Self-Esteem and Its Relationship to Mental Health and Qualityof Life in Adults with Cystic Fibrosis

Melanie Jane Platten • Emily Newman •

Ethel Quayle

� Springer Science+Business Media New York 2012

Abstract Research from the general population indicates

an important role for self-esteem in mental health, but lim-

ited research in this area exists in the cystic fibrosis (CF)

literature. This study aimed to explore the predictive value of

self-esteem and health-related quality of life (HRQoL) in

mental health symptoms in adults with CF. Seventy-four

participants, recruited online, completed the Clinical Out-

comes in Routine Evaluation-Outcome Measure 34 (CORE-

OM), Rosenberg Self-esteem Scale and Cystic Fibrosis

Questionnaire-Revised (CFQ-R). Comparably high levels of

self-esteem were found, but HRQoL was lower than previous

research. Thirty percent of participants scored within the

clinical range for mental health difficulty. Hierarchical

regression, controlling for gender, explored the value of four

CFQ-R subscales (physical, social, emotional and role

functioning) and self-esteem in predicting CORE-OM total

score. Gender accounted for 8.2 % of the variance in mental

health scores while the five independent variables accounted

for a further 73.0 % of variance. Of the five variables, CFQ-R

emotional functioning and self-esteem were significant

predictors of mental health symptoms. Results are discussed

in relation to clinical implications and potential uses for

internet technologies to promote socialisation.

Keywords Cystic fibrosis � Mental health �Quality of life � Self-esteem

Introduction

With the vast majority of people with cystic fibrosis (CF) now

living into adulthood researchers have become increasingly

interested in their long-term quality of life and psychological

well-being. Studies have indicated that people with CF report

high levels of quality of life (Abbott, 2009) but that mental

health difficulty varies. Some studies suggest higher levels of

depression and/or anxiety compared to the general population

(Goldbeck et al., 2010; Modi, Driscoll, Montag-Leifling, &

Acton, 2011; Quittner et al., 2008) whereas others maintain

that mental health symptoms are comparable to the general

population (Anderson, Flume, & Hardy, 2001). Factors iden-

tified as contributing to poorer mental health include being

female, older, unemployed and having more severe illness

(Goldbeck et al., 2010; Modi et al., 2011; Quittner et al., 2008).

Mental health research has indicated the important role

of self-esteem in the general population (Mann, Hosman,

Schaalma, & de Vries, 2004). Self-esteem has also been

shown to mediate the relationship between dysfunctional

thoughts and depression in adults (Simpson, Hillman, &

Crawford, 2010). However, this variable has received little

attention within the CF literature. To the authors’ knowl-

edge, only two papers have explicitly assessed self-esteem

in adults with CF with both papers focusing primarily on

body image (Abbott et al., 2000, 2007). A recent publica-

tion by Brucefors et al. (2011) speculated that low levels of

self-esteem may be an influential factor in the higher levels

of social dysfunction found in a sample of adults with CF

compared with healthy adults. However, the relationship

M. J. Platten (&)

Department of Psychological Services and Research,

Dumfries & Galloway NHS Health Board, Nithbank,

Dumfries DG1 2SA, Scotland, UK

e-mail: m.platten@nhs.net

E. Newman � E. Quayle

School of Health in Social Sciences, University of Edinburgh,

Edinburgh, UK

e-mail: emily.newman@ed.ac.uk

E. Quayle

e-mail: ethel.quayle@ed.ac.uk

123

J Clin Psychol Med Settings

DOI 10.1007/s10880-012-9346-8

between self-esteem and mental health in adults with CF

has not been investigated in the published literature to date.

A second factor particularly pertinent to adults with CF is

social functioning. Peer relationships have been seen to be

affected in chronic illnesses (Forgeron et al., 2010) and, with

the use of segregation in CF services to prevent cross-infection

of respiratory pathogens, it is important to consider how

people with CF can build and maintain relationships with and

access support from their CF peers (Quittner, Barker, Marciel,

& Grimley, 2009). The evidence from CF research seems to

indicate that higher levels of social functioning are related

to better coping (White et al., 2009), improved adherence to

treatment (Barker et al., 2011; White et al., 2009) and fewer

mental health difficulties (Casier et al., 2011). Researchers

have suggested that future studies continue to explore how

new technologies may enhance peer interaction and overcome

the restrictions of segregation for people with CF (Quittner

et al., 2009). Online resources are becoming increasingly

popular within the CF population (Hasenecz, 2010) and

involving this group in research enables the potential repre-

sentation of patients from a wide geographical area.

The present study was not an investigation into the

impact of involvement with online social environments

upon mental health, but aimed to:

1. Assess the self-esteem, mental health needs and

HRQoL (including social functioning) of adults with

CF who make use of online resources.

2. Ascertain whether, when controlling for gender, self-

esteem and four areas of quality of life were predictive

of mental health symptoms.

Based on knowledge from previous research involving

the general population and patients with CF, the following

hypotheses were made:

1. Symptoms of mental health difficulty would be higher

than the general population. Measures of self-esteem

and HRQoL would yield findings similar to those in

previous CF research, i.e. self-esteem would be com-

parable to the general population and participants

would have relatively high levels of HRQoL.

2. Lower levels self-esteem and quality of life would be

related to greater mental health difficulties. Self-

esteem would have a significant contribution to mental

health in the study sample population.

Methods

Design

This was a cross-sectional study of adults with CF who make

use of online discussion forums and social networking. Each

participant completed three quantitative assessment mea-

sures and provided demographic information. Data pre-

sented in this paper were collected as part of a larger project

which also aimed to explore the ways in which a CF-specific

online discussion forum was used by adults with CF. The

current paper reports on the findings of the online survey.

Preparation of a manuscript describing the findings from the

second, qualitative study is in progress.

Ethical Approval

Ethical approval was obtained from the School of Health in

Social Science, University of Edinburgh. Collaboration

with the CF Trust aided the development of the project and

research information page.

Participants

Participants were recruited online through an internet dis-

cussion forum and Facebook page hosted by the Cystic

Fibrosis Trust (CF Trust), a UK-based charity. Researchers

relied on the goodwill of participants to take part in the

study and a total of 105 eligible participants gave consent.

Incomplete surveys were submitted by 31 participants, with

complete data available for 74 participants.

Chi-squared and Mann–Whitney U tests revealed no

significant differences (p [ .05) between full- and partial-

completers on the demographic variables of age, self-report

of most recent FEV1% predicted (forced expiratory volume

in one second % predicted; a measure of lung function

frequently used to classify severity of respiratory disease),

gender, ethnicity or lung transplant status. Demographic

variables for participants completing a full set of survey

data are presented in Table 1.

Procedure

Recruitment was initiated via a message posted on the CF

Trust online discussion forum by a member of the CF Trust

communications team. This linked to an information page

describing the study. After 3 and 6 weeks, the researcher

replied to the initial thread to thank those who had already

taken part and to bring the notice to the top of the dis-

cussion area. In addition, 6 weeks after the original post on

the CF Trust discussion forum, the communications team

placed a recruitment notice on the CF Trust Facebook page

followed by a repeat post from the researcher 2 weeks

later. In total, the survey was open for ten weeks.

The information page contained a web-link to the online

survey, hosted by Survey Monkey (www.surveymonkey.

com). Participants self-selected to take part in the research

and were eligible if they were 16 years old or over and had

a diagnosis of CF. Participants were asked to provide

J Clin Psychol Med Settings

123

consent prior to completing the online survey. Those who

chose not to consent were directed to the end of the survey

and thanked for their time.

Measures

Cystic Fibrosis Questionnaire—Revised (CFQ-R)

The CFQ-R (Bryon & Stramik, 2005; Quittner, Buu,

Watrous, & Davis, 2002) is a CF-specific measure of health-

related quality of life (HRQoL). The 14 years old and over

teen/adult UK version was used in this instance. The mea-

sure consists of 50 items which assess HRQoL within nine

domains. Including all nine domain scores in analyses

would have significantly reduced the statistical power of the

research and previous research advocates the consideration

of four core domains when studying HRQoL (Casier et al.,

2011; Cella, 1998). In order to maintain statistical power

but include the key components of quality of life, Casier

et al.’s (2011) approach of using only CFQ-R subscales of

physical functioning (eight items), emotional functioning

(five items), role functioning (four items) and social func-

tioning (six items) was taken. Each item on the CFQ-R is

rated on a four-point Likert scale. A standardised score

ranging between 0 and 100 is obtained for each subscale,

with higher scores indicating better functioning. The

CFQ-R teen/adult version is well established, valid and

reliable (Palermo et al., 2008). Cronbach’s alpha internal

consistency analyses were carried out for each of the four

subscales: physical a = .96, emotional a = .82, role

a = .86 and social a = .63. These values are in line with

previous research (Casier et al., 2011; Quittner, Buu,

Messer, Modi, & Watrous, 2005).

Clinical Outcomes in Routine Evaluation—Outcome

Measure 34 (CORE-OM)

The CORE-OM (Evans et al., 2000) is a 34-item self-report

measure used to assess symptoms of mental health diffi-

culty and psychological distress. A total score can be cal-

culated in addition to scores for four sub-domains:

subjective well-being, functioning, symptoms and risk. In

this study, the total CORE-OM score was used. Each item

is rated on a five-point scale from 0 (not at all) to 4 (most or

all of the time). Higher scores indicate greater difficulty.

The measure has been shown to be reliable, valid and able

to distinguish between clinical and non-clinical samples in

the general population (Evans et al., 2002). CORE-OM

total scores in the current sample had good internal con-

sistency, Cronbach’s a = .96.

Table 1 Demographic and

basic clinical information

summary for full data sets

Demographic n (%) Clinical n (%)

Age (mean ± SD) 27.8 ± 9.2 FEV1% (mean ± SD) 61.7 ± 25.0

Gender (n, % female) 57, 77.0 % Lung transplant (n, % yes) 5, 6.8 %

Ethnicity (n, % White) 72, 97.3 % Age at CF diagnosis (N = 74)

Education (n, % higher ed) 45, 60.8 % At birth 19 (25.7)

Marital status (N = 74) \6 months old 18 (24.3)

Single/never married 28 (37.8) 6–12 months old 10 (13.5)

With a partner 25 (33.8) 1–4 years old 13 (17.5)

Married/civil partnership 20 (27.0) 5–11 years old 3 (4.1)

Widowed 1 (1.4) 12–17 years old 3 (4.1)

Education (N = 74) 18–25 years old 3 (4.1)

Some secondary school or less 1 (1.3) [25 years old 5 (6.7)

GCSEs/O-levels 11 (14.9) CF severity, no transplant (FEV1%; N = 54)

A/AS-levels 17 (22.9) Normal (FEV1% C 90 %) 6 (11.1)

Other higher education 13 (17.6) Mild (70–89 %) 13 (24.1)

University degree 21 (28.4) Moderate (40–69 %) 21 (38.9)

Professional or postgraduate 11 (14.9) Severe (\40 %) 14 (25.9)

Work status (N = 61) CF severity, transplant (FEV1%; N = 4)

Working full- or part-time 32 (52.5) Normal (FEV1% C 90 %) 3 (75.0)

Not attending school or work due to health 12 (19.7) Moderate (40–69 %) 1 (25.0)

Attending school 11 (18.0)

Seeking work 2 (3.3)

Not working for other reasons 2 (3.3)

Taking education courses at home 1 (1.6)

Full-time homemaker 1 (1.6)

J Clin Psychol Med Settings

123

Rosenberg Self-esteem Scale (Rosenberg, 1965)

This 10-item self-report questionnaire is designed to mea-

sure global self-esteem. Each item is rated on a four-point

scale (strongly disagree, disagree, agree, strongly agree)

and results in a total score ranging from 10 to 40. Higher

scores represent higher levels of self-esteem. This measure

has been shown to have satisfactory psychometric proper-

ties (Sinclair et al., 2010) and has been used in CF research

(Abbott et al., 2007). In the current sample the measure

showed good internal consistency, Cronbach’s a = .94.

Demographic Questionnaire

Demographic data including age, gender, occupation,

diagnosis and current physical health status (including

most recent self-reported FEV1% predicted reading and

lung transplant status) were collected. The demographic

questionnaire was completed at the same time as the three

outcome measures.

Data Analysis

Raw data were analyzed using SPSS version 17. Scores for

those participants who had fully completed the online

survey (N = 74) were included in descriptive statistics.

Some missing data points were found within the CORE-

OM and CFQ-R measures and dealt with according to the

individual assessment measure guidance. For the CORE-

OM, total score is calculated as the average item response.

Two participants had one missing item score; in these cases

the total score was calculated using the completed items.

For the CFQ-R, Quittner et al. (2002) advise users to take a

pro-rated score of completed items within a subscale and

use this figure in place of the missing data. This method is

acceptable if one or two items are missing within a sub-

scale. Ten participants had one item score missing in the

CFQ-R and pro-rated scores were entered in these cases.

For three participants, too many items were missing to

calculate a subscale score for social functioning on the

CFQ-R measure.

Consideration was given to removing data of partici-

pants who had undergone a lung transplant. Given the

small number of participants who were post-transplant

(N = 5) and, as mean scores were not changed signifi-

cantly when excluded, it was decided to include their data

in subsequent analyses.

Hierarchical Regression

Hierarchical regression using forced entry of two blocks of

variables was used to explore the factors predictive of

mental health symptoms as measured by the CORE-OM.

Cases with missing data were excluded list-wise; a total

number of 71 sets of participant data were included in the

regression. Preliminary analyses revealed that data met

appropriate assumptions regarding linear relationships,

singularity, homoscedasticity and normal distribution of

residuals. Scatter plots between the dependent and all

independent variables revealed no outliers.

Results

Descriptive Statistics

Table 2 presents the mean and standard deviation (SD) for

each measure completed within the online survey. Self-

esteem scores produced a mean of 29.9 (SD 7.1). The mean

score on the CORE-OM was 1.01 (SD 0.7) and when

classified according to clinical thresholds, 29.7 % (N = 22)

of participants were within the clinical range of symptoms.

Average scores on the CFQ-R subscales ranged between

46.96 (SD 32.5) for physical functioning and 65.61 (SD

23.4) for role functioning. Mean scores of 57.30 (SD 24.6)

and 59.23 (SD 20.4) were obtained for emotional and social

functioning respectively.

Control Variables

Gender has been shown to be a significant influence on many

aspects of life for adults with CF (Gee, Abbott, Conway,

Etherington, & Webb, 2003). Preliminary two-tailed t tests

were conducted to compare scores of males (N = 17) and

females (N = 57) on each measure (see Table 2). Females

scored significantly lower than males on the CFQ-R domains

of emotional functioning (t = 2.897, p = .005) and social

functioning (t = 2.730; p = .008). They also reported lower

Table 2 Means and SD of outcome measure scores

Outcome measures Mean scores (SD)

Male Female Total

FEV1% predicted 66.73 (26.9) 60.47 (24.6) 61.66 (25.0)

CFQ-R

Physical functioning 58.82 (37.6) 43.42 (30.3) 46.96 (32.5)

Role functioning 71.57 (23.8) 63.73 (23.2) 65.61 (23.4)

Emotional

functioning**

71.76 (20.9) 52.98 (24.2) 57.30 (24.6)

Social functioning** 70.59 (15.6) 55.85 (20.5) 59.23 (20.4)

CORE-OM total score* 0.64 (0.5) 1.13 (0.7) 1.01 (0.7)

Rosenberg Self-esteem

Scale**

33.94 (5.1) 28.68 (7.2) 29.89 (7.1)

* Gender difference significant at the level of p \ .05; ** gender

difference significant at the level of p \ .01

J Clin Psychol Med Settings

123

levels of self-esteem (t = 2.813; p = .006) and higher total

CORE-OM scores (t = 2.534; p = .013). No significant

gender differences in FEV1% predicted (t = .746; n.s.),

physical functioning (t = 1.739; n.s.) or role functioning

(t = 1.208; n.s.) were found. These significant differences and

agreement with previous research indicated that gender should

be controlled for within subsequent regression analyses.

Consideration was given to the inclusion of age and

FEV1% predicted as control variables within the regression

analysis. However, age was not seen to correlate with other

variables and was excluded from regression analysis. For

FEV1% predicted, many participants did not supply this

information within the survey (N = 58) and due to its self-

report nature, it was decided to exclude this from further

analysis to ensure validity and to maximize the available

sample size for regression analysis.

Independent Variables

The results of the Pearson’s correlation analyses are pre-

sented in Table 3. Significant positive correlations were

found between the four subscales of the CFQ-R. Correla-

tions between CFQ-R subscales and CORE-OM total score

were all negative, with lower HRQoL scores associated

with greater mental health difficulty. Significant positive

correlations between CFQ-R subscales and self-esteem

scores were also found, indicating that better HRQoL is

related to higher levels of self-esteem. Correlations also

indicated that higher self-esteem scores were associated

with fewer mental health difficulties.

Regression

The regression analysis used the CORE-OM total score

measure of mental health symptoms as the outcome measure.

When gender was entered in step 1, it explained 8.2 % of the

variance in mental health symptoms in adults with CF

(R2 = .08, F change (1, 69) = 6.15, p = .02). Entering

CFQ-R subscale scores for physical, emotional, role and

social functioning and RSES scores at step 2 explained an

additional 73.0 % of the variance in mental health symptoms

(R2 change = .73, F change (5, 64) = 49.10, p \ .001). The

model as a whole explained 81.0 % of variance in mental

health symptom scores (F (6, 64) = 45.52, p \ .001). Two

measures made a statistically significant contribution to this

model, with CFQ-R emotional functioning recording a

higher standardised beta value (b = -.57, p \ .001) than

the Rosenberg self-esteem measure (b = -.49, p \ .001).

The negative coefficients indicate that higher levels of

emotional functioning and self-esteem were associated with

fewer mental health symptoms. Coefficients for all variables,

including those with a non-significant contribution to the

model, are presented in Table 4.

Discussion

The first aim of the study was to assess the levels of self-

esteem, quality of life and mental health symptoms in a sample

of adults with CF recruited online. Secondly, the study aimed

to explore whether self-esteem and four domains of quality of

life were significant predictors of mental health symptoms in a

regression model. Results showed that participants had rea-

sonably high levels of self-esteem which compared well to

previous CF participants and healthy controls (Abbott et al.,

2007). Mental health symptoms were at clinical levels for

29.7 % of the sample, which is higher than would be expected

within the general population (Singleton, Bumpstead,

O’Brien, Lee, & Meltzer, 2001). This finding is in line with

other studies indicating elevated mental health difficulties in

the CF population (Goldbeck et al., 2010; Modi et al., 2011;

Quittner et al., 2008) but contradicts others (e.g. Anderson

et al., 2001). Participants had variable levels of HRQoL

depending on domain. Lowest scores were obtained in phys-

ical functioning whilst highest score were seen in role func-

tioning. Role functioning refers to how much CF interferes

Table 3 Correlation coefficients and significance of assessment

measure scores, age and FEV1% predicted

1 2 3 4 5 6 7 8

1. CORE-OM total score

r 1

N 74

2. Rosenberg self-esteem score

r -.83** 1

N 74 74

3. Physical functioning

r -.46** .48** 1

N 74 74 74

4. Role functioning

r -.59** .61** .76** 1

N 71 71 71 71

5. Emotional functioning

r -.84** .73** .57** .69** 1

N 74 74 74 71 74

6. Social functioning

r -.53** .59** .72** .71** .63** 1

N 74 74 74 71 74 74

7. Age

r -.21 .10 -.10 .05 .28* .07 1

N 73 73 73 70 73 73 73

8. FEV1% predicted

r -.14 .23 .76** .45** .23 .52** .04 1

N 58 58 58 55 58 58 57 74

* Correlation is significant at the .05 level (two-tailed); ** Correla-

tion is significant at .01 level

J Clin Psychol Med Settings

123

with attending and keeping up with school, work or daily

living activities and achieving goals in areas of school, work or

personal life. Compared to the baseline assessment scores

reported in a recent longitudinal study of HRQoL in adults

with CF (Sawicki et al., 2011), domain scores within this

study are considerably lower, yet Sawicki et al.’s (2011)

sample was of a similar mean age and condition severity to the

present sample.

Therefore, despite finding equivalent levels of self-

esteem and mental health difficulties to other research

studies, average HRQoL in the four domains was consider-

ably lower than another recent sample of participants with

similar demographic characteristics. One potential reason

for the lower overall mean levels of quality of life compared

to other studies may be due to the over-representation of

females within the current sample population. Prior research

has established that females with CF tend to fair worse

medically than males (Nick et al., 2010), experience higher

levels of anxiety (Goldbeck et al., 2010; Modi et al., 2011),

lower self-esteem (Abbott et al., 2007) and lower HRQoL

(Abbott, 2009). However, it is unlikely to be the full expla-

nation as average scores for males alone in the HRQoL

domains, with the exception of social functioning, are also

lower than Sawicki et al.’s (2011) sample.

The reasons for good self-esteem but low levels of

HRQoL are not directly discernable from the current study

design; however it is possible that intact roles within social

or family circles or other factors, such as social support,

may help protect levels of self-esteem. Alternatively, the

lower levels of HRQoL compared to other studies may

have been influenced by the recruitment method. Patients

with CF who have lower levels of quality of life and

physical fitness may have greater restrictions on activities

and abilities, turning to online resources to gain support

and seek information. These potential participants were

perhaps more like to see the recruitment post and have the

time available to complete the questionnaires. However, it

must be acknowledged that this is somewhat speculative

and another, unknown factor may be responsible for the

lower levels of HRQoL in the current sample.

Correlation analyses revealed that higher self-esteem

was related to better mental health and better HRQoL. The

significant relationships between higher mental health dif-

ficulty and lower levels of quality of life in all domains,

including social functioning, are consistent with the results

of previous research (Casier et al., 2011; Quittner et al.,

2008). There are no studies which have considered the role

of self-esteem in relation to mental health and HRQoL in

the CF population and the current research study fills this

gap in the published research literature. The significant

relationships found within this study mirror the association

between mental health and self-esteem in the general

population (Mann et al., 2004). In addition, as suggested by

Brucefors et al. (2011), they indicate that self-esteem may

have a role to play in low levels of social functioning and

psychological wellbeing of adults with CF.

Hierarchical regression revealed that emotional func-

tioning as measured by the CFQ-R and Rosenberg self-

esteem scores were significant predictors of mental health

symptoms after controlling for gender. Physical, role and

social functioning were not significant predictors. This

supports previous research indicating that physical func-

tioning is not solely or directly responsible for mental

health difficulties (e.g. Casier et al., 2011). However, the

published literature does highlight the potential negative

impact that mental health difficulties can have on adher-

ence to treatment and, subsequently, physical health status

(Cruz, Marciel, Quittner, & Schechter et al., 2009). The

significant relationship between the emotional functioning

subscale of the CFQ-R and mental health symptoms as

measured by the CORE-OM is perhaps unsurprising as

both questionnaires are related to emotional symptoms and

psychological wellbeing. Despite the fact that the CFQ-R

emotional functioning subscale is not designed to be a sole

measure of mental health, it is encouraging that scores on

this subscale are predictive of symptoms measured by an

established, valid and reliable measure of mental health.

The findings from these data appear intuitive and cor-

roborate previous research with the general population.

However, this is the first study to test the role of self-

esteem in functioning and mental health. It is important to

supply empirical evidence to support assumptions that

relationships between psychological variables and con-

structs are also found within adults with CF who, by the

nature of their condition, may face additional challenges

with regard to their physical, emotional and social

wellbeing.

Table 4 Hierarchical regression model predicting mental health

symptoms as measured by the CORE-OM total score in adults with

CF

Variables DF df t b DR2

Block 1 6.15* 1, 69 .08*

Gender 69 2.48 .29*

Block 2 49.10** 6, 64 .81**

CFQ-R physical

functioning

64 .03 .00

CFQ-R emotional

functioning

64 -6.21 -.57**

CFQ-R role

functioning

64 .34 .03

CFQ-R social

functioning

64 .96 .09

Rosenberg self-esteem

total

64 -5.83 -.49**

* Significant at p \ .05; ** Significant at p \ .001

J Clin Psychol Med Settings

123

Limitations

It is recognised that participants were self-selected and the

sample is therefore unlikely to be fully representative of the

target population. Secondly, participants were asked to

self-report their most recent FEV1% predicted score and

the accuracy of this cannot be guaranteed. Although it was

seen that the average lung function fell in the region of

previous studies of patients with CF recruited from clinical

settings (Sawicki et al., 2011), the limited available data

regarding FEV1% predicted and concerns regarding the

accuracy meant this variable was not included in the

regression analyses. Additionally, FEV1% predicted is only

a single variable of physical health and future research may

benefit from a more comprehensive physical health mea-

sure. Thirdly, the CORE-OM 34 was selected for its con-

sideration of a wide range of symptoms rather than a focus

on only one subset of symptoms, e.g. depression or anxiety.

While data were presented as the proportion of participants

who scored above recommended clinical thresholds to

allow comparison with previous studies, direct compari-

sons were difficult due to the use of different measures.

Clinical Implications and Future Research

This study of adults with CF contributes to the current

literature surrounding the mental health needs and well-

being of adults with CF. Its novel contribution is in the

exploration of self-esteem and HRQoL and their significant

contribution in a regression model predicting mental health

symptoms. For CF teams who make regular use of the

CFQ-R in reviewing and managing the care of their

patients, high scores on the emotional functioning subscale

indicate that further assessment of mental health may be

required. In addition, the RSES is a short, simple and freely

available measure which could be integrated into assess-

ment or annual reviews to provide further insight into

patients’ emotional wellbeing. Future studies which take a

longitudinal approach in assessing relevant factors in psy-

chological wellbeing and mental health may help disen-

tangle the respective contributions such variables as

gender, physical health status and self-esteem over time.

Factors which influence resilience in the face of the chal-

lenges CF brings would also be worthy of further research,

building on a recent study considering the role of accep-

tance in wellbeing of patients with CF (Casier et al., 2011).

The current study adds to the growing body of research

illustrating the higher levels of mental health difficulty in

adults with CF compared to the general population. Such

difficulties have wide-ranging implications for HRQoL and

treatment adherence (Quittner et al., 2008) and it is

important that these needs are recognized. Given the gen-

der differences in mental health difficulties and self-esteem

in the present study, it may be useful for clinical psy-

chologists working within CF services to remain particu-

larly vigilant for difficulties in females. In addition, in light

of the relationship between poorer self-esteem and greater

mental health difficulty irrespective of gender, the wider

health team could be supported to recognize signs of low

self-esteem and early detection of mental health difficulty.

Where clinical levels of distress are identified, psycho-

logical therapies may be a treatment option and may use-

fully focus on self-esteem. Further empirical research

assessing the efficacy of psychological therapies in CF is

still required (Glasscoe & Quittner, 2008). The value of

emotional, psychological and peer support for people with

long-term physical health conditions has been recently

recognized by the Scottish Government (Scottish Govern-

ment & Long Term Conditions Alliance Scotland, 2011). A

current randomized control trial in the USA is examining

the influence of CF-specific online support on perceived

social support, adherence and CF knowledge (Marciel,

Saiman, Quittell, Dawkins, & Quittner, 2010). This will be

a useful addition to the literature and may be followed by

further research to clarify the efficacy of online support for

people with CF. The current sample of participants with CF

who used online resources experienced lower levels of

HRQoL than reported in previous literature and greater

mental health difficulty compared to the general popula-

tion. Future research making a direct comparison between

people with CF who do and do not make use of the internet

for additional CF peer support could explore this further.

References

Abbott, J. (2009). Health-related quality of life measurement in cystic

fibrosis: Advances and limitations. Chronic Respiratory Disease,6, 31–41.

Abbott, J., Conway, S., Etherington, C., Fitzjohn, J., Gee, L., Morton,

A., et al. (2000). Perceived body image and eating behavior in

young adults with cystic fibrosis and their healthy peers. Journalof Behavioral Medicine, 23, 501–517.

Abbott, J., Morton, A., Musson, H., Conway, S., Etherington, C., Gee,

L., et al. (2007). Nutritional status, perceived body image and

eating behaviours in adults with cystic fibrosis. Clinical Nutri-tion, 26, 91–99.

Anderson, D. L., Flume, P. A., & Hardy, K. K. (2001). Psychological

functioning of adults with cystic fibrosis. Chest, 119, 1079–1084.

Barker, D. H., Driscoll, K. A., Modi, A. C., Light, M. J., & Quittner, A.

L. (2011). Supporting cystic fibrosis disease management during

adolescence: The role of family and friends. Child: Care, Healthand Development. doi:10.1111/j.1365-2214.2011.01286.x.

Brucefors, A. B., Hjelte, L., & Hochwalder, J. (2011). Mental health

and sense of coherence among Swedish adults with cystic

fibrosis. Scandinavian Journal of Caring Sciences, 25, 365–372.

Bryon, M., & Stramik. (2005). Cystic Fibrosis Questionnaire—Revised(English language version). New York: Forest Laboratories.

Casier, A., Goubert, L., Theunis, M., Huse, D., De Baets, F., Matthys,

D., et al. (2011). Acceptance and well-being in adolescents and

J Clin Psychol Med Settings

123

young adults with CF. Journal of Pediatric Psychology, 36,

476–487.

Cella, D. (1998). Quality of life. In J. C. Holland (Ed.), Psychoon-cology (pp. 1135–1146). New York: Oxford University Press.

Cruz, I., Marciel, K. K., Quittner, A. L., & Schechter, M. S. (2009).

Anxiety and depression in cystic fibrosis. Seminars in Respira-tory and Critical Care Medicine, 30, 569–578.

Evans, C., Connell, J., Barkham, M., Margison, F., McGrath, G.,

Mellor-Clark, J., et al. (2002). Towards a standardised brief

outcome measure: Psychometric properties and utility of the

CORE-OM. British Journal of Psychiatry, 180, 51–60.

Evans, C., Mellor-Clark, J., Margison, F., Barkham, M., McGrath, G.,

Connell, J., et al. (2000). Clinical Outcomes in Routine

Evaluation: The CORE-OM. Journal of Mental Health, 9,

247–255.

Forgeron, P. A., King, S., Stinson, J. N., McGrath, P. J., MacDonald,

A. J., & Chambers, C. T. (2010). Social functioning and peer

relationships in children and adolescents with chronic pain: A

systematic review. Pain Research and Management: TheJournal of the Canadian Pain Society, 15, 27–41.

Gee, L., Abbott, J., Conway, S. P., Etherington, C., & Webb, A. K.

(2003). Quality of life in cystic fibrosis: The impact of gender,

general health perceptions and disease severity. Journal of CysticFibrosis, 2, 206–213.

Glasscoe, C. A., & Quittner, A. L. (2008). Psychological interventions

for people with cystic fibrosis and their families. CochraneDatabase of Systematic Reviews (3), Art. No. CD003148.

Goldbeck, L., Besier, T., Singer, S., Quittner, A. L., Webb, A. K., &

Group, T. (2010). Depression in German patients with cystic

fibrosis. Chest, 138, 929–936.

Hasenecz, N. M. (2010). Cystic fibrosis social work—Support on a

changing journey. Social Work Today, 10, 22–26.

Mann, M., Hosman, C. M. H., Schaalma, H. P., & de Vries, N. K.

(2004). Self-esteem in a broad-spectrum approach for mental

health promotion. Health Education Research, 19, 357–372.

Marciel, K. K., Saiman, L., Quittell, L. M., Dawkins, K., & Quittner,

A. L. (2010). Cell phone intervention to improve adherence:

Cystic fibrosis care team, patient, and parent perspectives.

Pediatric Pulmonology, 45, 157–164.

Modi, A. C., Driscoll, K. A., Montag-Leifling, K., & Acton, J. D.

(2011). Screening for symptoms of depression and anxiety in

adolescents and young adults with cystic fibrosis. PediatricPulmonology, 46, 153–159.

Nick, J. A., Chacon, C. S., Brayshaw, S. J., Jones, M. C., Barboa, C.

M., Clair, C. G. S., et al. (2010). Effects of gender and age at

diagnosis on disease progression in long-term survivors of cystic

fibrosis. American Journal of Respiratory and Critical CareMedicine, 182, 614–626.

Palermo, T. M., Long, A. C., Lewandowski, A. S., Drotar, D., Quittner, A.

L., & Walker, L. S. (2008). Evidence-based assessment of health-

related quality of life and functional impairment in pediatric

psychology. Journal of Pediatric Psychology, 33, 983–996.

Quittner, A. L., Barker, D., Marciel, K., & Grimley, M. E. (2009).

Cystic fibrosis: A model for drug discovery and patient care. In

M. C. Roberts & R. G. Steele (Eds.), Handbook of pediatricpsychology (4th ed., pp. 271–286). New York: Guilford Press.

Quittner, A. L., Barker, D. H., Snell, C., Grimley, M. E., Marciel, K.,

& Cruz, I. (2008). Prevalence and impact of depression in cystic

fibrosis. Current Opinion in Pulmonary Medicine, 14, 582–588.

Quittner, A. L., Buu, A., Messer, M. A., Modi, A. C., & Watrous, M.

(2005). Development and validation of the Cystic Fibrosis

Questionnaire in the United States: A health-related quality-

of-life measure for cystic fibrosis. Chest, 128, 2347–2354.

Quittner, A. L., Buu, A., Watrous, M., & Davis, M. A. (2002). CysticFibrosis Questionnaire—Revised. New York: Forest Laboratories.

Rosenberg, M. (1965). Society and the adolescent self-image.

Princeton, NJ: Princeton University Press.

Sawicki, G. S., Rasouliyan, L., McMullen, A. H., Wagener, J. S.,

McColley, S. A., Pasta, D. J., et al. (2011). Longitudinal

assessment of health-related quality of life in an observational

cohort of patients with cystic fibrosis. Pediatric Pulmonology,46, 36–44.

Scottish Government, & Long Term Conditions Alliance Scotland.

(2011). Emotional support matters: Emotional and psycholog-ical support needs of people with long term conditions. Retrieved

10 Oct 2012 from www.alliance-scotland.org.uk/download/

library/lib_4e3ab46435632/.

Simpson, J., Hillman, R., & Crawford, T. (2010). Self-esteem and

self-disgust both mediate the relationships between dysfunc-

tional cognitions and depressive symptoms. Motivation andEmotion, 34, 399–406.

Sinclair, S. J., Blais, M. A., Gansler, D. A., Sandberg, E., Bistis, K., &

LoCicero, A. (2010). Psychometric properties of the Rosenberg

Self-esteem Scale: Overall and across demographic groups living

within the United States. Evaluation and the Health Professions,33, 56–80.

Singleton, N., Bumpstead, R., O’Brien, M., Lee, A., & Meltzer, H.

(2001). Psychiatric morbidity among adults living in privatehouseholds, 2000. London: ONS.

White, T., Miller, J., Smith, G. L., McMahon, W. M., White, T.,

Miller, J., et al. (2009). Adherence and psychopathology in

children and adolescents with cystic fibrosis. European Childand Adolescent Psychiatry, 18, 96–104.

J Clin Psychol Med Settings

123