A Systematically Tested Intervention for Managing Reactive Depression

Exploring the impact of pediatric short bowel syndrome on parent well-being using a disease-specific pilot survey

BACKGROUND

Children with short bowel syndrome (SBS) have complex care needs, most of which are met in the home by family caregivers who may experience a range of stressors unique to this experience. Prior research suggests that parents of children with SBS have poorer health-related quality of life than peers parenting children without health needs, but the mechanisms shaping parent outcomes are understudied.

METHODS

A pilot survey was developed using a community-driven research design to measure the impact of disease-specific items on parent-perceived well-being. The cross-sectional survey, which included both closed-ended and open-ended items, was distributed to a convenience sample of parents of children with SBS. Quantitative and qualitative data were integrated for a mixed-methods analysis of how individual items impacted parent well-being.

RESULTS

Twenty parents completed the survey. Sleep interruptions, lack of support and resources, and psychological stressors and their mental health implications were more frequently reported as stressors than logistics related to caregiving (e.g., managing therapies and preparing specialized meals).

CONCLUSION

The impact of a child's SBS on parent well-being may stem mainly from three interconnected domains: poor sleep and its consequences, lack of access to support and resources, and a range of psychological stressors that affect parent mental health. Understanding the mechanisms through which SBS shapes parent well-being is a necessary first step for developing targeted interventions to support parents and provide family-centered care.

Using telehealth to assess depression and suicide ideation and provide mental health interventions to groups of chronically ill adolescents and young adults

Telehealth distance health care is a significant resource for young, chronically ill patient populations given their numerous medical complexities and their concomitant depression and/or suicide ideation experiences. This manuscript shares the telehealth methods used to prepare for a larger study of interventions for increasing adolescents' and young adults' chronic care resiliency and skills for preventing depression. The young patients in this study were prescribed lifelong home parenteral nutrition infusions, treatment for those with short gut bowel diseases. The training methods for our mental health nurse and psychologist to conduct depression and suicide ideation assessments from a distance are presented. The study implementation methods of group facilitated interventions and discussion are reviewed. The group discussions were conducted via audiovisual telehealth devices over encrypted firewall-protected connections with patients in their own homes and professionals in an office. The results of assessments of the 40 participants, 25% (n = 10) with depressive symptoms or suicide ideation, are described. Following participants' assessments, their subsequent depression measures were all in the normal range, without any suicide ideation, across the year of the study. Patient evaluation ratings were high in the areas of being able to connect with other young patients in similar situations, using the audiovisual equipment, and learning new useful information from the interventions. The methods developed for the study ensured that the safety and well-being of participants were supported through telehealth.

Maintaining Intervention Fidelity When Using Technology Delivery Across Studies

The current standard in healthcare research is to maintain scientific fidelity of any intervention being tested. Fidelity is defined as the consistent delivery of interventions that ensures that all participants are provided the same information, guidance, and/or materials. Notably, the methods for ensuring fidelity of intervention delivery must also be consistent. This article describes our Intervention and Technology Delivery Fidelity Checklists used to ensure consistency. These checklists were completed by trained nurse observers who rated the intervention implementation and the technology delivery. Across our clinical trials and pilot studies, the fidelity scores were tabulated and compared. Intervention information and materials were delivered by a variety of devices including telehealth monitors, videophones, and/or iPads. Each of the devices allows audiovisual connections between health professionals from their offices and patients and participants in their homes. Our checklists guide the monitoring of fidelity of technology delivery. Overall checklist ratings across our studies demonstrate consistent intervention, implementation, and technology delivery approaches. Uniquely, the fidelity checklist verifies the interventionist's correct use of the technology devices to ensure consistent audiovisual delivery. Checklist methods to ensure intervention fidelity and technology delivery are essential research procedures, which can be adapted for use by researchers across multiple disciplines.

The effect of nurse-led group discussions by race on depressive symptoms in patients with heart failure

BACKGROUND

African Americans with heart failure (HF) have the highest rates of depression among all ethnicities in the USA.

OBJECTIVES

To compare the effects by race on depressive symptoms and topics discussed in the first clinic appointment after HF hospitalization.

METHODS

This study is a secondary analysis of data from a randomized clinical trial testing a patient group discussion of HF self-management with 93 Caucasians and 77 African Americans.

RESULTS

Reduction in depressive symptoms was significantly greater among African American patients within the intervention group (F = 3.99, p = .047) than controls. There were significant differences by race in four topics (dietitian referral, appointment date, help preparing discussion questions, and advice on worsening HF symptoms) concerning patient-physician discussions.

CONCLUSION

The intervention showed greater effect in reducing depressive symptoms among African Americans than Caucasians. Preparing patients for discussions at physician appointments on diet, depressive symptoms, and HF symptoms is recommended.

Telemedicine Support Groups for Home Parenteral Nutrition Users

Patients receiving home parenteral nutrition (HPN), a life-sustaining intravenous (IV) infusion that provides nourishment and hydration to patients with short gut or inflammatory bowel diseases, are often isolated and not in visual contact with peers or health providers. One completed clinical trial (Clinical Trials.gov NCT0190028) and 1 ongoing clinical trial (Clinical Trials.gov NCT02987569) are evaluating a mobile videoconferencing-delivered support group intervention for patients on HPN and their caregivers. This home-based telemedicine intervention uses encrypted tablet-based videoconferencing to connect multiple families in real time. The twice-daily IV regimen is challenging for patients who may experience infusion catheter-related bloodstream infections, difficulties with fatigue, loss of sleep, depressive disorders, and worry over the potential life-threatening side effects and the expenses of this therapy. Using secure telemedicine, the facilitated support group intervention aims to enhance HPN home care, daily functioning, and quality of life. The authors provide the rationale for the telemedicine approach with HPN users and caregivers. They provide "how-to" information about the content and process of the facilitated support group sessions via secure videoconferencing. They share lessons learned from the ongoing evaluation of the telemedicine approach.

Identification of Depressive Signs in Patients and Their Family Members During iPad-based Audiovisual Sessions

Home parenteral nutrition requires a daily life-sustaining intravenous infusion over 12 hours. The daily intravenous infusion home care procedures are stringent, time-consuming tasks for patients and family caregivers who often experience depression. The purposes of this study were (1) to assess home parenteral nutrition patients and caregivers for depression and (2) to assess whether depressive signs can be seen during audiovisual discussion sessions using an Apple iPad Mini. In a clinical trial (N = 126), a subsample of 21 participants (16.7%) had depressive symptoms. Of those with depression, 13 participants were home parenteral nutrition patients and eight were family caregivers; ages ranged from 20 to 79 years (with 48.9 [standard deviation, 17.37] years); 76.2% were female. Individual assessments by the mental health nurse found factors related to depressive symptoms across all 21 participants. A different nurse observed participants for signs of depression when viewing the videotapes of the discussion sessions on audiovisual technology. Conclusions are that depression questionnaires, individual assessment, and observation using audiovisual technology can identify depressive symptoms. Considering the growing provision of healthcare at a distance, via technology, recommendations are to observe and assess for known signs and symptoms of depression during all audiovisual interactions.

Technology Dependence in Home Care: Impact on Patients and Their Family Caregivers

BACKGROUND

The purpose of this review is to explore how home technology care affects patients, family caregivers, and quality of life (QOL).

METHODS

A literature search was conducted to identify studies of home parenteral nutrition (HPN) and other technology prescribed home care.

RESULTS

Technology dependence influences health-related QOL. Patients and their family caregivers must balance the positive aspects of being in the home environment with the challenges of administering complex therapies at home. Patients and caregivers need additional support to reduce the physical, emotional, social, and financial burdens they experience.

CONCLUSIONS

More research is needed to address effective interventions to reduce patient and caregiver burdens and to improve outcomes for technology-dependent individuals. A greater level of preparedness for managing home technology and technology-related problems may improve quality of life.

Nurse-Led Multidisciplinary Heart Failure Group Clinic Appointments: Methods, Materials, and Outcomes Used in the Clinical Trial

BACKGROUND

The Self-management and Care of Heart Failure through Group Clinics Trial evaluated the effects of multidisciplinary group clinic appointments on self-care skills and rehospitalizations in high-risk heart failure (HF) patients.

OBJECTIVE

The purpose of this article is to (1) describe key Self-management and Care of Heart Failure through Group Clinics Trial group clinic interactive learning strategies, (2) describe resources and materials used in the group clinic appointment, and (3) present results supporting this patient-centered group intervention.

METHODS

This clinical trial included 198 HF patients (randomized to either group clinical appointments or to standard care). Data were collected from 72 group clinic appointments via patients' (1) group clinic session evaluations, (2) HF self-care behaviors skills, (3) HF-related discouragement and quality of life scores, and (4) HF-related reshopitalizations during the 12-month follow-up. Also, the costs of delivery of the group clinical appointments were tabulated.

RESULTS

Overall, patients rated group appointments as 4.8 of 5 on the "helpfulness" in managing HF score. The statistical model showed a 33% decrease in the rate of rehospitalizations (incidence rate ratio, 0.67) associated with the intervention over the 12-month follow-up period when compared with control patients (χ(2)1=3.9, P=.04). The total cost for implementing 5 group appointments was $243.58 per patient.

CONCLUSION

The intervention was associated with improvements in HF self-care knowledge and home care behavior skills and managing their for HF care. In turn, better self-care was associated with reductions in HF-related hospitalizations.

A Clinical Trial of Translation of Evidence Based Interventions to Mobile Tablets and Illness Specific Internet Sites

This article describes a method to translate an evidence based health care intervention to the mobile environment. This translation assisted patient participants to: avoid life threatening infections; monitor emotions and fatigue; keep involved in healthy activities. The mobile technology also decreased costs by reducing for example travel to visit health care providers. Testing of this translation method and its use by comparison groups of patients adds to the knowledge base for assessing technology for its impact on health outcome measures. The challenges and workflow of designing materials for the mobile format are described. Transitioning clinical trial verified interventions, previously provided in person to patients, onto tablet and internet platforms is an important process that must be evaluated. In this study, our evidence based guide's intravenous (IV) homeCare interventions (IVhomeCare) were delivered via Apple iPad mini™ tablet audiovisual instruction / discussion sessions and on a website. Each iPad audiovisual session (n = 41), included three to five families, a mental health specialist, and healthcare professionals. Patients and their family caregivers readily learned to use the wireless mobile tablets, and the IVhomeCare interventions, as described here, were successfully translated onto these mobile technology platforms. Using Likert scale responses on a questionnaire (1 = not helpful and 5 = very helpful) participants indicated that they gained problem solving skills for home care through iPad group discussion (M = 4.60, SD = 0.60). The firewall protected videoconferencing in real time with multiple healthcare professionals effectively allowed health history taking and visual inspection of the patient's IV insertion site for signs of infection. Supportive interactions with peer families on videoconferencing were documented during discussions. Discussion topics included low moods, fatigue, infection worry, how to maintain independence, and need for support from others with their same lifelong IV experiences. The visual family interactions, discussions with professionals, and the iPad internet links were highly rated. Mobile distance care delivery can result in saved time and money for both healthcare professionals and families.

Reasoning Exercises in Assisted Living: a cluster randomized trial to improve reasoning and everyday problem solving

PURPOSE OF THE STUDY

Assisted living (AL) residents are at risk for cognitive and functional declines that eventually reduce their ability to care for themselves, thereby triggering nursing home placement. In developing a method to slow this decline, the efficacy of Reasoning Exercises in Assisted Living (REAL), a cognitive training intervention that teaches everyday reasoning and problem-solving skills to AL residents, was tested.

DESIGN AND METHODS

At thirteen randomized Midwestern facilities, AL residents whose Mini Mental State Examination scores ranged from 19-29 either were trained in REAL or a vitamin education attention control program or received no treatment at all. For 3 weeks, treated groups received personal training in their respective programs.

RESULTS

Scores on the Every Day Problems Test for Cognitively Challenged Elders (EPCCE) and on the Direct Assessment of Functional Status (DAFS) showed significant increases only for the REAL group. For EPCCE, change from baseline immediately postintervention was +3.10 (P<0.01), and there was significant retention at the 3-month follow-up (d=2.71; P<0.01). For DAFS, change from baseline immediately postintervention was +3.52 (P<0.001), although retention was not as strong. Neither the attention nor the no-treatment control groups had significant gains immediately postintervention or at follow-up assessments. Post hoc across-group comparison of baseline change also highlights the benefits of REAL training. For EPCCE, the magnitude of gain was significantly larger in the REAL group versus the no-treatment control group immediately postintervention (d=3.82; P<0.01) and at the 3-month follow-up (d=3.80; P<0.01). For DAFS, gain magnitude immediately postintervention for REAL was significantly greater compared with in the attention control group (d=4.73; P<0.01).

IMPLICATIONS

REAL improves skills in everyday problem solving, which may allow AL residents to maintain self-care and extend AL residency. This benefit is particularly important given the growing population of AL residents at risk for cognitive and self-care decline.

Targeting memory improvement in assisted living: a pilot study

This pilot study tested an intervention designed to improve memory for assisted-living (AL) residents. Seven residents in one Midwestern AL facility participated in a six-session memory program based on qualitative research that identified typical memory challenges of residents (e.g., remembering names, schedules, and appointments). Scores on memory self-efficacy (the Memory Complaint in Age-Associated Impairment) and performance (Rivermead Behavioral Memory Test) measures were compared before and after the intervention. Self-efficacy improved significantly after the program (z = 2.37, p = .018) for remembering names, phone numbers, lists of items, and facts. Increases in actual memory performance were not statistically significant. However, three out of seven participants (43%) improved in recalling first and last names. Ongoing testing on larger samples with a control group design is needed to verify effects and determine any effects on daily functioning. This study suggests that cognitive interventions targeting frail elder populations are feasible to provide to older adults in AL.

Creating patient and family education web sites: design and content of the home parenteral nutrition family caregivers web site

When managing chronic illnesses, caregivers repeatedly seek online information about providing complex, long-term care but often neglect to find information about how to care for themselves. Poor health among caregivers is not only detrimental to their own well-being but may also result in harm to those for whom they care. For this reason, caregivers need access to information and activities about caring for themselves in addition to the information about managing home care they are already likely to seek. The HPN Family Caregivers Web site was developed to guide caregivers through the process of caring for themselves by establishing a caregiving routine, self-monitoring their mental and physical health, and practicing good sleep hygiene, while also managing the complexities of home care. While Web site information, activities, and algorithms for managing chronic illnesses need to be specific to each population, the content guiding caregivers to care for their own health is universal.

Effects of patient education and progressive muscle relaxation alone or combined on adherence to continuous positive airway pressure treatment in obstructive sleep apnea patients

PURPOSE

The purpose of this study is to explore the effects of patient education and progressive muscle relaxation (PMR) alone or combined on adherence to continuous positive airway pressure (CPAP) treatment in obstructive sleep apnea (OSA) patients.

METHODS

One hundred and fifty-two Han Chinese OSA patients were randomly assigned to a control group (C), an education group (E), a PMR group (P), and an education + PMR group (E + P), with 38 patients each group. The adherence to CPAP was defined as 4 or more hours of CPAP usage per night and at least 9 of each 14 nights of ventilator use. The CPAP adherence rates, cumulative patient dropout rates, CPAP usage, and scores of daytime sleepiness, sleep quality, anxiety, and depression were compared among the groups at 4, 8, and 12 weeks of intervention.

RESULTS

All study groups were comparable in baseline characteristics. Group E + P showed significant improvement in CPAP adherence, daytime sleepiness, and sleep quality compared with group C at 4, 8, and 12 weeks of intervention. Compared with group C, group E only showed significant improvement in CPAP adherence, daytime sleepiness, and sleep quality at 4 weeks of intervention, while group P showed no significant improvement over time. Scores of anxiety and depression were significantly improved in group E + P compared with group C at 12 weeks of intervention.

CONCLUSIONS

Combined intervention with patient education and PMR can significantly improve CPAP adherence in OSA patients for at least 12 weeks. The intervention paradigm may serve as an important reference for future studies on CPAP adherence.

Comparing patient and nurse specialist reports of causative factors of depression related to heart failure

PURPOSE

The purpose of this study was to compare participants' and a psychiatric nurse specialist's reports on factors precipitating depression and to validate a depression screening instrument.

DESIGN AND METHODS

Participants were screened for and asked to self-report causative factors of their depression. Participants with moderately severe and severe depressive symptoms received a psychiatric nurse specialist assessment.

FINDINGS

Participants self-reported several causative factors of depression. The psychiatric nurse specialist discovered these plus additional factors. The screening instrument was found to be reliable and valid for the measurement of depressive symptoms.

PRACTICE IMPLICATIONS

Participant self-report identifies many causative factors of depression. The psychiatric nurse specialist identifies additional factors, allowing individualized diagnoses and treatments.

Patient education combined in a music and habit-forming intervention for adherence to continuous positive airway (CPAP) prescribed for sleep apnea

OBJECTIVE

As many as 50% of patients diagnosed with obstructive sleep apnea stop adhering to the prescribed medical treatment of continuous positive airway pressure (CPAP) within 1-3 weeks of onset. Thus, a theory-based intervention using music to support habit formation was designed to improve CPAP adherence at onset. The intervention materials included directions for CPAP nightly use, a diary for recording nightly use and writing about CPAP benefits or problems. In addition, an audiotape with softly spoken instructions for placing the CPAP mask comfortably, using deep breathing and muscle relaxation along with the slowly decreasing music tempo was provided to listen to at bedtime each night.

METHODS

Effects of this music intervention were tested in a randomized, placebo-controlled trial of 97 patients with 53 males (55%) and 44 females (45%). Moderate to severe apnea/hyponea scores (per sleep laboratory data) and medical diagnosis of OSA were required for study inclusion.

RESULTS

Compared to placebo controls, a greater proportion of experimental patients were adhering (chi(2)=14.67, p<0.01; a large difference, Phi=0.39) at the end of the first month of CPAP onset. There were no differences in CPAP adherence at 3 (X(2)=0.065, p=0.79) and 6 (X(2)=.118, p=0.73) months. Patients' diary data and satisfaction survey results indicated the intervention was rated as helpful and guided formation of a relaxing, habitual routine of CPAP nightly use.

CONCLUSION

The intervention had a strong effect for improving adherence to CPAP at 1 month.

PRACTICE IMPLICATIONS

Adherence at the onset of treatment is critical and the audio music intervention was easily administered. Other interventions that target problems interfering with longer-term CPAP adherence are needed.

The impact of home parenteral nutrition on daily life-a review

BACKGROUND

Total parenteral nutrition (TPN) is a lifesaving therapy in patients with severe intestinal failure that can be administered at home. However, patients have to face complex technological nutritional support issues at home, which will influence their personal life.

OBJECTIVES

This review aims to describe the implications of home parenteral nutrition (HPN) on the quality of life, as experienced by patients, as well as to describe the caregiver's reactions regarding these notions.

SEARCH STRATEGY

A systematic review of the literature published between 1965 and 2005 was conducted. Cinahl, Medline, and Psychlit databases were searched. Systematic data extraction and narrative data synthesis were performed.

SELECTION CRITERIA

Papers were included if they described original research published in a peer reviewed journal, with a focus on adult patients on HPN and/or their family caregivers. DATA COLLECTION (AND ANALYSIS): A standardised record was used for data extraction.

MAIN RESULTS

A total of 26 studies were included. The quality of life reported by patients was moderate to good, but psychological problems, e.g. depression and anxiety, were common. Social life was disturbed due to the venous access device, the time schedule for HPN administration, the inability to have normal oral intake, gastrointestinal mobility problems, and physical complaints. Frequently mentioned somatic problems included fatigue, diarrhoea, pain, polyuria during infusion and sleep disruption. Despite social restrictions, depression and fatigue, caregivers reported their overall QoL as similar to the norms for healthy populations.

CONCLUSION

Patients on HPN meet a broad range of problems. Apart from the well-known metabolic and infectious complications, many of these are psychological or social in nature.