Mental health and cystic fibrosis: Time to move from secondary prevention to predictive medicine

(1)

Article

Reference

Mental health and cystic fibrosis: Time to move from secondary prevention to predictive medicine

AMERIO, Andrea, et al.

AMERIO, Andrea, et al . Mental health and cystic fibrosis: Time to move from secondary

prevention to predictive medicine. Pediatric Pulmonology , 2020, vol. 55, no. 9, p. 2204-2206

DOI : 10.1002/ppul.24928 PMID : 32634297

Available at:

http://archive-ouverte.unige.ch/unige:153253

Disclaimer: layout of this document may differ from the published version.

1 / 1

(2)

|

₁

DOI: 10.1002/ppul.24928

L E T T E R T O T H E E D I T O R

Mental health and cystic fibrosis: Time to move from secondary prevention to predictive medicine

To the Editor,

Thanks to advances in care over the last six decades, in countries with well‐developed healthcare systems the onus of cystic fibrosis (CF) care has progressively shifted to adult populations. Median survival age for CF is now in the late forties and the recent in- troduction of CF transmembrane conductance regulator modulators is expected to further improve the survival rates.¹

In spite of these improvements and the positive outlook, CF is still a life‐limiting condition with chronic symptoms and a heavy daily treatment burden. Not surprisingly, depression and anxiety are re- ported to be among the most frequent CF comorbidities.²Depression is a common psychiatric condition characterized by depressed mood and loss of interest in most activities, and it may affect thoughts, feelings, behaviors, physical health and impair social and occupational functioning. Anxiety can be described as a“state of intense appre- hension, uncertainty, and fear resulting from the anticipation of a threatening event or situation to the degree that normal physical and psychological functioning is disrupted”.

The largest study conducted on depression and anxiety detection in CF population is the International Depression/Anxiety Epidemio- logical Study that screened more than 6000 patients with CF aged 12 years and older across nine countries, reporting depressive and anxiety prevalence rates 2 to 3 times higher in the study population, as compared with the general population; the gap increased to three to four times in CF patients with at least one parent with depression or anxiety symptoms.³

The association between CF, depression and anxiety is complex:

depressive and anxiety symptoms can be associated with decreased lung function, lower body mass index, lower adherence to treatment and health‐related quality of life (HRQoL), higher sleep disorders rates, more frequent hospitalizations and greater healthcare costs.²

Besides, the risk of depression in patients with CF is associated with age and household members' mental health.

In a European multi‐center study the prevalence of depression in patients with CF increased with age from 6% in the 12 to 20 year old group to 11% in the 21 to 30 year old group, and 14% in the 31 to 50 year old group. The trend was interpreted as an age‐dependent association with increasingly severe lung disease and higher expectations (eg, financial and family independency).⁴

Parental depression and anxiety can affect CF patients' adherence and health outcomes. Depression is more common among

mothers that have often been found to be overly involved and protective of CF sons.⁵

Overall, data from the literature strongly argue for a significant association between CF and mental health issues and the need to screen both patients and parents to identify and manage mental health comorbidities and to provide adequate treatment.²

This evidence led to the establishment of the International Committee on Mental Health in patients with CF that identified and recommended the best screening tools and the best intervention practices.⁶ The patient health questionnaire (PHQ‐9) and the gen- eralized anxiety disorder (GAD‐7) were recommended for depression and anxiety annual screening both in CF patients and parent caregivers because of their brevity, high positive predictive value and good reliability. PHQ‐9 and GAD‐7 are used both as secondary prevention tools to screen symptoms on an annual basis, as well as to monitor treatment response. In addition, the Columbia suicide severity screen use was suggested to measure suicide ideation in in- dividuals who screened positive for suicide risk.

However, because of the complexity of CF disease and the potential mental health implications, more attention should be paid to potential risk factors in childhood and adolescence to be used as potential prime target for interventions in later psychiatric disorders.

Kraepelin's hypothesis that temperament can predispose to or be a risk factor for later psychiatric disorders has been confirmed by several studies. Temperament can be defined as a“genetically de- termined emotional reactivity to the environment, which—in combi- nation with life experiences—leads to the development of personality traits.”⁷ In the eighties, based on Kraepelin's work, the Armenian psychiatrist Hagop Akiskal proposed criteria to define five different temperaments: depressive (low levels of energy and introversion), cyclothymic (chronic cycling of mood polarities with unstable self‐ esteem and energy), hyperthymic (increased levels of energy and optimism), irritable (irritable and angry behaviors), and anxious (worrying attitudes).⁷

Akiskal et al developed the Temperament Evaluation of Mem- phis, Pisa, Paris and San Diego‐autoquestionnaire version (TEMPS‐A), a self‐report, yes‐or‐no type questionnaire, designed to quantify temperament in psychiatric patients and healthy subjects since the adolescence.⁷The subscales (depressive, cyclothymic, hyperthymic, irritable and anxious) of the TEMPS‐A attempt to capture not only emotional, cognitive, psychomotor and circadian traits which might

(3)

predispose one to major mood disorders, but could also serve an adaptive role in an evolutionary context.

According to Akiskal, affective temperaments would play a key role in the clinical presentation and evolution of mood episodes and would influence course of illness, symptoms' severity, and treatment's response. Moreover, evidence from the literature confirmed that cyclothymic, depressive, and irritable temperaments are more frequently associated with a higher risk of suicidal behaviors, whereas hyperthymic temperament seems to be a protective factor.⁸ In particular, adolescence temperament traits have been shown to be associated with mood and anxiety disorders in later life.⁹ Furthermore, the stability of temperament across development would suggest that it can be act as a potential risk factor for later mood and anxiety disorders.

Identifying adolescents at higher risk of developing mood and anxiety disorders allow to plan, implement and monitor targeted preventive interventions in the context of CF care and management.

These should include multi‐disciplinary supportive interventions de- livered by teams of ad hoc trained pneumologists, psychologists, and psychiatrists with regular follow‐up visits. Accurate information around the risk to develope depressive and anxiety symptoms, their treatment and prognosis, should be given to patients with CF and families to help them in the long‐term management of their condition.

To the best of our knowledge, no prospective studies have in- vestigated temperament traits in patients with CF and parents and the possible association between temperament and later onset of mood and anxiety disorders. Temperament could also modulate the impact of life‐limiting chronic condition, such as CF on different do- mains, including coping strategies, HRQoL, and adherence to treatments. In addition to temperament, it would be interesting to assess the predictive value of other biological traits, like sensitivity in behavioral inhibition and behavioral activation systems, related to mood disorders in patients with CF.

CF mental healthcare is at a turning point. New pharmacological CF treatments will improve survival, with a growing number of adult patients requiring good quality of life and social functioning.

According to the predictive medicine model that aims to identify patients at risk of developing a disease, the evaluation of temperament, behavioral inhibition and activation, and other potential biological traits in childhood and adolescence could allow to move from the current secondary prevention screening strategy to a better comprehension of risk factors for depressive and anxiety disorders in patients with CF, so as to support a patient‐centered approach to CF mental health care.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.

AUTHOR CONTRIBUTIONS

AA, FS, RP, RC, RC, FC, PGF, CP, AC, and AA wrote the first draft of the manuscript. AO, GS, MA, and CC carefully revised the final version of the manuscript. The manuscript has been approved by all authors.

Andrea Amerio PhD^1,2,3 Francesca Sibilla MD^1,2

Rita Pescini PsyD⁴ Riccardo Ciprandi PsyD⁴ Rosaria Casciaro MD⁴ Pietro Grimaldi Filioli MD^1,2 Chiara Porcelli MD^1,2 Anna Odone PhD^5,6 Alessandra Costanza MD^7,8 Andrea Aguglia PhD^1,2 Gianluca Serafini PhD^1,2

Mario Amore MD^1,2 Carlo Castellani MD⁴ Federico Cresta MD⁴

1Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, Genoa, Italy

2IRCCS Ospedale Policlinico San Martino, Genoa, Italy

3Department of Psychiatry, Tufts University, Boston, Massachusetts

4Cystic Fibrosis Center, IRCCS Istituto Giannina Gaslini–Ospedale Pediatrico, Genoa, Italy

5School of Medicine, Vita‐Salute San Raffaele University, Milan, Italy

6Clinical Epidemiology and HTA, IRCCS San Raffaele Scientific Institute, Milan, Italy

7Department of Psychiatry, Faculty of Medicine, University of Geneva (UNIGE), Geneva, Switzerland

8Department of Psychiatry, ASO Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy

Correspondence Andrea Amerio, PhD, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, IRCCS San Martino, Largo Rosanna Benzi 10, 16100 Genova, Italy.

Email:andrea.amerio@unige.it

ORCID

Andrea Amerio http://orcid.org/0000-0002-3439-340X Anna Odone http://orcid.org/0000-0002-5657-9774 Alessandra Costanza http://orcid.org/0000-0001-6387-6462 Andrea Aguglia http://orcid.org/0000-0002-2003-2101 Gianluca Serafini http://orcid.org/ 0000-0002-6631-856X

REFERENCES

1. Elborn JS. Cystic fibrosis.Lancet. 2016;388(10059):2519‐2531.

2. Havermans T, Willem L. Prevention of anxiety and depression in cystic fibrosis.Curr Opin Pulm Med. 2019;25(6):654‐659.s.

3. Quittner AL, Goldbeck L, Abbott J, et al. 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;69(12):1090‐1097.

4. Goldbeck L, Besier T, Hinz A, Singer S, Quittner AL, TIDES Group.

Prevalence of symptoms of anxiety and depression in German patients with cystic fibrosis.Chest. 2010;138(4):929‐936.

2

|

LETTER TO THE EDITOR

(4)

5. Barker DH, Quittner AL. Parental depression and pancreatic enzymes adherence in children with cystic fibrosis. Pediatrics. 2016;137:

e20152296.

6. Quittner AL, Abbott J, Georgiopoulos AM, et al. 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;71(1):26‐34.

7. Akiskal HS, Akiskal KK, Haykal RF, Manning JS, Connor PD.

TEMPS‐A: progress towards validation of a self‐rated clinical

version of the Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire. J Affect Disord. 2005;

85(1‐2):3‐16.

8. Pompili M, Rihmer Z, Akiskal HS, et al. Temperament and personality dimensions in suicidal and nonsuicidal psychiatric inpatients.Psycho- pathology. 2008;41:313‐321.

9. Merikangas KR, Swendsen JD, Preisig MA, Chazan RZ. Psycho- pathology and temperament in parents and offspring: results of a family study.J Affect Disord. 1998;51(1):63‐74.

LETTER TO THE EDITOR

|

³