Does a symptom management intervention affect depression among cancer patients: Results from a clinical trial

Helping Her Heal-Ghana: A pilot feasibility study of a culturally adapted educational counseling intervention for spouse caregivers of women with breast cancer

INTRODUCTION

Breast cancer is the leading cancer in Ghana, Africa, accounting for 31% of all cancers in women. The effects of breast cancer are not limited to the woman but also impact the spouse's anxiety, depressed mood, and coping behavior. Helping Her Heal (HHH)-Ghana is a culturally adapted evidenced-based intervention with potential to improve health outcomes of spouse caregivers.

OBJECTIVES

The purpose of the study was to ascertain the feasibility, acceptability, and short-term impact of HHH-Ghana, a culturally adapted evidenced-based intervention for spouses of women with breast cancer in Ghana.

METHODS

The study used a single group pre-post design. Participants (n = 14) were recruited from medical care providers and were eligible if they were spouse caregivers of wives with Stage I, II, or III breast cancer, were 18 years or older, and had been living with their wives for at least 6 months. Data were obtained by spouse self-report on standardized measures of depressed mood, anxiety, self-care skills, self-efficacy to support their wife, self-efficacy to carry out their own self-care, and the quality of marital communication about breast cancer. Exit interviews were additionally obtained to describe the gains spouses attributed to their participation in the study.

RESULTS

The HHH-Ghana study was feasible and acceptable. Spouses actively engaged in each intervention session and completed the at-home assignments; retention was 87.5%. Spouses significantly improved on standardized measures of anxiety (p = 0.010), depressed mood (p = 0.002), self-care skills (p = 0.006), and their self-efficacy in supporting their wife (p = 0.001) and in carrying out their own self-care (p = 0.011). Although there was no statistically significant change in marital communication, spouses reported in their exit interviews that the intervention enabled them to communicate better and be more attentive listeners to their wives.

SIGNIFICANCE OF RESULTS

Results warrant a larger clinical trial in Ghana.

Behavioral-Emotional Functioning of Children of Parents with Early Compared to Advanced Cancer

Background: Parental cancer represents a substantial psychological threat to children, but little is known about the relative impact of advanced compared to early-stage cancer on children's behavioral-emotional functioning. Objectives: To compare the behavioral-emotional functioning in children of parents with early compared to advanced cancer. Design: Single occasion, two-group design with historical comparison group. Setting/Participants: Participants were recruited through cancer centers, oncologists, service organizations, and self-referrals in the United States. Eligible parents had advanced or early-stage cancer, a child 5-17 years old, and spoke and read English. The Child Behavior Checklist was administered to parents to assess their children's Internalizing and Externalizing Problems. Data were obtained from 236 diagnosed parents, 176 with early and 57 with advanced cancer. Results: Internalizing and Externalizing Problems and Anxious/Depressed Mood were significantly greater for children of parents with advanced compared to early-stage cancer, even after controlling for covariates. Differences in children's functioning were not affected by parents' anxiety, depressed mood, treatment, or measures of social determinants of health. Conclusions: This is the first study to systematically compare the effects of parents' stage of cancer on children's behavioral-emotional functioning while controlling for potential confounders. Results demonstrate significantly elevated levels of behavioral-emotional problems in children affected by advanced compared to early-stage cancer that were explained by parents' stage of cancer, not other sources. Future studies need to identify mutable protective and risk factors to reduce the threat of parental cancer.

A pilot feasibility study of Conexiones, a telephone-delivered cancer parenting education program for Hispanic mothers

OBJECTIVE

To test the short-term impact of Conexiones, a culturally adapted cancer parenting education program for diagnosed child-rearing Hispanic mothers.

DESIGN

Single group, pre-post-test design.

SAMPLE

18 U.S. Hispanic mothers diagnosed within 2 years with early-stage cancer (0-III) raising a child (5-17 years).

METHODS

Participants completed consent, baseline measures, and five telephone-delivered Conexiones sessions at 2-week intervals from trained patient educators in English or Spanish. Outcomes were assessed at baseline and at 3 months.

RESULTS

Maternal depressed mood, parenting self-efficacy, and parenting quality significantly improved. Children's anxious/depressed mood tended to significantly improve. Outcomes did not co-vary with mothers' level of acculturation.

CONCLUSIONS

Conexiones appears to positively improve Hispanic mothers' distress and parenting competencies; efficacy testing is warranted within a larger randomized control trial.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS

A brief, culturally adapted cancer parenting education program has potential to enhance Hispanic mothers' and children's behavioral-emotional adjustment to a mother's cancer.

Psychiatric and Psychosomatic Consultation-Liaison Services in General Hospitals: A Systematic Review and Meta-Analysis of Effects on Symptoms of Depression and Anxiety

BACKGROUND

Psychiatric and psychosomatic consultation-liaison services (CL) are important providers of diagnosis and treatment for hospital patients with mental comorbidities and psychological burdens.

OBJECTIVE

To perform a systematic review and meta-analysis investigating the effects of CL on depression and anxiety.

METHODS

Following PRISMA guidelines, a systematic literature search was conducted until 2017. Included were published randomized controlled trials using CL interventions with adults in general hospitals, treatment as usual as control groups, and depression and/or anxiety as outcomes. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Level of integration was assessed using the Standard Framework for Levels of Integrated Healthcare. Meta-analyses were performed using random effects models and meta-regression for moderator effects.

RESULTS

We included 38 studies (9,994 patients). Risk of bias was high in 17, unclear in 15, and low in 6 studies. Studies were grouped by type of intervention: brief interventions tailored to the patients (8), interventions based on specific treatment manuals (19), and integrated, collaborative care (11). Studies showed small to medium effects on depression and anxiety. Meta-analyses for depression yielded a small effect (d = -0.19, 95% CI: -0.30 to -0.09) in manual studies and a small effect (d = -0.33, 95% CI: -0.53 to -0.13) in integrated, collaborative care studies, the latter using mostly active control groups with the possibility of traditional consultation.

CONCLUSIONS

CL can provide a helpful first treatment for symptoms of depression and anxiety. Given that especially depressive symptoms in medically ill patients are long-lasting, the results underline the benefit of integrative approaches that respect the complexity of the illness.

A pilot feasibility study of a group-delivered cancer parenting program: Enhancing Connections-Group

OBJECTIVE

The purpose of this study was to examine the feasibility and short-term impact of a 5-session fully manualized, group-delivered cancer parenting education program to diagnosed parents or surrogate parents with a school-age child.

DESIGN

Single group, pre-post-test design with intent to treat analysis.

SAMPLE

A total of 16 parents completed the program who were diagnosed within 12 months with non-metastatic cancer of any type (Stages 0-III), read and wrote English, had a child 5-17 years old who knew the parent's diagnosis.

METHODS

Assessments occurred at baseline and at 2 months post-baseline on standardized measures of parental depressed mood, anxiety, parenting self-efficacy, parenting quality, parenting skills and child behavioral-emotional adjustment.

FINDINGS/RESULTS

The program was feasible and well accepted: 16/18 (89%) of the enrolled participants were included in the intent to treat analysis. Program staff were consistently positive and enthusiastic about the demonstrated skills they observed in group attendees during the group-delivered sessions, including the emergence of support between attendees. Outcomes on all measures improved between baseline and post-intervention; changes were statistically significant on measures of parents' anxiety, parents' self-efficacy, parents' skills, and parenting quality.

CONCLUSIONS

The group-delivered Enhancing Connections cancer parenting program has potential to improve behavioral-emotional outcomes on standardized measures of skills and emotional adjustment in parents, parent-surrogates and children. Future testing is warranted.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS

After a brief training, a fully manualized cancer parenting program can enhance parenting competencies and parent-reported child outcomes.

Enhancing Connections-Palliative Care: A Quasi-Experimental Pilot Feasibility Study of a Cancer Parenting Program

Background: In 2018, >75,000 children were newly affected by the diagnosis of advanced cancer in a parent. Unfortunately, few programs exist to help parents and their children manage the impact of advanced disease together as a family. The Enhancing Connections-Palliative Care (EC-PC) parenting program was developed in response to this gap. Objective: (1) Assess the feasibility of the EC-PC parenting program (recruitment, enrollment, and retention); (2) test the short-term impact of the program on changes in parent and child outcomes; and (3) explore the relationship between parents' physical and psychological symptoms with program outcomes. Design: Quasi-experimental two-group design employing both within- and between-subjects analyses to examine change over time and change relative to historical controls. Parents participated in five telephone-delivered and fully manualized behavioral intervention sessions at two-week intervals, delivered by trained nurses. Behavioral assessments were obtained at baseline and at three months on parents' depressed mood, anxiety, parenting skills, parenting self-efficacy, and symptom distress as well as children's behavioral-emotional adjustment (internalizing, externalizing, and anxiety/depression). Subjects: Parents diagnosed with advanced or metastatic cancer and receiving noncurative treatment were eligible for the trial provided they had one or more children aged 5-17 living at home, were able to read, write, and speak English, and were not enrolled in a hospice program. Results: Of those enrolled, 62% completed all intervention sessions and post-intervention assessments. Within-group analyses showed significant improvements in parents' self-efficacy in helping their children manage pressures from the parent's cancer; parents' skills to elicit children's cancer-related concerns; and parents' skills to help their children cope with the cancer. Between-group analyses revealed comparable improvements with historical controls on parents' anxiety, depressed mood, self-efficacy, parenting skills, and children's behavioral-emotional adjustment. Conclusion: The EC-PC parenting program shows promise in significantly improving parents' skills and confidence in supporting their child about the cancer. Further testing of the program is warranted.

Systematic screening and assessment of psychosocial well-being and care needs of people with cancer

BACKGROUND

Receiving a diagnosis of cancer and the subsequent related treatments can have a significant impact on an individual's physical and psychosocial well-being. To ensure that cancer care addresses all aspects of well-being, systematic screening for distress and supportive care needs is recommended. Appropriate screening could help support the integration of psychosocial approaches in daily routines in order to achieve holistic cancer care and ensure that the specific care needs of people with cancer are met and that the organisation of such care is optimised.

OBJECTIVES

To examine the effectiveness and safety of screening of psychosocial well-being and care needs of people with cancer. To explore the intervention characteristics that contribute to the effectiveness of these screening interventions.

SEARCH METHODS

We searched five electronic databases in January 2018: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, and CINAHL. We also searched five trial registers and screened the contents of relevant journals, citations, and references to find published and unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised controlled trials (NRCTs) that studied the effect of screening interventions addressing the psychosocial well-being and care needs of people with cancer compared to usual care. These screening interventions could involve self-reporting of people with a patient-reported outcome measures (PROMs) or a semi-structured interview with a screening interventionist, and comprise a solitary screening intervention or screening with guided actions. We excluded studies that evaluated screening integrated as an element in more complex interventions (e.g. therapy, coaching, full care pathways, or care programmes).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed methodological quality for each included study using the Cochrane tool for RCTs and the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool for NRCTs. Due to the high level of heterogeneity in the included studies, only three were included in meta-analysis. Results of the remaining 23 studies were analysed narratively.

MAIN RESULTS

We included 26 studies (18 RCTs and 8 NRCTs) with sample sizes of 41 to 1012 participants, involving a total of 7654 adults with cancer. Two studies included only men or women; all other studies included both sexes. For most studies people with breast, lung, head and neck, colorectal, prostate cancer, or several of these diagnoses were included; some studies included people with a broader range of cancer diagnosis. Ten studies focused on a solitary screening intervention, while the remaining 16 studies evaluated a screening intervention combined with guided actions. A broad range of intervention instruments was used, and were described by study authors as a screening of health-related quality of life (HRQoL), distress screening, needs assessment, or assessment of biopsychosocial symptoms or overall well-being. In 13 studies, the screening was a self-reported questionnaire, while in the remaining 13 studies an interventionist conducted the screening by interview or paper-pencil assessment. The interventional screenings in the studies were applied 1 to 12 times, without follow-up or from 4 weeks to 18 months after the first interventional screening. We assessed risk of bias as high for eight RCTs, low for five RCTs, and unclear for the five remaining RCTs. There were further concerns about the NRCTs (1 = critical risk study; 6 = serious risk studies; 1 = risk unclear).Due to considerable heterogeneity in several intervention and study characteristics, we have reported the results narratively for the majority of the evidence.In the narrative synthesis of all included studies, we found very low-certainty evidence for the effect of screening on HRQoL (20 studies). Of these studies, eight found beneficial effects of screening for several subdomains of HRQoL, and 10 found no effects of screening. One study found adverse effects, and the last study did not report quantitative results. We found very low-certainty evidence for the effect of screening on distress (16 studies). Of these studies, two found beneficial effects of screening, and 14 found no effects of screening. We judged the overall certainty of the evidence for the effect of screening on HRQoL to be very low. We found very low-certainty evidence for the effect of screening on care needs (seven studies). Of these studies, three found beneficial effects of screening for several subdomains of care needs, and two found no effects of screening. One study found adverse effects, and the last study did not report quantitative results. We judged the overall level of evidence for the effect of screening on HRQoL to be very low. None of the studies specifically evaluated or reported adverse effects of screening. However, three studies reported unfavourable effects of screening, including lower QoL, more unmet needs, and lower satisfaction.Three studies could be included in a meta-analysis. The meta-analysis revealed no beneficial effect of the screening intervention on people with cancer HRQoL (mean difference (MD) 1.65, 95% confidence interval (CI) -4.83 to 8.12, 2 RCTs, 6 months follow-up); distress (MD 0.0, 95% CI -0.36 to 0.36, 1 RCT, 3 months follow-up); or care needs (MD 2.32, 95% CI -7.49 to 12.14, 2 RCTs, 3 months follow-up). However, these studies all evaluated one specific screening intervention (CONNECT) in people with colorectal cancer.In the studies where some effects could be identified, no recurring relationships were found between intervention characteristics and the effectiveness of screening interventions.

AUTHORS' CONCLUSIONS

We found low-certainty evidence that does not support the effectiveness of screening of psychosocial well-being and care needs in people with cancer. Studies were heterogeneous in population, intervention, and outcome assessment.The results of this review suggest a need for more uniformity in outcomes and reporting; for the use of intervention description guidelines; for further improvement of methodological certainty in studies and for combining subjective patient-reported outcomes with objective outcomes.

Helping Her Heal: Randomized clinical trial to enhance dyadic outcomes in couples

OBJECTIVE

The objective of this study was to test the short-term efficacy of a brief, fully manualized marital communication and interpersonal support intervention for couples facing recently diagnosed breast cancer.

METHODS

A total of 322 women diagnosed within 6 months with stages 0 to III breast cancer and their 322 spouse caregivers were enrolled. Spouses in the experimental group received five 30- to 60-minute intervention sessions at 2-week intervals by master's-prepared patient educators; controls received the booklet, "What's Happening to the Woman I Love?" Outcomes were assessed at 3, 6, and 9 months using the linear mixed models within an intent-to-treat analysis.

RESULTS

Compared with controls, at 3 months, spouse caregivers significantly improved on standardized measures of depressed mood, anxiety, cancer-related marital communication, interpersonal support, and self-care. All differences except depressed mood and anxiety were sustained at 9 months. Wives significantly improved at 3 months on marital communication and positive appraisal of spouses' interpersonal support; gains remained significant at 9 months. Compared with controls on chemotherapy, wives in the experimental group additionally improved on depressed mood and tended to improve on anxiety.

CONCLUSIONS

A brief, fully manualized intervention delivered directly to spouse caregivers early in the course of their wives' medical treatment improves caregivers' self-care and behavioral-emotional adjustment and wives' positive view of their spouses' support and communication. The brevity and manualized structure of the intervention argue strongly for its scalability, use in cost-sensitive settings, and its potential dissemination through e-health channels.

The Enhancing Connections-Telephone study: a pilot feasibility test of a cancer parenting program

PURPOSE

The purposes of the study were to (1) test the short-term impact of a telephone-delivered cancer parenting education program, the Enhancing Connections-Telephone (EC-T) Program, on maternal anxiety, depressed mood, parenting competencies, and child behavioral-emotional adjustment and (2) compare those outcomes with outcomes achieved from an in-person delivery of the same program (EC).

METHODS

Thirty-two mothers comprised the sample for the within-group design and 77 mothers for the between-group design. Mothers were eligible if they had one or more dependent children and were recently diagnosed with stages 0-III breast cancer. Mothers in both groups received five intervention sessions at 2-week intervals from a patient educator using a fully scripted intervention manual.

RESULTS

Outcomes from the within-group analysis revealed significant improvements on maternal anxiety, parenting competencies, and the child's behavioral-emotional functioning. Outcomes from the between-group analysis showed the EC-T did as well or better than EC in positively affecting maternal anxiety, depressed mood, parenting competencies, and the child's behavioral-emotional adjustment. Furthermore, the EC-T had a significantly greater impact than the EC on maternal confidence in helping their family and themselves manage the cancer's impact and in staying calm during emotionally charged conversations about the breast cancer with their child.

CONCLUSIONS

Regardless of the channel of delivery, the Enhancing Connections Program has the potential to positively affect parenting competencies and behavioral-emotional adjustment in mothers and dependent children in the first year of stages 0-III maternal breast cancer. Its positive impact from telephone delivery holds promise for sustainability.

Putting evidence into practice: evidence-based interventions for depression

Depression is a distressing emotion that occurs during various times of the cancer trajectory. Depression often goes unrecognized and untreated, which can significantly affect cost, quality of life, and treatment adherence. The Oncology Nursing Society's Putting Evidence Into Practice depression project team reviewed current literature to identify evidence-based interventions to reduce depression in people with cancer. Pharmacologic and nonpharmacologic interventions were evaluated, and opportunities for nurses to integrate recommendations into practice are offered in this article.

The Enhancing Connections Program: a six-state randomized clinical trial of a cancer parenting program

OBJECTIVE

The purpose of this study was to test the efficacy of a cancer parenting program for child rearing mothers with breast cancer, the Enhancing Connections Program. Primary goals were to decrease maternal depressed mood and anxiety, improve parenting quality, parenting skills and confidence, and enhance the child's behavioral-emotional adjustment to maternal breast cancer.

METHOD

A total of 176 mothers diagnosed within 6 months with Stage 0 to Stage III breast cancer and their 8- to 12-year-old child were recruited from medical providers in 6 states: Washington, California, Pennsylvania, Minnesota, Arizona, and Indiana. After consenting and obtaining baseline measures, study participants were randomized into experimental or control groups. Experimental mothers received 5, 1-hr educational counseling sessions at 2-week intervals; controls received a booklet and phone call on communicating and supporting their child about the mother's cancer. Outcomes were assessed at 2 and 12 months.

RESULTS

Compared to controls, at 2 months experimental mothers significantly improved on depressed mood and parenting skills; experimental children improved on behavioral-emotional adjustment: total behavior problems, externalizing problems, and anxiety/depressed mood significantly declined. At 1 year, experimental children remained significantly less depressed than controls on both mother- and child-reported measures. The intervention failed to significantly affect parenting self-efficacy or maternal anxiety.

CONCLUSIONS

The Enhancing Connections Program benefitted mothers and children in specific areas and warrants refinement and further testing.

Testing the differential effects of symptom management interventions in cancer

OBJECTIVE

The purpose of this study was to test for moderating effects of patient characteristics on self-management interventions developed to address symptoms during cancer treatment. Patient's age, education, and depressive symptomatology were considered as potential moderators.

METHODS

A secondary analysis of data of 782 patients from two randomized clinical trials was performed. Both trials enrolled patients with solid tumors undergoing chemotherapy. After completing baseline interviews, patients were randomized to a nurse-delivered intervention versus intervention delivered by a 'coach' in trial I and to a nurse-delivered intervention versus an intervention delivered by an automated voice response system in trial II. In each of the two trials, following a six-contact 8-week intervention, patients were interviewed at week 10 to assess the primary outcome of symptom severity.

RESULTS

Although nurse-delivered intervention proved no better than the coach or automated system in lowering symptom severity, important differences in the intervention by age were found in both trials. Patients aged ≤45 years responded better to the coach or automated system, whereas those aged ≥75 years favored the nurse. Education and depressive symptomatology did not modify the intervention effects in either of the two trials. Depressive symptomatology had a significant main effect on symptom severity at week 10 in both trials (p = 0.03 and p < 0.01, respectively). Education was not associated with symptom severity over and above age and depressive symptomatology.

CONCLUSIONS

Clinicians need to carefully consider the age of the population when using or testing interventions to manage symptoms among cancer patients.

Effects of Psycho-Oncologic Interventions on Emotional Distress and Quality of Life in Adult Patients With Cancer: Systematic Review and Meta-Analysis

Purpose

This study aimed to evaluate the effects of psycho-oncologic interventions on emotional distress and quality of life in adult patients with cancer.

Methods

Literature databases were searched to identify randomized controlled trials that compared a psycho-oncologic intervention delivered face-to face with a control condition. The main outcome measures were emotional distress, anxiety, depression, and quality of life. Outcomes were evaluated for three time periods: post-treatment, ≤ 6 months, and more than 6 months. We applied standard meta-analytic techniques to analyze both published and unpublished data from the retrieved studies. Sensitivity analyses and meta-regression were used to explore reasons for heterogeneity.

Results

We retrieved 198 studies (covering 22,238 patients) that report 218 treatment-control comparisons. Significant small-to-medium effects were observed for individual and group psychotherapy and psychoeducation. These effects were sustained, in part, in the medium term (≤ 6 months) and long term (> 6 months). Short-term effects were evident for relaxation training. Studies that preselected participants according to increased distress produced large effects at post-treatment. A moderator effect was found for the moderator variable “duration of the intervention,” with longer interventions producing more sustained effects. Indicators of study quality were often not reported. Small-sample bias indicative of possible publication bias was found for some effects, particularly with individual psychotherapy and relaxation training.

Conclusion

Various types of psycho-oncologic interventions are associated with significant, small-to-medium effects on emotional distress and quality of life. These results should be interpreted with caution, however, because of the low quality of reporting in many of the trials.

Who benefits from a psychosocial counselling versus educational intervention to improve psychological quality of life in prostate cancer survivors?

OBJECTIVE

We examined selected survivor characteristics to determine what factors might moderate the response to two psychosocial interventions.

DESIGN

Seventy-one prostate cancer survivors (PCSs) were randomly assigned to either a telephone-delivered health education (THE) intervention or a telephone-delivered interpersonal counselling (TIP-C) intervention.

MEASURES

Psychological quality of life (QOL) outcomes included depression, negative and positive affect, and perceived stress.

RESULTS

For three of the psychological outcomes (depression, negative affect and stress), there were distinct advantages from participating in THE. For example, more favourable depression outcomes occurred when men were older, had lower prostate specific functioning, were in active chemotherapy, had lower social support from friends and lower cancer knowledge. Participating in the TIP-C provided a more favourable outcome for positive affect when men had higher education, prostate specific functioning, social support from friends and cancer knowledge.

CONCLUSION

Unique survivor characteristics must be considered when recommending interventions that might improve psychological QOL in PCSs. Future research must examine who benefits most and from what components of psychosocial interventions to enable clinicians to recommend appropriate psychosocial care.

The effectiveness of patient-family carer (couple) intervention for the management of symptoms and other health-related problems in people affected by cancer: a systematic literature search and narrative review

CONTEXT

Cancer is widely acknowledged to impact on the whole family. Yet, we do not know if there is benefit (or harm) from patient-family carer interventions in the context of cancer care.

OBJECTIVES

To report a systematic search for and narrative review of patient-family carer interventions tested in the context of cancer care for effect on symptoms and other health-related problems in patients and/or their family members.

METHODS

A systematic literature search was carried out using Cochrane principles. Searches were of MEDLINE, EMBASE, PsycINFO, and CINAHL databases for reported trials of patient-family carer focused interventions. Outcomes of interest were health indicators; measures of physical, psychological, social, and quality-of-life status of the patient and/or family member(s). Limits were English language; 1998 to March 2010; and adults. Relevant information was extracted, quality assessed using the Cochrane Collaboration's tool for assessing risk of bias, and presented as a narrative synthesis (meta-analysis was not appropriate).

RESULTS

The review found no empirically tested interventions for family groups (patient and two or more family members), but 22 interventions for patient-family carer partnerships (couple interventions) tested in 23 studies and reported in 27 publications. Recruitment and attrition were problematic in these studies, limiting the reliability and generalizability of their results.

CONCLUSION

In the trials of cancer couple interventions included in the review, a pattern emerged of improvement in the emotional health of cancer patients and their carers when the intervention included support for the patient-family carer relationship. Further investigation is warranted.

Outcome measures to evaluate the effectiveness of pain management in older adults with cancer

PURPOSE/OBJECTIVES

To identify the most appropriate outcome measures to determine the effectiveness of pain management plans in older adults with cancer.

DATA SOURCES

PubMed literature searches, medical and nursing textbooks, and clinical experience.

DATA SYNTHESIS

Unrelieved chronic pain can have a significant impact on older adults' activity levels and their ability to function. Hence, effective pain management in older adults requires a comprehensive approach, including assessment of functional outcomes. Because the goals of pain management are broad, healthcare professionals should use an array of functional outcome measures along with pain intensity ratings to better assess the effectiveness of analgesic medications.

CONCLUSIONS

Particularly in older adults, evaluation of functional outcomes provides a better indication of the effectiveness of pain management strategies than pain intensity ratings. Appropriate outcome measures for older adults in the outpatient setting include pain relief, physical functioning, emotional functioning, patients' ratings of global improvement and satisfaction with treatment, and symptoms and adverse effects associated with analgesic medications.

IMPLICATIONS FOR NURSING

Healthcare providers should manage pain in older adults with cancer in an interdisciplinary environment with pharmacologic and nonpharmacologic interventions. The primary goals are decreasing pain and improving function and quality of life.

Deconstruction of nurse-delivered patient self-management interventions for symptom management: factors related to delivery enactment and response

This research examines the processes by which patient self-management interventions are related to symptom responses among cancer patients. A total of 333 patients from two randomized clinical trials were combined. Each patient received a six-contact 8-week patient self-management intervention delivered by a nurse to address symptoms. Nurses' decisions to deliver the strategies, patient enactment of strategies, and their success were investigated using patient- and symptom-level characteristics. Generalized estimating equation modeling accounted for clustering of symptoms and strategies delivered for each symptom within patient. Patient self-management intervention strategies were classified into four classes. Strategies were delivered by nurses for symptoms with higher interference and longer duration. Patient and symptom factors were related to enactment strategies. Symptom responses were related to number of strategies tried by patients. Delivery and enactment of strategies were related to both patient and symptom characteristics.

Cognitive-behavioural therapy for depression in people with a somatic disease: meta-analysis of randomised controlled trials

BACKGROUND

Meta-analyses on psychological treatment for depression in individuals with a somatic disease are limited to specific underlying somatic diseases, thereby neglecting the generalisability of the interventions.

AIMS

To examine the effectiveness of cognitive-behavioural therapy (CBT) for depression in people with a diversity of somatic diseases.

METHOD

Meta-analysis of randomised controlled trials evaluating CBT for depression in people with a somatic disease. Severity of depressive symptoms was pooled using the standardised mean difference (SMD).

RESULTS

Twenty-nine papers met inclusion criteria. Cognitive-behavioural therapy was superior to control conditions with larger effects in studies restricted to participants with depressive disorder (SMD = -0.83, 95% CI -1.36 to -0.31, P<0.001) than in studies of participants with depressive symptoms (SMD = -0.16, 95% CI -0.27 to -0.06, P = 0.001). Subgroup analyses showed that CBT was not superior to other psychotherapies.

CONCLUSIONS

Cognitive-behavioural therapy significantly reduces depressive symptoms in people with a somatic disease, especially in those who meet the criteria for a depressive disorder.

A pilot study of an automated voice response system and nursing intervention to monitor adherence to oral chemotherapy agents

This study was designed to develop and test a system to monitor adherence with nonhormonal oral chemotherapeutic agents using an automated voice response (AVR) system plus nursing intervention. Participants were patients diagnosed with solid tumor cancers, primarily breast, colon, and lung cancers, who received the Symptom Management Toolkit and participated in an interview for symptom severity, satisfaction, and beliefs about oral agents. Patients received weekly AVR calls, which assessed adherence to oral agents and severity of 15 symptoms. Patients who reported adherence of below 100% of the prescribed oral agents or symptoms of 4 or greater (0-10 scale) for 3 consecutive weeks were called by a nurse for assistance with symptom management and adherence to oral chemotherapy medications. After the 8 weekly AVR calls, patients participated in a follow-up interview and medical record review. Participants were 30 oncology patients who were ambulatory and treated at 2 cancer centers in Midwest United States. The results indicate 23.3% nonadherence rate to oral chemotherapy medications due to symptoms and forgetting to take the medication. An association between symptom management and adherence was found. Symptom severity and beliefs about medications were not significantly different between adherent and nonadherent patients. This pilot study demonstrated the ability to accrue patients for a longitudinal trial and informed intervention design while providing guidance for future interventions and research studies.

Analyzing symptom management trials: the value of both intention-to-treat and per-protocol approaches

PURPOSE/OBJECTIVES

Two analytical approaches are described for a randomized trial testing interventions for symptom management.

DESIGN

To compare an intention-to-treat with a perprotocol approach.

SETTING

Patients were accrued from six cancer centers.

SAMPLE

94 men and 140 women with solid tumors were accrued.

METHODS

An intention-to-treat approach (as randomized) and per-protocol analyses (at least one symptom reaching threshold and one follow-up intervention) were compared. The analysis determines how each approach affects results. A two-arm, six-contact, eight-week trial was implemented. In one arm, nurses followed a cognitive behavioral protocol. In the second arm, a non-nurse coach referred patients to a symptom management guide.

MAIN RESEARCH VARIABLES

Trial arm; summed severity scores; interference-based severity categories at intake, 10 weeks, and 16 weeks; site; and stage of cancer.

FINDINGS

Each arm produced a reduction in severity at 10 and 16 weeks with no differences between arms. In the per-protocol analyses, symptoms reported at the first contact required more time to resolve. Older patients exposed to the nurse arm resolved in fewer contacts.

CONCLUSIONS

The intention-to-treat analyses indicated that both arms were successful but offered few insights into how symptoms or patients influenced severity. Per-protocol analyses (intervention and dose), when, and which strategies affected symptoms.

IMPLICATIONS FOR NURSING

Each analytical strategy serves a purpose. Intention-to-treat defines the success of a trial. Per-protocol analyses allow nurses to pose clinical questions about response and dose of the intervention. Nurses should participate in analyses of interventions to understand the conditions where interventions are successful.

Controlled trial of nursing interventions to improve health outcomes of older African American women with type 2 diabetes

BACKGROUND

Type 2 diabetes affects one in five African American women older than 60 years. These women face distinct challenges in managing diabetes self-care. Therefore, tailored self-care interventions for this population need to be developed and tested.

OBJECTIVES

The effectiveness of a tailored, four-visit, in-home symptom-focused diabetes intervention with and without booster telephone calls was compared with an attentional control focused on skills training for weight management and diet.

METHODS

African American women (n = 180; >55 years old, Type 2 diabetes mellitus >1 year, HbA1c >7%) were randomly assigned to the intervention or attentional control condition. Half the intervention participants were assigned to also receive a telephone-delivered booster intervention. Participants were evaluated at baseline and 3, 6, and 9 months.

RESULTS

: Baseline HbA1 was 8.3 in the intervention group (n = 60), 8.29 in the intervention with booster group (n = 55), and 8.44 in the attentional control condition (n = 59). HbA1c declined significantly in the whole sample (0.57%) with no differences between study arms. Participants in the booster arm decreased HbA1c by 0.76%. Symptom distress, perceived quality of life, impact of diabetes, and self-care activities also improved significantly for the whole sample with no significant differences between study arms.

DISCUSSION

Parsimonious interventions of four in-person visits yielded clinically significant decreases in HbA1c. Although the weight and diet program was intended as an attentional control, the positive effects suggest it met a need in this population. Because the contents of both the intervention and the attentional control were effective despite different approaches, a revised symptom-focused intervention that incorporates weight and diet skills training may offer even better results.

Computer-mediated patient education: opportunities and challenges for supporting women with ovarian cancer

A majority of women with ovarian cancer will face recurrent disease despite receiving aggressive chemotherapy at the time of diagnosis. Given the complex medical and psychosocial needs of women with ovarian cancer and the time constraints within busy clinical settings, providing women with the necessary education related to their disease and treatments can be challenging. The advent of computers and web-based technologies has created new opportunities for educating cancer patients and supporting them to better cope with their disease. This article reviews prior studies of computer-based patient education interventions to identify key intervention components and other factors associated with improved patient outcomes. Opportunities for using computer-based technologies to support women with ovarian cancer are discussed and WRITE Symptoms (a Written Representational Intervention To Ease Symptoms), a web-based, symptom management intervention for women with recurrent ovarian cancer, is introduced.

Helping Her Heal: a pilot study of an educational counseling intervention for spouses of women with breast cancer

Breast cancer is known to cause substantial anxiety, depressed mood, and diminished marital functioning in the diagnosed woman's spouse. Despite the scope and magnitude of these issues, few intervention studies have included spouses or addressed the causes of their lower functioning. The purpose of this pilot study was to evaluate the short-term impact of a 5-session, clinic-based, educational counseling intervention for spouses whose wife was recently diagnosed with early stage breast cancer. The goals of the intervention were to enhance spouses' skills and confidence to communicate and interpersonally support his wife about the breast cancer as well as improve spouses' self-care, depressed mood, anxiety, and marital adjustment. Pre-post-test results obtained from 20 spouses from valid and reliable standardized questionnaires showed significant improvements in spouses' depressed mood, anxiety, skills, self-confidence, and self-care. Confidential post-intervention interviews with spouses and wives included detailed examples of positive changes in the spouse's communication and support to his wife about the breast cancer, diminished tension in the spouse, and improved quality in the couple's relationship. Further evaluation of the Helping Her Heal Program is warranted within a clinical trial.

Advancing the science in the measurement of health care quality influenced by nurses

A robust set of quality measures is essential to provide consumers with a vehicleto evaluate nurses' contributions to the care of hospitalized patients, providers, and systems with a set of nursing processes and outcomes to guide quality improvement, and insurers with indicators to reward hospitals for high quality nursing services. The processes employed by the Nursing Care Performance Measures Steering Committee convened by the National Quality Forum (NQF) in 2004 resulted in the endorsement of 15 indicators of health care quality influenced by nurses and contributed to the identification of significant gaps in measurement and priority areas for future research. This critical review of the state of the science related to health care processes and outcomes that reflect nurses' contributions to the quality of care for hospitalized patients is intended to push the boundaries in the measurement of nursing performance. Specific recommendations for future research and measure development are presented.

CBT for emotional distress of people with cancer: some personal observations

The detrimental effect of a helpless coping response on the quality of life of cancer patients is well documented. Helplessness is significantly related to emotional distress. There is also evidence that this coping response is an independent prognostic factor associated with a significantly increased risk of disease recurrence and death. These findings highlight the need to develop specific strategies to enable patients to overcome helplessness. Recent research in patients with advanced cancer indicates that emotional distress appears to be caused by low levels of positive effect. Consequently, attention should be paid to the much neglected study of positive psychological states such as fighting spirit and resilience. In the meantime, some suggestions-based on clinical experience-of inducing and fostering positive effect in our patients are outlined.

Psychosocial and behavioral interventions for chronic medical conditions

PURPOSE OF REVIEW

This paper critically reviews recent studies that have used behavioral or psychosocial interventions aimed at preventing type 2 diabetes mellitus, cardiovascular disease and HIV/AIDS as well as the psychosocial management of cardiovascular disease, HIV and cancer.

RECENT FINDINGS

Behavioral (lifestyle) interventions can decrease risk of type 2 diabetes mellitus and cardiovascular disease. Psychosocial interventions have proven efficacy for alleviating distress in patients medically treated for cancer, cardiovascular disease and HIV/AIDS. These interventions may also help to prevent HIV infection, and improve medication adherence in HIV/AIDS.

SUMMARY

Behavioral and psychosocial interventions are useful in preventing some chronic diseases and for alleviating distress in patients who have been medically treated for diseases such as cancer, cardiovascular disease and HIV/AIDS. Findings regarding the effects of psychosocial interventions on disease processes, morbidity and mortality are not yet well established and require appropriate clinical trials.

The impact of providing symptom management assistance on caregiver reaction: results of a randomized trial

This research evaluates the impact of a randomized clinical trial for lowering family members' reactions and increasing their involvement in assisting cancer patients undergoing chemotherapy to better manage their symptoms. The cognitive behavioral intervention was directed toward both the patient and family caregivers. At 10 weeks, caregivers who received the experimental intervention had significantly lower total reactions to assisting with symptoms and assisted with significantly fewer symptoms (linked to patient improvement in symptom severity) than caregivers receiving conventional care alone. Female caregivers receiving the intervention reported significantly lower reaction per symptom where assistance was provided compared to female caregivers in the control group. Thus, the intervention did not increase caregiver involvement in symptom management, quite possibly due to reduced symptom severity among patients in the intervention group. This research offers a model for evaluating trials directed toward both members of a dyad.

The effectiveness of treatment for depression/depressive symptoms in adults with cancer: a systematic review

Depression is common in cancer patients, and this often remains undetected and untreated. Depression has been associated with poorer quality of life, in addition to increased impairment of immune response and poorer survival in cancer patients. Previous systematic reviews and meta-analyses of the efficacy of interventions for cancer patients with depression have failed to distinguish between caseness for depression and depressive symptoms. The findings from this systematic review show that there is limited trial data on the efficacy of prescribed antidepressants in reducing the incidence of major depression and depressive symptoms in cancer patients. Contrary to previous reviews that failed to distinguish between depressive symptoms and depression, this review found very little data from clinical trials (without the possibility of confounding factors) to demonstrate that psychotherapeutic interventions are effective in reducing depression in cancer patients. A number of small-scale, single-centre trials indicated that psychotherapeutic interventions (especially cognitive behavioural therapy) can have effects on depressive symptoms in cancer patients. However, given the methodological limitations of studies to date, lack of evidence should not be interpreted as implying lack of efficacy. In conclusion, there is a need for adequately powered studies of pharmacological and psychotherapeutic studies, which are targeted at cancer patients with a diagnosis of depression and include monitoring of the use of other pharmacological/psychotherapeutic and complementary and alternative medicine interventions.