Predicting future major depression and persistent depressive symptoms: Development of a prognostic screener and PHQ-4 cutoffs in breast cancer patients

The Assessment of Social Isolation and Loneliness in Cancer Patients and Survivors in the Pre-COVID-19 Period: A Systematic Review

BACKGROUND

In the context of cancer research, identifying social isolation and loneliness is a priority given how both exacerbate poor outcomes and lead to increased mortality in oncological populations. The purpose of this systematic review is to identify all quantitative instruments that have been used to assess either social isolation or loneliness in patients previously or currently diagnosed with cancer in the pre-COVID-19 period.

METHOD

PubMed (Web), Scopus, CINAHL, and PsycINFO were searched on August 22, 2019. All databases were searched from inception with no filters applied. The search strategies included terms that captured the following concepts: instruments/tools, social isolation or loneliness, and cancer.

RESULTS

A total of 289 titles/abstracts were returned. Upon review, 114 titles/abstracts were deemed to be potentially eligible and the full text was retrieved. Of the 114 full texts, 69 articles met inclusion criteria and comprised the final sample. Publications span years 1980 through 2019, with the majority (71%) occurring in the last decade prior to this review, between 2009 and 2019. Average age of the study samples, with few exceptions, was often over 50 years old. Many studies used all-female samples, while only one study used an all-male sample. The most common cancer diagnosis of participants was breast cancer. The most common measure was the UCLA Loneliness Scale, used in 22 studies. Most measures we identified were used only once, and 11 measures were used 2-3 times. When the information was given, response ranges were always Likert-type scales most often ranging from 1-4 or 1-5, and sometimes from 1-10 possible response options. In terms of psychometrics, test-retest reliability and validity were rarely reported; by contrast, internal consistency (Cronbach's alpha) was reported more than half of the time (60.9%).

CONCLUSION

When selecting a measure to assess loneliness in cancer populations, the UCLA Loneliness Scale is both psychometrically strong and versatile across patients with different cancers, ages, and racial backgrounds. When selecting a measure to assess social isolation in cancer populations, both the PROMIS-SF V 2.0 social isolation and the Berkman-Syme Network Index are brief and have been used in patients with non-White racial backgrounds.

Perceived risk, illness perception and dispositional optimism related to COVID-19 among oncologic outpatients undergoing in-hospital treatments and healthy controls

OBJECTIVE

This study aimed to explore risk estimations (perceived risk, dispositional optimism) related to COVID-19 perception and distress in oncologic outpatients undergoing active hospital treatments compared to the general population.

DESIGN AND MAIN OUTCOME MEASURES

Data were collected during the Italian lockdown on 150 oncologic outpatients and a sample of 150 healthy subjects. They completed a battery of questionnaires including the Perceived Risk scale, the Brief Illness Perception Questionnaire, the Life Orientation Test- Revised and the Patient Health Questionnaire-4. Descriptive statistics, correlation analysis, and a moderated mediation model were performed to test the study hypotheses.

RESULTS

The moderated mediation model attested significant conditional indirect associations of both clinical status and dispositional optimism with distress through the mediation of COVID-19 perceived risk. Healthy individuals and less optimistic people were more likely than others to report higher psychological distress only when they showed neutral or negative COVID-19-related illness perception.

CONCLUSIONS

Cancer patients manifest a lower risk perception and a more positive illness representation related to COVID-19 compared to control subjects; the distress level is not associated with the clinical status, but it is moderated by illness perception. Adequate protective behaviors in cancer patients may avoid a dangerous underestimation of objective risks.

Psychometric properties of the Patient Health Questionnaire-4 among Hong Kong young adults in 2021: Associations with meaning in life and suicidal ideation

Background

Young adults in Hong Kong are subject to elevated psychological distress given the societal stressors such as civil unrest and COVID-19 pandemic and suicide is a leading cause of death among them. The present study aimed to evaluate the psychometric properties and measurement invariance of the 4-item Patient Health Questionnaire-4 (PHQ-4) as a brief measure of psychological distress and its associations with meaning in life and suicidal ideation (SI) in young adults.

Materials and methods

A mobile survey recruited a large and random sample of 1,472 young adults (Mean age = 26.3 years, 51.8% males) in Hong Kong in 2021. The participants completed the PHQ-4 and Meaning in Life Questionnaire–short form (MLQ-SF) for presence of meaning in life (MIL), SI, COVID-19 impact, and exposure to suicide. Confirmatory factor analysis was conducted to examine the factorial validity, reliability, and measurement invariance of PHQ-4 and MLQ-SF across gender, age, and distress subgroups. Multigroup structural equation model evaluated and compared the direct and indirect effects of latent MIL factor on SI via latent PHQ-4 factor across distress groups.

Results

Both MIL and PHQ-4 supported a 1-factor model with good composite reliability (Ω = 0.80–0.86) and strong factor loadings (λ = 0.65–0.88). Both factors showed scalar invariance across gender, age, and distress groups. MIL showed significant and negative indirect effects (αβ = −0.196, 95% CI = −0.254 to −0.144) on SI via PHQ-4. PHQ-4 showed a stronger mediating role between MIL and SI in the distress group (Δ = −0.146, 95% CI = −0.252 to −0.049) than the non-distress group. Higher MIL predicted higher likelihoods of help-seeking (Odds ratios = 1.46, 95% CI = 1.14–1.88).

Conclusion

The present results support adequate psychometric properties in terms of factorial validity, reliability, convergent validity, and measurement invariance for the PHQ-4 in young adults in Hong Kong. The PHQ-4 demonstrated a substantial mediating role in the relationship between meaning in life and SI in the distress group. These findings support clinical relevance for using the PHQ-4 as a brief and valid measure of psychological distress in the Chinese context.

Distress in soft-tissue sarcoma and GIST patients -Results of a German multicentre observational study (PROSa)

OBJECTIVE

Soft tissue sarcomas (STS) and gastrointestinal stromal tumours (GIST) are a group of rare malignant tumours with a high and heterogenous disease burden. As evidence is lacking, we aimed to determine the prevalence of increased emotional distress and to identify associated factors in these patients.

METHODS

The PROSa-study (Burden and medical care of sarcoma) was conducted between 2017 and 2020 in 39 study centres. Cross-sectional data from adult STS and GIST patients were analysed. Distress was measured with the Patient Health Questionnaire (PHQ-4). The relation of socioeconomic and clinical factors with distress was explored in adjusted logistic regression models.

RESULTS

Among 897 patients, prevalence of elevated anxiety and depression was 17% resp. 19%. Unemployed patients (odds ratio (OR) 6.6 (95% confidence interval (CI) 2.9-15.0)) and those with a disability pension (OR 3.1 (95% CI 1.9-5.0)) were more likely to experience distress (vs. employed patients). Patients with a disability pass (vs. none) had higher odds of increased distress (OR 1.8 (95% CI 1.2-2.7)). Lowest distress was observed in patients 2-<5 years and ≥5 years after diagnosis (comparison: <6 months) (OR 0.4 (95% CI 0.2-0.6) and 0.3 (95% CI 0.2-0.6)). Patients with thoracic STS (vs. lower limbs) had twice the odds to experience distress (OR 2.0 (95% CI 1.1-3.6)). Distress was seen almost twice as often in patients with progressive disease (vs. complete remission) (OR 1.7 (95% CI 1.1-2.8)).

CONCLUSION

Prevalence of elevated distress in STS and GIST patients is high. Unemployed patients, those with a disability pension and newly diagnosed patients are more often distressed than other patients. Clinicians and psycho-oncologists should be aware of these factors and consider the social aspects of the disease. This article is protected by copyright. All rights reserved.

Assessing an Internet-Delivered, Emotion-Focused Intervention Compared With a Healthy Lifestyle Active Control Intervention in Improving Mental Health in Cancer Survivors: Protocol for a Randomized Controlled Trial

BACKGROUND

Cancer survivors are vulnerable to experiencing symptoms of anxiety and depression and may benefit from accessible interventions focused on improving emotion regulation. CanCope Mind (CM) was developed as an internet-delivered intervention adapted from the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders to improve emotion regulation and support the mental health of cancer survivors.

OBJECTIVE

This protocol aims to provide an outline of the CanCope Study, a trial comparing the efficacy of a Unified Protocol-adapted internet-delivered intervention (CM) designed for cancer survivors compared with an active control condition-an internet-delivered healthy lifestyle intervention, CanCope Lifestyle (CL). The primary aim is to assess and compare the efficacy of both interventions in improving emotion regulation, anxiety and depressive symptoms, and quality of life. The secondary aims involve assessing the mechanisms of the CM intervention.

METHODS

This trial is a 2-arm randomized controlled trial that allocates cancer survivors to either CM or CL. Both interventions comprise 4 web-based modules and are expected to take participants at least 8 weeks to complete. Participants' mental and physical health will be assessed via self-reported surveys at baseline (T0), between each module (T1, T2, and T3), immediately after the intervention (T4), and at 3-month follow-up (T5). The study aims to recruit 110 participants who have completed T4.

RESULTS

The CanCope study began recruitment in September 2020. A total of 224 participants have been randomized to the CM (n=110, 49.1%) and CL (n=114, 50.9%) groups.

CONCLUSIONS

This is one of the first trials to develop and investigate the efficacy of a web-based intervention for cancer survivors that specifically targets emotion regulation.

TRIAL REGISTRATION

Australian Clinical Trials ACTRN12620000943943; https://tinyurl.com/b3z9cjsp.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/36658.

Impact of the COVID-19 Pandemic on Oncology Patients’ Mental Health and Treatment Plans

The COVID-19 pandemic has disrupted cancer care to a certain degree. There is objective evidence that COVID-19 outbreaks are causing substantial emotional distress among cancer patients regardless of their disease severity. This study aims to measure the levels of psychological distress, depression, and pandemic anxiety among cancer patients in Saudi Arabia during the outbreak of COVID-19 and their impact on patients’ cancer treatment plans. Methods: This was a cross-sectional study conducted among oncology patients in Saudi Arabia in November of 2020. The levels of stress, depression, and anxiety symptoms during the COVID-19 outbreak were measured using the Questionnaire for Depression and Anxiety (PHQ-4), and patients were classified as depressed/distressed if the total score was 6 and above and classified as not depressed/distressed if they scored less than 6. Results: Among the sampled population, anxiety symptoms and depression were detected in 61.5% and 70.2%, respectively. Statistical analyses revealed that feeling more isolated was significant for anxiety symptoms (p = 0.005), while patients who used institutions as a source of COVID-19 information had significant depression (p = 0.010) compared to patients who accessed information from other sources. In the binary regression model, feeling more isolated than before was 3.208 times more likely to be associated with anxiety symptoms (OR = 3.208; 95% CI = 1.391–7.396; p = 0.006), while those patients who had a support institution as a source of COVID-19 information were 4.2 times more likely to be associated with depression (OR = 4.200; 95% CI = 1.328–13.280; p = 0.015). Conclusion: The COVID-19 pandemic has added to the burden on cancer patients. The increased risk of anxiety symptoms and depression was clearly demonstrated in this study. Feeling isolated had a greater impact on anxiety symptoms, while obtaining COVID-19 information from a patient support institution negatively affected depression.

Associations of patient-reported care satisfaction with symptom burden and healthcare use in hospitalized patients with cancer

BACKGROUND

Hospitalized patients with cancer often experience a high symptom burden, which may impact care satisfaction and healthcare utilization.

METHODS

We prospectively enrolled patients with cancer and unplanned hospitalizations from September 2014 to April 2017. Upon admission, we assessed patients' care satisfaction (FAMCARE items: satisfaction with care coordination and speed with which symptoms are treated) and physical (Edmonton Symptom Assessment System [ESAS]) and psychological (Patient Health Questionnaire-4 [PHQ-4]) symptoms. We used regression models to identify factors associated with care satisfaction and associations of satisfaction with symptom burden and hospital length of stay (LOS).

RESULTS

Among 1,576 participants, most reported being "satisfied"/ "very satisfied" with care coordination (90%) and speed with which symptoms are treated (89%). Older age (coordination: B < 0.01, P = 0.02, speed: B = 0.01, P < 0.01) and admission to a dedicated oncology service (B = 0.20, P < 0.01 for each) were associated with higher satisfaction. Higher satisfaction with care coordination was associated with lower ESAS-physical (B =  - 1.28, P < 0.01), ESAS-total (B =  - 2.73, P < 0.01), PHQ4-depression (B =  - 0.14, P = 0.02), and PHQ4-anxiety (B =  - 0.16, P < 0.01) symptoms. Higher satisfaction with speed with which symptoms are treated was associated with lower ESAS-physical (B =  - 1.32, P < 0.01), ESAS-total (B =  - 2.46, P < 0.01), PHQ4-depression (B =  - 0.14, P = 0.01), and PHQ4-anxiety (B =  - 0.17, P < 0.01) symptoms. Satisfaction with care coordination (B =  - 0.48, P = 0.04) and speed with which symptoms are treated (B =  - 0.44, P = 0.04) correlated with shorter LOS.

CONCLUSIONS

Hospitalized patients with cancer report high care satisfaction, which correlates with older age and admission to a dedicated oncology service. Significant associations among higher care satisfaction, lower symptom burden, and shorter hospital LOS highlight the importance of improving symptom management and care coordination in this population.

Machine Learning-Based Prediction Models for Depression Symptoms Among Chinese Healthcare Workers During the Early COVID-19 Outbreak in 2020: A Cross-Sectional Study

BACKGROUND

The 2019 novel coronavirus (COVID-19)-related depression symptoms of healthcare workers have received worldwide recognition. Although many studies identified risk exposures associated with depression symptoms among healthcare workers, few have focused on a predictive model using machine learning methods. As a society, governments, and organizations are concerned about the need for immediate interventions and alert systems for healthcare workers who are mentally at-risk. This study aims to develop and validate machine learning-based models for predicting depression symptoms using survey data collected during the COVID-19 outbreak in China.

METHOD

Surveys were conducted of 2,574 healthcare workers in hospitals designated to care for COVID-19 patients between 20 January and 11 February 2020. The patient health questionnaire (PHQ)-9 was used to measure the depression symptoms and quantify the severity, a score of ≥5 on the PHQ-9 represented depression symptoms positive, respectively. Four machine learning approaches were trained (75% of data) and tested (25% of data). Cross-validation with 100 repetitions was applied to the training dataset for hyperparameter tuning. Finally, all models were compared to evaluate their predictive performances and screening utility: decision tree, logistics regression with least absolute shrinkage and selection operator (LASSO), random forest, and gradient-boosting tree.

RESULTS

Important risk predictors identified and ranked by the machine learning models were highly consistent: self-perceived health status factors always occupied the top five most important predictors, followed by worried about infection, working on the frontline, a very high level of uncertainty, having received any form of psychological support material and having COVID-19-like symptoms. The area under the curve [95% CI] of machine learning models were as follows: LASSO model, 0.824 [0.792-0.856]; random forest, 0.828 [0.797-0.859]; gradient-boosting tree, 0.829 [0.798-0.861]; and decision tree, 0.785 [0.752-0.819]. The calibration plot indicated that the LASSO model, random forest, and gradient-boosting tree fit the data well. Decision curve analysis showed that all models obtained net benefits for predicting depression symptoms.

CONCLUSIONS

This study shows that machine learning prediction models are suitable for making predictions about mentally at-risk healthcare workers predictions in a public health emergency setting. The application of multidimensional machine learning models could support hospitals' and healthcare workers' decision-making on possible psychological interventions and proper mental health management.

Insomnia and Fatigue Symptom Trajectories in Breast Cancer: A Longitudinal Cohort Study

Objective: Insomnia and fatigue are common, although not inevitable, during breast cancer. This study is one of the first aiming to describe distinct trajectory classes of insomnia and fatigue symptoms, and their correlates, from diagnosis through treatment.Methods: This longitudinal cohort study was conducted at a comprehensive cancer center and community oncology practices. Participants (N = 460) were women diagnosed with any stage of breast cancer in the previous 4 months. Primary outcomes for this ancillary study of the existing cohort were self-reported insomnia and fatigue symptoms assessed repeatedly across 12 months.Results: Four distinct classes of insomnia symptoms emerged: persistently very high, clinically elevated symptoms (13.7%); high, clinically elevated symptoms (65.9%); stable low (17.2%) or very low (2.6%) symptoms. Five fatigue symptom classes included high, increasing fatigue (9.6%), two recovery classes starting at high (26.3%), or moderate (18.0%) severity at diagnosis, stable low (33.3%) or very low (12.2%) classes. In multivariate analyses, higher depressive symptoms, anxiety, and chronic life stress were associated with being in the very high insomnia class versus the low symptom class. Oncologic factors were not associated with insomnia class membership. Receiving chemotherapy was linked significantly to high and recovery fatigue symptom classes versus the low class. Higher chronic life stress was associated with more persistent fatigue symptoms.Conclusions: Distinct classes of insomnia and fatigue symptoms were evident; 79.6% of the women had clinically elevated, persistent insomnia symptoms, 53.9% had elevated fatigue. A substantial minority evidenced low symptoms, suggesting targeted or stepped-care approaches to symptom management.

Transitions in coping profiles after breast cancer diagnosis: implications for depressive and physical symptoms

The objective of this study was to determine whether: (a) cancer-related coping profiles change across time; (b) coping profile transition types predict changes in depressive and physical symptoms. Latent transition analysis was conducted with repeated measures of seven cancer-related coping processes from 460 women recently diagnosed with breast cancer. In multilevel models, coping profile transition groups were entered as predictors of symptoms across 12 months. Three coping profiles emerged at study entry, with two profiles at later assessments. Forty-eight percent of women maintained high-moderate approach-oriented coping over time. Specific factors (e.g., age, acceptance of emotions) differentiated the transition groups. Women who increased and then maintained high-moderate approach-oriented coping had relatively high initial depressive symptoms that declined steeply. When cancer-related acceptance predominated, women experienced increasing physical symptoms. Distinct cancer-related coping patterns are related to the level of and change in depressive and physical symptoms longitudinally. Early intervention to increase approach-oriented coping strategies could yield favorable outcomes.

A preventive intervention to modify depression risk targets after breast cancer diagnosis: Design and single-arm pilot study

OBJECTIVE

Apply the National Institutes of Health (NIH) Stage Model to design and test an intervention to prevent depression in breast cancer patients at risk for depression.

METHODS

We identified mindful emotion awareness, along with approach and avoidance strategies for cancer-related coping and emotion regulation, as targets for a preventive intervention adapted from the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. Patients' preferences for individual, in-person, and time-efficient sessions informed the design. Patients at risk for depression received a 6-week, 5-hour intervention with daily exercises. Intervention targets were assessed at baseline, before each session, and 4-weeks post intervention. Mixed effects analysis of variance (ANOVA) assessed change over the follow-up period, controlling for age, partnered status, and disease stage.

RESULTS

Fifty-five percent (40/72) of women screened within 6 months of diagnosis had elevated depression risk. Of these, 24 (60%) signed consent. Sixteen received intervention after five were excluded for current depressive disorder, cognitive impairment, or death. Three dropped out. Ninety-eight percent attendance and 77% practice days indicated feasibility. Effect sizes (Cohen's d) corrected for regression to the mean (RTM) were 0.82 for cancer-related acceptance coping, 0.65 for cancer-related emotional expression, and 0.32 and 0.42 for decreased cancer-related avoidance coping and depressive symptoms, respectively. Effect sizes for variables lacking data to correct for RTM were 1.0, 0.7, and 0.5 for decreased rumination, experiential avoidance, and fear of depression, respectively, and 1.3, 0.6, and 0.4 for increased cognitive flexibility, distress tolerance, and describing/not judging emotions, respectively.

CONCLUSIONS

The feasibility of this intervention and malleability of its targets support its further investigation.

Association of Financial Burden With Self-Rated and Mental Health in Older Adults With Cancer

Objective: Financial problems in cancer survivors are associated with distress and reduced quality of life. Most studies have been cross-sectional, and a longitudinal study is needed to guide clinical interventions. Method: We used data from two surveys of the National Health and Aging Trends Study (NHATS). Participants (n = 307) reported whether they experienced six indicators of financial burden. The Patient Health Questionnaire 4 assessed depressive symptoms and general anxiety. Cross-lagged panel analyses assessed whether financial burden predicted distress and health or vice versa. Results: In the total sample, financial burden at the first survey predicted depressive symptoms (p < .01), general anxiety (p < .01), and self-rated health (p < .01) at the second survey. Depressive symptoms, general anxiety, and self-rated health at the first survey did not predict later financial burden (ps > .05). Discussion: Results suggest financial problems predict later distress and poor health. This study highlights the need to address financial burden in cancer survivors.