174-201
• 18 Weems C F, Silverman W K, Rapee R R, Pina A A. The role of control in childhood anxiety disorders.  Cognit Ther Res. 2003;  27 557-568
• 19 Ollendick T H. Reliability and validity of the Revised Fear Survey Schedule for Children (FSSC-R).  Behav Res Ther. 1983;  21 685-692
• 20 Burnham J J, Gullone E. The Fear Survey Schedule for Children, II: A psychometric investigation with American data.  Behav Res Ther. 1997;  35 165-173
• 21 Zigmond A S, Snaith R P. The hospital anxiety and depression scale.  Acta Psychiatr Scand. 1983;  67 361-370
• 22 March J S, Parker J DA, Sullivan K, Stallings P, Conners C K. The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity.  J Am Acad Child Adolesc Psychiatry. 1997;  36 554-565
• 23 March J S, Sullivan K, James P. Test–retest reliability of the multidimensional anxiety scale for children.  J Anxiety Disord. 1999;  13 349-358
• 24 Chorpita B F, Tracey S A, Brown T A, Collica T J, Barlow D H. Assessment of worry in children and adolescents: an adaptation of the Penn State Worry Questionnaire.  Behav Res Ther. 1997;  35 569-581
• 25 Chorpita B F, Moffitt C E, Gray J. Psychometric properties of the Revised Child Anxiety and Depression Scale in a clinical sample.  Behav Res Ther. 2005;  43s 309-322
• 26 Chorpita B F, Yim L, Moffitt C, Umemoto L A, Francis S E. Assessment of symptoms of DSM-IV anxiety and depression in children: a revised child anxiety and depression scale.  Behav Res Ther. 2000;  38 835-855
• 27 Reynolds C R, Richmond B O. Revised Children's Manifest Anxiety Scale: Manual. Los Angeles; Western Psychological Services 1985
• 28 Birmaher B, Khetarpal S, Brent D A et al.. The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics.  J Am Acad Child Adolesc Psychiatry. 1997;  36 545-553
• 29 Spence S H. A measure of anxiety symptoms among children.  Behav Res Ther. 1998;  36 545-566
• 30 Spielberger C D. Manual for the State-Trait Anxiety Inventory for Children. Palo Alto; Consulting Psychologists Press 1973
• 31 Lowe P A. Common and Uncommon Manifestations of Anxiety across the Life Span. Ph.D. diss. College Station; Texas A&M University 2000
• 32 Reynolds C R, Richmond B O, Lowe P A. The Adult Manifest Anxiety Scale: Manual. Los Angeles; Western Psychological Services 2003
• 33 Fydrich T, Dowdall D, Chambless D L. Reliability and validity of the Beck Anxiety Inventory.  J Anxiety Disord. 1992;  6 55-61
• 34 Osman A, Kopper B A, Barrios F X, Osman J R, Wade T. The Beck Anxiety Inventory: reexamination of factor structure and psychometric properties.  J Clin Psychol. 1997;  53 7-14
• 35 Van Zuuren F J. The fear questionnaire: some data on validity, reliability and layout.  Br J Psychiatry. 1988;  153 659-662
• 36 Reynolds W M. Multidimensional Anxiety Questionnaire. Lutz, FL; Psychological Assessment Resources, Inc. 2003
• 37 Meyer T J, Miller M L, Metzger R L, Borkovec T D. Development and validation of the Penn State worry questionnaire.  Behav Res Ther. 1990;  28 487-495
• 38 Barnes L LB, Harp D, Jung W S. Reliability generalization of scores on the Spielberger State-Trait Anxiety Inventory.  Educ Psychol Meas. 2002;  62 603-618
• 39 Spielberger C D, Gorsuch R L, Lushene R E. Manual for the State-Trait Anxiety Inventory. Palo Alto; Consulting Psychologists Press 1970
• 40 Holmbeck G N, Thill A W, Bachanas P et al.. Evidence-based assessment in pediatric psychology: Measures of psychosocial adjustment and psychopathology.  J Pediatr Psychol. 2008;  33 958-980 discussion 981-982
• 41 Silverman W K, Ollendick T H. Evidence-based assessment of anxiety and its disorders in children and adolescents.  J Clin Child Adolesc Psychol. 2005;  34 380-411
• 42 Costello E J, Egger H, Angold A. 10-year research update review: The epidemiology of child and adolescent psychiatric disorders, I: Methods and public health burden.  J Am Acad Child Adolesc Psychiatry. 2005;  44 972-986
• 43 Southam-Gerow M A, Chorpita B F. Anxiety in children and adolescents. In: Mash EJ, Barkley RA Assessment of Childhood Disorders. New York; Guilford Press 2007: 347-397
• 44 Costello E J, Costello A J, Edelbrock C et al.. Psychiatric disorders in pediatric primary care: prevalence and risk factors.  Arch Gen Psychiatry. 1988;  45 1107-1116
• 45 Cartwright-Hatton S, McNicol K, Doubleday E. Anxiety in a neglected population: prevalence of anxiety disorders in pre-adolescent children.  Clin Psychol Rev. 2006;  26 817-833
• 46 Dantzer C, Swendsen J, Maurice-Tison S, Salamon R. Anxiety and depression in juvenile diabetes: a critical review.  Clin Psychol Rev. 2003;  23 787-800
• 47 Szajnberg N, Krall V, Davis P, Treem W, Hyams J. Psychopathology and relationship measures in children with inflammatory bowel disease and their parents.  Child Psychiatry Hum Dev. 1993;  23 215-232
• 48 Albano A M, Chorpita B F, Barlow D H. Childhood anxiety disorders. In: Mash EJ, Barkley RA Child Psychopathology. New York; Guilford 2003: 279-329
• 49 Essau C A, Conradt J, Petermann F. Frequency, comorbidity, and psychosocial impairment of specific phobia in adolescents.  J Clin Child Psychol. 2000;  29 221-231
• 50 Piacentini J, Graae F. Childhood OCD. In: Hollander E, Stein D Obsessive-Compulsive Disorders: Etiology, Treatment. New York; Marcel Dekker 1997: 23-46
• 51 Goodwin R D, Gotlib I H. Panic attacks and psychopathology among youth.  Acta Psychiatr Scand. 2004;  109 216-221
• 52 Burke P, Meyer V, Kocoshis S et al.. Depression and anxiety in pediatric inflammatory bowel disease and cystic fibrosis.  J Am Acad Child Adolesc Psychiatry. 1989;  28 948-951
• 53 Casier A, Goubert L, Huse D et al.. The role of acceptance in psychological functioning in adolescents with cystic fibrosis: a preliminary study.  Psychol Health. 2008;  23 629-638
• 54 Cepuch G, Debska G, Wordliczek J, Mazurek H. Evaluation of anxiety and depression incidence in adolescents with cystic fibrosis or malignant disease.  Advances in Palliative Medicine. 2007;  6 75-82
• 55 Pumariega A J, Pearson D A, Seilheimer D K. Family and childhood adjustment in cystic fibrosis.  J Child Fam Stud. 1993;  2 109-118
• 56 White T, Miller J, Smith G L, McMahon W M. Adherence and psychopathology in children and adolescents with cystic fibrosis.  Eur Child Adolesc Psychiatry. 2009;  18 96-104
• 57 Hodges K, Kline J, Stern L, Cytryn L, McKnew D. The development of a child assessment interview for research and clinical use.  J Abnorm Child Psychol. 1982;  10 173-189
• 58 Thompson Jr R J, Gustafson K E, Gil K M, Godfrey J, Murphy L M. Illness specific patterns of psychological adjustment and cognitive adaptational processes in children with cystic fibrosis and sickle cell disease.  J Clin Psychol. 1998;  54 121-128
• 59 Besier T, Quittner A L, Goldbeck L. Symptoms of anxiety and depression, pulmonary function and their association with life satisfaction in patients with cystic fibrosis [abstract].  J Cyst Fibros. 2008;  S7 107
• 60 Goldbeck L, Quittner A L, Besier T. Anxiety and depression in dyads of adolescents with CF and their caregivers [abstract].  J Cyst Fibros. 2008;  S7 107
• 61 Bregnballe V, Thastum M, Schiøtz P O. Psychosocial problems in children with cystic fibrosis.  Acta Paediatr. 2007;  96 58-61
• 62 Howland R H, Thase M E. Comorbid depression and anxiety: when and how to treat.  Journal of Psychiatry. 2005;  329 891-1047
• 63 Kroenke K, Spitzer R L, Williams J BW, Monahan P O, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection.  Ann Intern Med. 2007;  146 317-325
• 64 Chapman E, Bilton D. Patients’ knowledge of cystic fibrosis: genetic determinism and implications for treatment.  J Genet Couns. 2004;  13 369-385
• 65 Delelis G, Christophe V, Leroy S, Vanneste J, Wallaert B. The effects of cystic fibrosis on couples: marital satisfaction, emotions, and coping strategies.  Scand J Psychol. 2008;  49 583-589
• 66 Pearson D A, Pumariega A J, Seilheimer D K. The development of psychiatric symptomatology in patients with cystic fibrosis.  J Am Acad Child Adolesc Psychiatry. 1991;  30 290-297
• 67 Anderson D L, Flume P A, Hardy K K. Psychological functioning of adults with cystic fibrosis.  Chest. 2001;  119 1079-1084
• 68 Havermans T, Colpaert K, Dupont L J. Quality of life in patients with cystic Fibrosis: association with anxiety and depression.  J Cyst Fibros. 2008;  7 581-584
• 69 Birmaher B, Ryan N D, Williamson D E. Depression in children and adolescents: clinical features and pathogenesis. In: Shulman KI, Tohen M, Kutcher SP Mood Disorders across the Life Span. New York; Wiley-Liss 1996: 51-81
• 70 Birmaher B, Ryan N D, Williamson D E et al.. Childhood and adolescent depression: a review of the past 10 years. Part I.  J Am Acad Child Adolesc Psychiatry. 1996;  35 1427-1439
• 71 Costello E J, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and adolescence.  Arch Gen Psychiatry. 2003;  60 837-844
• 72 Shaffer D, Fisher P, Dulcan M K et al.. The NIMH Diagnostic Interview Schedule for Children version 2.3 (DISC-2.3): description, acceptability, prevalence rates and performance in the MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study.  J Am Acad Child Adolesc Psychiatry. 1996;  35 865-877
• 73 Substance Abuse and Mental Health Services Administration .Results from the 2004 National Survey on Drug Use and Health: National Findings. NSDUH Series H-28 Rockville, MD; Office of Applied Studies 2005
• 74 Burke P, Elliott M. Depression in pediatric chronic illness: a diathesis-stress model.  Psychosomatics. 1999;  40 5-17
• 75 Smith B A, Modi A C, Quittner A L, Wood B L. Co-morbidity of depression and cystic fibrosis in children and adolescents: associations with adherence to medical treatment. Under review
• 76 Egede L E. Major depression in individuals with chronic medical disorders: prevalence, correlates and association with health resource utilization, lost productivity and functional disability.  Gen Hosp Psychiatry. 2007;  29 409-416
• 77 Evans D L, Charney D S, Lewis L et al.. Mood disorders in the medically ill: scientific review and recommendations.  Biol Psychiatry. 2005;  58 175-189
• 78 Kessler R C, Nelson C B, McGonagle K A, Liu J, Swartz M, Blazer D G. Comorbidity of DSM-III-R major depressive disorder in the general population: results from the US National Comorbidity Survey.  Br J Psychiatry Suppl. 1996;  17-30
• 79 Hirschfeld R MA. The comorbidity of major depression and anxiety disorders: Recognition and management in primary care.  Prim Care Companion J Clin Psychiatry. 2001;  3 244-254
• 80 Löwe B, Spitzer R L, Williams J BW, Mussell M, Schellberg D, Kroenke K. Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment.  Gen Hosp Psychiatry. 2008;  30 191-199
• 81 Schechter M S. Non-genetic influences on cystic fibrosis lung disease: the role of sociodemographic characteristics, environmental exposures, and healthcare interventions.  Semin Respir Crit Care Med. 2003;  24 639-652
• 82 Katon W, Lin E H, Kroenke K. The association of depression and anxiety with medical symptom burden in patients with chronic medical illness.  Gen Hosp Psychiatry. 2007;  29 147-155
• 83 James A, Soler A, Weatherall R. Cognitive behavioural therapy for anxiety disorders in children and adolescents.  Cochrane Database Syst Rev. 2005;  4 CD004690
• 84 Riekert K A, Bartlett S J, Boyle M P, Krishnan J A, Rand C S. The association between depression, lung function, and health-related quality of life among adults with cystic fibrosis.  Chest. 2007;  132 231-237
• 85 Greer J A, Pirl W F, Park E R, Lynch T J, Temel J S. Behavioral and psychological predictors of chemotherapy adherence in patients with advanced non-small cell lung cancer.  J Psychosom Res. 2008;  65 549-552
• 86 Luyster F S, Hughes J W, Gunstad J. Depression and anxiety symptoms are associated with reduced dietary adherence in heart failure patients treated with an implantable cardioverter defibrillator.  J Cardiovasc Nurs. 2009;  24 10-17
• 87 Minkovitz C S, Strobino D, Scharfstein D et al.. Maternal depressive symptoms and children's receipt of health care in the first 3 years of life.  Pediatrics. 2005;  115 306-314
• 88 Smith B A, Wood B L. Psychological factors affecting disease activity in children and adolescents with cystic fibrosis: medical adherence as a mediator.  Curr Opin Pediatr. 2007;  19 553-558
• 89 Sredl D, Werner T, Springhart D, Watkins D, Shaner M, McBride G. An evidence-based pilot study exploring relationships between psychologic and physiologic factors in post-lung-transplant adolescents with cystic fibrosis.  J Pediatr Nurs. 2003;  18 216-220
• 90 Quittner A L, Barker D H, Geller D et al.. Effects of maternal depression on electronically monitored enzyme adherence and changes in weight for children with CF [abstract].  J Cyst Fibros. 2007;  S6 77
• 91 Cully J A, Graham D P, Stanley M A et al.. Quality of life in patients with chronic obstructive pulmonary disease and comorbid anxiety or depression.  Psychosomatics. 2006;  47 312-319
• 92 Quittner A L, Buu A, Messer M A, Modi A C, Watrous M. Development and validation of The Cystic Fibrosis Questionnaire in the United States: a health-related quality-of-life measure for cystic fibrosis.  Chest. 2005;  128 2347-2354
• 93 Cipriani A, Brambilla P, Furukawa T et al.. Fluoxetine versus other types of pharmacotherapy for depression.  Cochrane Database Syst Rev. 2005;  4 CD004185
• 94 Pampallona S, Bollini P, Tibaldi G, Kupelnick B, Munizza C. Combined pharmacotherapy and psychological treatment for depression: a systematic review.  Arch Gen Psychiatry. 2004;  61 714-719
• 95 Kirkwood C K, Hayes P E. Anxiety disorders. In: Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM Pharmocotherapy: A Pathophysiologic Approach. Stamford; Appleton & Lange 2005: 1443-1462
• 96 Sykes R, Kittel F, Marcus M, Tarter E, Schroth M. Mirtazapine for appetite stimulation in children with cystic fibrosis [abstract].  Pediatr Pulmonol. 2006;  S40 389
• 97 Bostic J Q, Rubin D H, Prince J, Schlozman S. Treatment of depression in children and adolescents.  J Psychiatr Pract. 2005;  11 141-154
• 98 US Food and Drug Administration .Worsening depression and suicidality in patients treated with antidepressant medications. 2004. Available at: http://www.fda.gov/cder/drug/antidepressants/AntidepressanstPHA.htm (Accessed May 22, 2008)
• 99 Deshauer D, Moher D, Fergusson D, Moher E, Sampson M, Grimshaw J. Selective serotonin reuptake inhibitors for unipolar depression: a systematic review of classic long-term randomized controlled trials.  CMAJ. 2008;  178 1293-1301
• 100 de Maat S M, Dekker J, Schoevers R A, de Jonghe F. Relative efficacy of psychotherapy and combined therapy in the treatment of depression: a meta-analysis.  Eur Psychiatry. 2007;  22 1-8
• 101 Beck A T, Rush A J, Shaw B F, Emery G. Cognitive Therapy of Depression. New York; Guilford Press 1979
• 102 Clark D M, Fairburn C G. Science and Practice of Cognitive Behaviour Therapy. New York; Oxford University Press 2005
• 103 Kapornai K, Vetró A. Depression in children.  Curr Opin Psychiatry. 2008;  21 1-7
• 104 Weisz J R, McCarty C A, Valeri S M. Effects of psychotherapy for depression in children and adolescents: a meta-analysis.  Psychol Bull. 2006;  132 132-149
• 105 Cuijpers P, van Straten A, Warmerdam L. Behavioral activation treatments of depression: a meta-analysis.  Clin Psychol Rev. 2007;  27 318-326
• 106 Duff A JA. Psychological interventions in cystic fibrosis and asthma.  Paediatr Respir Rev. 2001;  2 350-357
• 107 Caron A, Weissman M M. Interpersonal psychotherapy in the treatment of depression in medical patients.  Prim Psychiatry. 2006;  13 43-50
• 108 Kilbourne A M, Daugherty B, Pincus H A. What do general medical guidelines say about depression care? Depression treatment recommendations in general medical practice guidelines.  Curr Opin Psychiatry. 2007;  20 626-631
• 109 Glasscoe C A, Quittner A L. Psychological interventions for people with cystic fibrosis and their families.  Cochrane Database Syst Rev. 2008;  3 CD003148
• 110 US Preventive Services Task Force . Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force Recommendation Statement.  Pediatrics. 2009;  123 1223-1228