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\begin{document}

\title{National integration of mental health screening and treatment into
specialized care for cystic fibrosis: What predicts success?}



\author[1]{Alexandra L. Quittner}%
\author[2]{David Barker}%
\author[3]{Sonia Graziano}%
\author[4]{Anna Georgiopoulos}%
\author[5]{Emily Muther}%
\author[6]{Marieke Verkleij}%
\author[7]{Michael S. Schechter}%
\author[8]{Laura Tillman}%
\author[9]{Amy Mueller}%
\author[10]{Paula Lomas}%
\author[10]{Sarah Hempstead}%
\author[11]{Beth Smith}%
\affil[1]{Pulmonary and Sleep of Tampa Bay Inc}%
\affil[2]{Brown University}%
\affil[3]{Bambino Gesù Children’s Hospital IRCCS}%
\affil[4]{Massachusetts General Hospital Department of Psychiatry}%
\affil[5]{University of Colorado Hospital}%
\affil[6]{University of Amsterdam}%
\affil[7]{Children's Hospital of Richmond at Virginia Commonwealth University}%
\affil[8]{Community Member}%
\affil[9]{Hartford Hospital}%
\affil[10]{Cystic Fibrosis Foundation Therapeutics Inc}%
\affil[11]{University at Buffalo Department of Psychiatry}%


\vspace{-1em}



  
  \date{May 20, 2024}


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\selectlanguage{english}
\begin{abstract}
\textbf{Objectives:} The CF Foundation sponsored competitive awards for
Mental Health Coordinators (MHCs) from 2016-2018 to implement the
international guidelines for mental health screening and treatment in US
CF centers. Longitudinal surveys evaluated success in implementing these
guidelines using the Consolidated Framework for Implementation Research
(CFIR). \textbf{Methods:} MHCs completed annual surveys assessing
implementation from Preparation/Basic Implementation (e.g., using
recommended screeners) to Full Implementation/Sustainability (e.g.,
providing evidence-based treatments). Points were assigned to questions
through consensus, with higher scores assigned to more complex tasks.
Linear regression and mixed effects models were used to: 1) examine
differences in centers and MHC characteristics, 2) identify predictors
of success, 3) model the longitudinal trajectory of implementation
scores. \textbf{Results:} 122 MHCs (88.4\% responded): Cohort 1
\emph{N}=80, Cohort 2 N=30, Cohort 3 \emph{N}=12. No differences in
center characteristics were found. Significant improvements in
implementation were observed across centers over time. Years of
experience on a CF team was the only significant predictor of success;
those with 1-5 years or longer reported the highest implementation
scores. Change over time was predicted by \textgreater{}5 years of
experience. \textbf{Conclusions:} Implementation of the mental health
guidelines was highly successful over time. Funding for MHCs with
dedicated time was critical. Longitudinal modeling indicated that CF
centers with diverse characteristics could implement them, supported by
evidence from the CF Patient Registry showing nearly universal uptake of
mental health screening in the US. Years of experience predicted better
implementation, suggesting that education and training of MHCs and
retention of experienced providers are critical to success.%
\end{abstract}%



\sloppy


\textbf{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.\textsuperscript{1-5} In addition, these psychological symptoms
have been linked to worse health outcomes, such as increased
inflammation, more frequent exacerbations and earlier
mortality.\textsuperscript{6} Additionally, they are associated with
worse adherence to prescribed treatments, worse health-related quality
of life and increased hospitalizations and healthcare
utilization.\textsuperscript{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).\textsuperscript{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 .\textsuperscript{2-5,9-10}These 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.\textsuperscript{12} These mental health
guidelines have been widely disseminated and adopted in the US and
Europe.\textsuperscript{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,\textsuperscript{15} implementation of new clinical practices have
been relatively slow and inconsistent,\textsuperscript{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,\textsuperscript{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.\textsuperscript{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.

\textbf{METHODS}

From 2016 through 2018, the CF Foundation sponsored competitive awards
for grants to fund a MHC to implement the international mental health
guidelines in US CF programs.\textsuperscript{17} Three cohorts were
funded, each for 3 years: Cohort 1 N =84, Cohort 2 N = 36, Cohort 3
N=18. Survey data was collected to evaluate the success of each program
in implementing the Mental Health Guidelines. Additionally, respondents
rank ordered barriers and facilitators of implementation and long-term
success.

\textbf{Participants and procedure}

The CFF distributed the survey (via SurveyMonkey) to the first 84 CF
pediatric and adult programs that received the award in the fall of 2016
and subsequently each fall for the next 2 years. As additional CF
programs received funding (Cohort 2, N = 36; Cohort 3, N = 18) they were
included in this distribution as well. Surveys were sent to the grant
Principal Investigator (typically the CF Program Director) and MHC, with
instructions requesting that the MHC complete the survey questions. Data
was collected from September 2016-December 2016, September 2017-May
2018, and October 2018-December 2018.

\textbf{Measures}

Survey questions were developed by members of the MHAC using an
iterative, consensus-based process. Each year, the set of questions was
revised to reflect evolving challenges in implementation, such as
development of newly developed, condition-specific interventions for
depression and anxiety, use of telehealth, and sustainability of the
mental health program as the 3-year funding cycle was ending. Items that
had 100\% endorsement in Year 1 (e.g., use of recommended screening
tools, ability to score them) were removed from subsequent surveys to
make room for questions related to more advanced implementation. In Year
1, the survey had 50 items, in Year 2 this was expanded to 80 items, and
in Year 3, a total of 71 items were included.

To quantify implementation success, points were assigned to survey
answers (0-1, 0-3, 0-4) based on the level of difficulty in achieving
them. Discussions among study co-authors were held to reach consensus on
level of implementation difficulty. For example, success in counseling
individuals with moderate to severe symptomatology was assigned more
points than counseling those reporting mild symptoms. See Table 1 for
example items and scoring.

\textbf{Application of the CFIR model}

First, survey questions assessing each CF Program's experience were
grouped into 1 of the 5 primary domains of the CFIR model:
1)\emph{Intervention Characteristics} ---annual mental health screening,
provision of psychological interventions by CF care team members,
referrals for treatment; 2) \emph{Outer Setting} ---educational
materials developed by the MHAC, courses and presentations focused on
mental health at the North American CF Conference (NACFC), leadership at
the CF Foundation; 3) \emph{Inner Setting} ---program characteristics,
the practice of utilizing a multidisciplinary team, training in quality
improvement, family education days, leadership provided by the CF Center
Director; 4) \emph{Characteristics of Individuals} ---professional
background and training of the MHC and years of experience working on a
CF team; and 5) \emph{Processes of Implementation} ---development of the
role of the MHC on the multidisciplinary team, integration of mental
health data into team discussions, plans for execution of annual
screening, follow-up of elevated scores and/or suicidal ideation and
provision of mental health interventions.

The next step of this pragmatic application of the CFIR
model\textsuperscript{18} quantified each CF program's success with
implementation based on response scores that ranged from basic to
advanced. As seen in Figure 1, levels of implementation were categorized
as follows: 1) Pre-implementation/Basic, 2) Implementation of
standardized screening, 3) Addressing barriers to implementation, 4)
Full Implementation, and 5) Sustainability.

\textbf{Analytic approach}

Across the 3 cohorts, 122 CF Programs participated in the study (80 in
Cohort 1, 30 in Cohort 2, \& 12 in Cohort 3), which represented 88.4\%
of grant recipients. Programs in Cohorts 1 and 2 completed multiple
yearly surveys, and 39 programs had more than one provider complete the
survey for a given year. All analyses were performed at the level of the
CF program and scores from multiple providers were aggregated within
each program using the mean implementation score and the maximum number
of years at the program across providers. Descriptive statistics were
calculated for each cohort and compared across cohorts using chi-square
tests of independence. To account for nesting of programs within years,
a random intercept linear mixed effect model was used to estimate the
total implementation score by cohort and year. To examine differences in
implementation across programs and to identify predictors of
implementation scores, we used a linear regression model with the
following predictors: type of program (pediatric, adult, both), size of
the program (small, medium, large), and years of experience working on
the CF team. Cohort was included as a covariate. To examine differences
in implementation over time, we used a random effect model to predict
both initial implementation and change in implementation across time
(i.e., interactions between predictors and year) using grant year, type
of program, program size, and MHC years of experience as predictor
variables. Random effects included the intercept and year. All analyses
were performed using the \emph{lme4 v1.1-26} , Table one v0.13.0,
and\emph{stats v4.0.3} R packages.

\textbf{Results}

Descriptive statistics are presented by CF program cohort in Table 2 and
represent aspects of the Inner Setting. There were no statistically
significant differences in characteristics of CF programs across cohorts
and thus, analyses were conducted across programs.

The first aim was to analyze the top-ranked barriers and successes of
this implementation effort. Barriers were rank-ordered in terms of their
significance, and successes were evaluated by their frequency of
endorsement.

\emph{Barriers to implementation.} Respondents were asked to rank order
a list of 9 potential barriers each year from 1 (most significant) to 10
(least significant). Rank ordering of barriers for Cohort 1 across the 3
years was highly consistent, with staff time, dedicated space (e.g., to
screen adolescents privately from parents), and perceived patient burden
(time and availability) ranked as the top 3 barriers to implementation.
Rank ordering of barriers across all cohorts and years yielded similar
results, in a slightly different order: \#1) patient burden, \#2) space
limitations, and \#3) limited staff time. These barriers represent
characteristics of the Inner Setting that are difficult to ameliorate.

\emph{Successes of implementation.} Respondents were asked to report the
top 3 successes of implementation. The 4 most frequently endorsed
successes in 2018, representing the 3\textsuperscript{rd} year of
implementation were (representing Cohort 1 year 3, Cohort 2 year 2, and
Cohort 3 year 1) were: \#1) early identification of depression/anxiety
(mental health issues); \textbf{tied} --\#2) improved access to
psychological services and interventions and \#2) increased
awareness/education in the CF team about depression/anxiety. The
4\textsuperscript{th} most frequently endorsed success was reduced
stigma about mental health/normalization.

The second objective was to evaluate the success of implementation in
the first year and whether it improved over subsequent years, using the
survey scoring criteria outlined above. As can be seen in Table E.1
(supplement), implementation scores were very similar across cohorts in
Year 1, ranging from 21.12 to 26.17. Implementation scores increased
significantly over time (see 95\% confidence intervals), nearly doubling
with each year of implementation. The longitudinal trajectories of these
implementation scores were then modeled over time for individual
programs. The estimated implementation scores and 95\% confidence
intervals for each cohort across the 3 years of the study are depicted
in Figure 2, along with the trajectories for individual centers. As
expected, there was a pronounced increase in implementation scores over
time, with improved implementation reported each year. In addition,
there was marked variability among programs both in terms of initial
implementation and progression across time.

The third aim was to identify predictors of implementation success,
considering Characteristics of the Inner Setting and of Individuals.
Predictors for the first year of implementation are listed in Table 3
and indicate that the mental health providers' years of experience on
the CF team was significantly related to higher implementation scores.
Predictors for changes across time for Cohort 1 are presented in Table
4. Similar to the first-year model, years of experience on the CF team
was significantly related to both implementation scores in Year 1 and
changes in implementation over time.

\emph{Convergent validity using registry data.} An external source of
data from the Outer Setting, the Cystic Fibrosis Foundation Patient
Registry (CFFPR),\textsuperscript{19} was used to evaluate convergent
validity with the survey results. Annual data from the CFFPR on national
rates of mental health screening were obtained for the year
\emph{prior}to the initiation of MHC grants in 2015 and for the 3 years
of the implementation study (2016-2018). Responses to the following 2
questions were recorded: ``\emph{Was the patient screened for symptoms
of classic depression using the Patient Health Questionnaire (PHQ-9) or
other valid depression screening tools?''} {[}yes, no, unknown{]};
``\emph{Was the patient screened for an anxiety disorder using the
Generalized Anxiety Disorder Tool (GAD-7 or similar?)?''} {[}yes, no,
unknown{]}. As expected, rates of screening in 2015 for depression were
quite low: 21.4\% for those 12-17 years (adolescents) and 24.1\% for
those 18 and older (adults). Similarly low rates of screening for
anxiety were documented: 17.6\% for adolescents and 19.5\% for adults.
In 2016, when the MHC grants were launched, depression screening rates
more than doubled to 57\% for adolescents and 61.2\% for adults; anxiety
screening rates increased to 53.2\% for adolescents and 59.2\% for
adults. Screening rates for depression continued to increase in 2017 and
2018 to 69\% and 73.2\% for adolescents and 75.1\% and 80.1\% for
adults, respectively. Anxiety screening demonstrated similar increases
across those two years: 67.2\% and 72.5\% for adolescents and 73.9\% and
79.5\% for adults.\textsuperscript{19}

\textbf{Discussion}

To our knowledge, this is the largest systematic, national effort to
integrate routine mental health screening and treatment into the care of
adolescents and adults with a serious, chronic illness. This study was
conducted with a geographically diverse, nationally representative group
of CF programs including large and small programs and those from urban
and rural areas. As recommended by the mental health guidelines, CF
programs began to implement annual screening of depression and anxiety
using 2 brief, validated tools with suggested practices for intervention
and follow-up.\textsuperscript{12} A well-established implementation
model was utilized to evaluate the process over 3 years in 3 cohorts of
CF programs. Results demonstrated substantial increases in
implementation scores both at the cohort and individual program level,
with confirmation of success implementing of screening in the CFFPR.

Dissemination and implementation of new practice guidelines is extremely
challenging and often delayed by the complexity of the healthcare
system, the difficulties of hiring and retraining staff, and the
ever-present time constraints faced by busy
clinics.\textsuperscript{15-16} It is hard to over-estimate the
challenge for CF programs of adding systematic assessment and treatment
of mental health symptoms to the existing difficulty of addressing a
complex, chronic disease affecting multiple organ systems. Barriers to
implementation included introduction of new standardized measures and
scoring procedures, the necessity of addressing suicidal ideation if
endorsed, the addition of a new role for a mental health expert on the
multidisciplinary team, and the perennial shortages of staff time and
clinic space. How did this implementation effort succeed?

First, the CFF (Outer Setting) took a leadership role in supporting the
development of the mental health guidelines (i.e., co-sponsoring the
guidelines with ECFS, with an executive member of the CFF serving on the
guidelines committee) and the subsequent establishment and funding of
competitive grants for a Mental Health Coordinator for 3 years. This
greatly facilitated the hiring, training/retraining and financing of a
team member with mental health expertise.

The establishment of the MHAC by the CFF was a critical contributor to
implementation success. The MHAC research subcommittee documented
implementation barriers, successes and training needs. To augment the
Implementation Guide included as an Appendix to the mental health
guidelines, \textsuperscript{12} the MHAC offered a CF mental health
Quality Improvement Change Package and a customized, interactive
screening tracker. New MHC's had access to 1:1 consultations and peer
mentoring, a group peer supervision program, and in-person networking
events. As a centerpiece of creating robust psychosocial conference
programming, guided by MHC survey needs assessment and CF healthcare
provider feedback, the MHAC developed a series of specialized 4-8 hour
training courses delivered at the NACFC and later adapted for
international use; from 2016-2018, these included: \emph{Depression and
anxiety treatment in CF: Therapy, medications and preventative
strategies; Mental health in CF: Taking your team to the next level~to
support emotional wellness for individuals with CF; Foundational
motivational interviewing skills for every CF clinician} ;
and\emph{Advanced strategies to address misuse of alcohol \& other
substances} . An ``emotional wellness'' section was added to the
public-facing CFF website (cff.org), to house multimedia content
targeted to the needs of CF healthcare providers and CF community
members. Topics initially included depression, anxiety, substance
misuse, and caregiver resilience, with subsequent expansion to include
helping CF siblings cope, procedural anxiety, and strategies for adults
with CF who become parents). To further promote communication and
dissemination of their work, the MHAC created an international mental
health listserv, a ``Dropbox'' of resources accessible to all healthcare
providers, and an email point of contact,\emph{mentalhealth@cff.org}.

The CF Foundation Care Center Network's support of a multidisciplinary
team approach also augments characteristics of the Inner Setting, making
inclusion of a new team member, or new role for an existing team member,
a ``normal'' part of the culture of CF care. Inner Setting
characteristics, such as regular Family Education Days at CF programs,
also fostered communication about the new mental health guidelines to
pwCF and their families. Our prior analysis of data from the first year
of Cohort 1 demonstrated substantial ``buy in'' from the CF community,
with over 95\% of pwCF and caregivers rating the new mental health
screening program ``somewhat to very'' positively.\textsuperscript{17}

Importantly, the only significant predictor of implementation success
identified by our study was length of MHC experience on the CF team.
This has important implications for the larger healthcare
system---reinforcing the importance of investing in healthcare staff and
promoting continuity of care providers. The experience and longevity of
providers may be particularly important when implementing new clinical
guidelines that require a higher level of knowledge of the patient
population and their clinical challenges, familiarity with the
complexity of their own healthcare system, knowledge of referral sources
within the hospital as well as within the community, and establishment
of trust among multidisciplinary team members.

As implementation progressed over time, concerns about the
sustainability of these positive changes in clinical care increased and
were expressed by CF care teams and advocates in the CF community.
Efforts to seek funding from departmental and hospital sources, to
identify cost savings related to addressing mental health concerns
(e.g., improved adherence and clinic attendance, reduced
hospitalizations) and information about billing for psychological
services, were all explored as options to maintain mental health
screening and treatment. There was widespread reluctance to lose the
gains that had been made in addressing mental health while caring for
pwCF and their families. The Outer Setting leadership at the CFF shared
these concerns and recognized the importance of mental health care
delivered by the CF programs. A line item was added in the 2020-2021 CFF
care center grants to maintain the role and function of the Mental
Health Coordinator across the US. This may be the strongest indicator of
implementation success; the healthcare system shifted to permanently
establish a minimal level of psychological support in CF care.

\emph{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,\textsuperscript{20-21} a consideration of mental health
screening in this age group of children with CF is timely and
appropriate.\textsuperscript{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).\textsuperscript{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.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Quittner AL, Goldbeck L, Abbott J, Duff A, Lambrecht P, Sol\selectlanguage{ngerman}é A,
  Tibosch MM, Bergsten Brucefors A, Yüksel H, Catastini P, Blackwell L,
  Barker D. Prevalence of depression and anxiety in patients with cystic
  fibrosis and parent caregivers: results of The International
  Depression Epidemiological Study across nine countries. Thorax. 2014
  Dec;69(12):1090-7. doi: 10.1136/thoraxjnl-2014-205983. Epub 2014 Sep
  21. PMID: 25246663.
\item
  Graziano S, Spanò B, Majo F, Righelli D, Lucidi V, Quittner A,
  Tabarini P. Rates of depression and anxiety in Italian patients with
  cystic fibrosis and parent caregivers: Implementation of the Mental
  Health Guidelines. Respir Med. 2020 Oct;172:106147. doi:
  10.1016/j.rmed.2020.106147. Epub 2020 Sep 10. PMID: 32961510.
\item
  Verkleij M, Appelman I, Altenburg J, Twisk J, Quittner AL, Haarman E.
  Anxiety and depression in Dutch patients with primary ciliary
  dyskinesia and their caregivers: associations with health-related
  quality of life. ERJ Open Res. 2021 Oct 25;7(4):00274-2021. doi:
  10.1183/23120541.00274-2021. PMID: 34708110; PMCID: PMC8542938.
\item
  Quittner AL, Varley CD, \& Henkle E. (2022). Non-CF bronchiectasis and
  Nontuberculous Mycobacteria: Integration of mental health and quality
  of life into patient care. Pp 211-233. In Bronchiectasis, Teneback \&
  Garcia (Eds). Humana Press, Springer Nature Switzerland AG.
\item
  Bock K, Bendstrup E, Hilberg O, Løkke A. Screening tools for
  evaluation of depression in Chronic Obstructive Pulmonary Disease
  (COPD). A systematic review. Eur Clin Respir J. 2017 Jan
  1;4(1):1332931. doi: 10.1080/20018525.2017.1332931. PMID: 28649311;
  PMCID: PMC5475296.
\item
  Schechter MS, Ostrenga JS, Fink AK, Barker DH, Sawicki GS, Quittner
  AL. Decreased survival in cystic fibrosis patients with a positive
  screen for depression. J Cyst Fibros. 2021 Jan;20(1):120-126. doi:
  10.1016/j.jcf.2020.07.020. Epub 2020 Aug 13. PMID: 32800486.
\item
  Barker DH, Quittner AL. Parental Depression and Pancreatic Enzymes
  Adherence in Children With Cystic Fibrosis. Pediatrics. 2016
  Feb;137(2):e20152296. doi: 10.1542/peds.2015-2296. Epub 2016 Jan 5.
  PMID: 26738883; PMCID: PMC4732358.
\item
  Barker DH \& Quittner AL. A biopsychosocial model of CF: social and
  emotional functioning, adherence and quality of life. In: Allen J,
  Panitch H, Rubenstein R, editors. Lung biology in health and disease
  series: cystic fibrosis. New York: Informa Healthcare; 2010;468--481.
\item
  Järvholm S, Ericson P, Gilljam M. Patient acceptance and outcome of
  mental health screening in Swedish adults with cystic fibrosis. Qual
  Life Res. 2020 Jun;29(6):1579-1585. doi: 10.1007/s11136-020-02417-5.
  Epub 2020 Jan 9. PMID: 31919786; PMCID: PMC7253508.
\item
  Quon BS, Bentham WD, Unutzer J, Chan YF, Goss CH, Aitken ML.
  Prevalence of symptoms of depression and anxiety in adults with cystic
  fibrosis based on the PHQ-9 and GAD-7 screening questionnaires.
  Psychosomatics. 2015 Jul-Aug;56(4):345-53. doi:
  10.1016/j.psym.2014.05.017. Epub 2014 Jun 2. PMID: 25556569.
\item
  Verkleij M, de Winter D, Hurley MA, Abbott J. Implementing the
  International Committee on Mental Health in Cystic Fibrosis (ICMH)
  guidelines: Screening accuracy and referral-treatment pathways. J Cyst
  Fibros. 2018 Nov;17(6):821-827. doi: 10.1016/j.jcf.2018.02.005. Epub
  2018 Mar 2. PMID: 29503039.
\item
  Quittner AL, Abbott J, Georgiopoulos AM, Goldbeck L, Smith B,
  Hempstead SE, Marshall B, Sabadosa KA, Elborn S; International
  Committee on Mental Health; EPOS Trial Study Group. International
  Committee on Mental Health in Cystic Fibrosis: Cystic Fibrosis
  Foundation and European Cystic Fibrosis Society consensus statements
  for screening and treating depression and anxiety. Thorax. 2016
  Jan;71(1):26-34. doi: 10.1136/thoraxjnl-2015-207488. Epub 2015 Oct 9.
  PMID: 26452630; PMCID: PMC4717439.
\item
  Abbott J, Havermans T, Jarvholm S, Landau E, Prins Y, Smrekar U, Staab
  D, Verity L, Verkleij M; ECFS Mental Health Working Group. Mental
  Health screening in cystic fibrosis centres across Europe. J Cyst
  Fibros. 2019 Mar;18(2):299-303. doi: 10.1016/j.jcf.2018.09.003. Epub
  2018 Sep 27. PMID: 30268370.
\item
  Landau EC, Verkleij M, Graziano S, Quittner AL, Georgiopoulos AM,
  Smith BA, Schechter MS, Abbott J; ECFS and CFF Mental Health Working
  Group/Advisory Committee. Mental health screening in Cystic Fibrosis
  as an intervention: Patient and caregiver feedback on improving these
  processes. Respir Med. 2022 Oct;202:106955. doi:
  10.1016/j.rmed.2022.106955. Epub 2022 Aug 27. PMID: 36084563.
\item
  Beauchemin M, Cohn E, Shelton RC. Implementation of Clinical Practice
  Guidelines in the Health Care Setting: A Concept Analysis. ANS Adv
  Nurs Sci. 2019 Oct/Dec;42(4):307-324. doi:
  10.1097/ANS.0000000000000263. PMID: 30839334; PMCID: PMC6717691.
\item
  Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L,
  Whitty P, Eccles MP, Matowe L, Shirran L, Wensing M, Dijkstra R,
  Donaldson C. Effectiveness and efficiency of guideline dissemination
  and implementation strategies. Health Technol Assess. 2004
  Feb;8(6):iii-iv, 1-72. doi: 10.3310/hta8060. PMID: 14960256.
\item
  Quittner AL, Abbott J, Hussain S, Ong T, Uluer A, Hempstead S, Lomas
  P, Smith B. Integration of mental health screening and treatment into
  cystic fibrosis clinics: Evaluation of initial implementation in 84
  programs across the United States. Pediatr Pulmonol. 2020
  Nov;55(11):2995-3004. doi: 10.1002/ppul.24949. Epub 2020 Jul 21. PMID:
  32649006.
\item
  Safaeinili N, Brown-Johnson C, Shaw JG, Mahoney M, Winget M. CFIR
  simplified: Pragmatic application of and adaptations to the
  Consolidated Framework for Implementation Research (CFIR) for
  evaluation of a patient-centered care transformation within a learning
  health system. Learn Health Syst. 2019 Sep 26;4(1):e10201. doi:
  10.1002/lrh2.10201. PMID: 31989028; PMCID: PMC6971122.
\item
  Cystic Fibrosis Foundation Patient Registry 2020 Annual Data Report
  Bethesda, Maryland ©2021 Cystic Fibrosis Foundation.
\item
  Tanne JH. US task force recommends screening children for anxiety and
  depression. BMJ. 2022 Oct 18;379:o2490. doi: 10.1136/bmj.o2490. PMID:
  36257677.
\item
  US Preventive Services Task Force, Mangione CM, Barry MJ, Nicholson
  WK, Cabana M, Coker TR, Davidson KW, Davis EM, Donahue KE, Jaén CR,
  Kubik M, Li L, Ogedegbe G, Pbert L, Ruiz JM, Silverstein M, Stevermer
  J, Wong JB. Screening for Anxiety in Children and Adolescents: US
  Preventive Services Task Force Recommendation Statement. JAMA. 2022
  Oct 11;328(14):1438-1444. doi: 10.1001/jama.2022.16936. PMID:
  36219403.
\item
  Prieur MG, Christon LM, Mueller A, Smith BA, Georgiopoulos AM, Boat
  TF, Filigno SS. Promoting emotional wellness in children with cystic
  fibrosis, Part I: Child and family resilience. Pediatr Pulmonol. 2021
  Feb;56 Suppl 1:S97-S106. doi: 10.1002/ppul.24958. PMID: 32658376.
\item
  Georgiopoulos AM, Christon LM, Filigno SS, Mueller A, Prieur MG, Boat
  TF, Smith BA. Promoting emotional wellness in children with CF, part
  II: Mental health assessment and intervention. Pediatr Pulmonol. 2021
  Feb;56 Suppl 1:S107-S122. doi: 10.1002/ppul.24977. PMID: 32706527.
\end{enumerate}

\textbf{Hosted file}

\verb`Figures 1 and 2.docx`  available at \url{https://authorea.com/users/567032/articles/613569-national-integration-of-mental-health-screening-and-treatment-into-specialized-care-for-cystic-fibrosis-what-predicts-success}

\textbf{Hosted file}

\verb`Tables 1-4_Implementation Paper.docx`  available at \url{https://authorea.com/users/567032/articles/613569-national-integration-of-mental-health-screening-and-treatment-into-specialized-care-for-cystic-fibrosis-what-predicts-success}

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