Phase II trial of a depression self-care intervention for adult cancer survivors

Recruitment of Patients With Cancer for a Clinical Trial Evaluating a Web-Based Psycho-Oncological Intervention: Secondary Analysis of a Diversified Recruitment Strategy in a Randomized Controlled Trial

BACKGROUND

Participant recruitment poses challenges in psycho-oncological intervention research, such as psycho-oncological web-based intervention studies. Strict consecutive recruitment in clinical settings provides important methodological benefits but is often associated with low response rates and reduced practicability and ecological validity. In addition to preexisting recruitment barriers, the protective measures owing to the COVID-19 pandemic restricted recruitment activities in the clinical setting since March 2020.

OBJECTIVE

This study aims to outline the recruitment strategy for a randomized controlled trial evaluating the unguided emotion-based psycho-oncological online self-help (epos), which combined traditional and web-based recruitment.

METHODS

We developed a combined recruitment strategy including traditional (eg, recruitment in clinics, medical practices, cancer counseling centers, and newspapers) and web-based recruitment (Instagram, Facebook, and web pages). Recruitment was conducted between May 2020 and September 2021. Eligible participants for this study were adult patients with any type of cancer who were currently receiving treatment or in posttreatment care. They were also required to have a good command of the German language and access to a device suitable for web-based interventions, such as a laptop or computer.

RESULTS

We analyzed data from 304 participants who were enrolled in a 17-month recruitment period using various recruitment strategies. Web-based and traditional recruitment strategies led to comparable numbers of participants (151/304, 49.7% vs 153/304, 50.3%). However, web-based recruitment required much less effort. Regardless of the recruitment strategy, the total sample did not accurately represent patients with cancer currently undergoing treatment for major types of cancer in terms of various sociodemographic characteristics, including but not limited to sex and age. However, among the web-recruited study participants, the proportion of female participants was even higher (P<.001), the mean age was lower (P=.005), private internet use was higher (on weekdays: P=.007; on weekends: P=.02), and the number of those who were currently under treatment was higher (P=.048). Other demographic and medical characteristics revealed no significant differences between the groups. The majority of participants registered as self-referred (236/296, 79.7%) instead of having followed the recommendation of or study invitation from a health care professional.

CONCLUSIONS

The combined recruitment strategy helped overcome general and COVID-19-specific recruitment barriers and provided the targeted participant number. Social media recruitment was the most efficient individual recruitment strategy for participant enrollment. Differences in some demographic and medical characteristics emerged, which should be considered in future analyses. Implications and recommendations for social media recruitment based on personal experiences are presented.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00021144; https://drks.de/search/en/trial/DRKS00021144.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1016/j.invent.2021.100410.

Adaptation and outcomes of a lay-guided mental health self-care model: Results of six trials

OBJECTIVE

To synthesize results of six controlled trials of self-care interventions for depression and/or anxiety, focusing on five trials in which lay guidance was compared to self-directed use of the same self-care tools.

METHODS

The trials were conducted in Canada in different target populations. Self-care tools were adapted to each population. Guidance was provided in 3-15 calls over a period of 6-26 weeks. Depression and/or anxiety were assessed at follow-up (6-26 weeks). Pooled analyses used a meta-analytic approach. Engagement with the self-care tools was compared using the standardized difference or Cohen's d effect size.

RESULTS

In studies with homogeneous outcomes (three for depression, four for anxiety), the pooled effect sizes of guidance vs. self-directed use of the self-care tools were 0.36 (95% CI 0.10, 0.62, N = 235) for depression and 0.21 (95% CI -0.03, 0.44, N = 285) for anxiety. Guidance consistently led to greater engagement with the tools.

CONCLUSIONS

The intervention model is a potentially sustainable and accessible alternative to professionally guided self-care for people with mild-moderate depression. Factors which may have limited implementation success include: co-interventions, reduced number of guide calls (3 vs 6 or more), and delivery to dyads (patient-caregiver).

Digital Health Interventions for Depression and Anxiety Among People With Chronic Conditions: Scoping Review

BACKGROUND

Chronic conditions are characterized by their long duration (≥1 year), need for ongoing medical attention, and limitations in activities of daily living. These can often co-occur with depression and anxiety as common and detrimental comorbidities among the growing population living with chronic conditions. Digital health interventions (DHIs) hold promise in overcoming barriers to accessing mental health support for these individuals; however, the design and implementation of DHIs for depression and anxiety in people with chronic conditions are yet to be explored.

OBJECTIVE

This study aimed to explore what is known in the literature regarding DHIs for the prevention, detection, or treatment of depression and anxiety among people with chronic conditions.

METHODS

A scoping review of the literature was conducted using the Arksey and O'Malley framework. Searches of the literature published in 5 databases between 1990 and 2019 were conducted in April 2019 and updated in March 2021. To be included, studies must have described a DHI tested with, or designed for, the prevention, detection, or treatment of depression or anxiety in people with common chronic conditions (arthritis, asthma, diabetes mellitus, heart disease, chronic obstructive pulmonary disease, cancer, stroke, and Alzheimer disease or dementia). Studies were independently screened by 2 reviewers against the inclusion and exclusion criteria. Both quantitative and qualitative data were extracted, charted, and synthesized to provide a descriptive summary of the trends and considerations for future research.

RESULTS

Database searches yielded 11,422 articles across the initial and updated searches, 53 (0.46%) of which were included in this review. DHIs predominantly sought to provide treatment (44/53, 83%), followed by detection (5/53, 9%) and prevention (4/53, 8%). Most DHIs were focused on depression (36/53, 68%), guided (32/53, 60%), tailored to chronic physical conditions (19/53, 36%), and delivered through web-based platforms (20/53, 38%). Only 2 studies described the implementation of a DHI.

CONCLUSIONS

As a growing research area, DHIs offer the potential to address the gap in care for depression and anxiety among people with chronic conditions; however, their implementation in standard care is scarce. Although stepped care has been identified as a promising model to implement efficacious DHIs, few studies have investigated the use of DHIs for depression and anxiety among chronic conditions using such models. In developing stepped care, we outlined DHI tailoring, guidance, and intensity as key considerations that require further research.

Trained lay coaches and self-care cognitive-behavioral tools improve depression outcomes

OBJECTIVES

Identify the key effective components of a depression self-care intervention.

METHODS

Secondary analysis of data from 3 studies that demonstrated effectiveness of a similar depression self-care intervention (n = 275): 2 studies among patients with chronic physical conditions and 1 among cancer survivors. The studies used similar tools, and telephone-based lay coaching. Depression remission and reduction at 6 months were assessed with either PHQ-9 (chronic condition cohorts) or CES-D (cancer survivor cohort). Multiple logistic regression was used to analyze data when the interaction p-value with cohort was < 0.10.

RESULTS

The 3 coached cohorts achieved better depression outcomes than usual care. The combination of coaching and joint use of 2 tools based on cognitive-behavioral therapy (CBT) was associated with depression remission and reduction among chronic condition cohorts but not among cancer survivors. Neither the number nor the length of coach calls were associated with outcomes in pooled data.

CONCLUSIONS

Trained lay coaching and use of CBT-based self-care tools were associated with improved depression outcomes in patients with chronic conditions but not among cancer survivors.

PRACTICE IMPLICATIONS

Trained lay coaching and CBT tools are key components of depression self-care interventions. Further research is needed on the effective components in cancer survivors.

CanDirect: Effectiveness of a Telephone-Supported Depression Self-Care Intervention for Cancer Survivors

PURPOSE

Depression in post-treatment cancer survivors is common and can impair quality of life. CanDirect is a novel, telephone-delivered depression self-care intervention for cancer survivors. We conducted a randomized controlled superiority trial to compare CanDirect with usual care (UC) in this population.

METHODS

Participants completing cancer treatment within the past 10 years who had mild-moderate depressive symptoms with or without major depression were recruited from clinical and community settings in Quebec and Ontario. Permuted block random assignment allocated participants to CanDirect plus UC or to UC alone. Assessments of depression severity (Center for Epidemiological Studies-Depression scale [CES-D]; primary outcome) and secondary outcomes health-related quality of life (Short Form Survey-12 mental and physical component summaries), anxiety symptoms (Hospital Anxiety and Depression Scale), activation (Patient Activation Measure), depression diagnosis (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-IV), and health services (self-report) were conducted at baseline, as well as 3 and 6 months (primary time point). Analyses of outcomes were adjusted for covariates using linear regression and missing data by inverse probability weighting.

RESULTS

Participants recruited between September 2016 and October 2018 were randomly assigned to CanDirect (n = 121) or UC (n = 124). Among 245 participants randomly assigned, 218 (89.0%) completed the primary outcome at 6 months. CanDirect participants reported less severe depressive symptoms on the CES-D than UC participants at 6 months, adjusted effect size (ES) 0.61 (95% CI, 0.33 to 0.88). CanDirect participants also had significantly greater quality of life, lower anxiety, more activation, and lower rates of depression diagnoses, compared with UC. Exploratory analysis suggested that sex was a modifier of the primary outcome (interaction term P value = .03); the intervention was less effective in men (ES, 0.12; 95% CI, -0.45 to 0.69).

CONCLUSION

The findings suggest that CanDirect is an effective method of managing mild-moderate depression symptoms in cancer survivors.

Heeding the psychological concerns of young cancer survivors: a single-arm feasibility trial of CBT and a cognitive behavioral conceptualization of distress

Background

A subgroup of adolescent and young adult (AYA) survivors of cancer during adolescence report high levels of psychological distress. To date, evidence-based psychological interventions tailored to the cancer-related concerns experienced by this population are lacking. The present study aimed to (1) examine the feasibility and preliminary efficacy of an individualized cognitive behavioral therapy (CBT) intervention for AYA survivors of cancer during adolescence; and (2) identify and conceptualize cancer-related concerns as well as maintaining factors using cognitive-behavioral theory.

Methods

A single-arm trial, whereby AYA survivors of cancer during adolescence (aged 17–25 years) were provided individualized face-to-face CBT at a maximum of 15 sessions. Clinical outcomes were assessed at baseline, post-intervention, and three-month follow-up. Intervention uptake, retention, intervention delivery, and reliable change index scores were examined. An embedded qualitative study consisted of two unstructured interviews with each participant pre-intervention. Along with individual behavioral case formulations developed to guide the intervention, interview data was analyzed to identify and conceptualize cancer-related concerns and potential maintaining factors.

Results

Ten out of 213 potential participants invited into the study were included, resulting in an overall participation rate of 4.7%. Nine participants completed the intervention, with respectively seven and eight participants completing the post-intervention and three month follow-up assessment. The majority of reported cancer-related concerns and maintaining factors were conceptualized into four themes: social avoidance, fear of emotions and bodily symptoms, imbalance in activity, and worry and rumination.

Conclusions

Given significant recruitment difficulties, further research is required to examine barriers to help-seeking in the AYA cancer survivor population. However, the conceptualization of cancer-related concerns and maintaining factors experienced by the population may represent an important first step in the development of psychological support tailored toward AYA cancer survivors’ unique needs.

Psychological support for patients with cancer: evidence review and suggestions for future directions

PURPOSE OF REVIEW

Psychological distress and mental health comorbidity are common in cancer. Various therapeutic frameworks have been used for interventions to improve psychological wellbeing and quality of life in cancer patients with mixed results. This article reviews contributions to that literature published since January 2017.

RECENT FINDINGS

The majority of new psychological intervention research in cancer has used cognitive behavioural therapy (CBT) or mindfulness-based interventions. CBT has been considered a gold-standard intervention and recent evidence justifies continuation of this. Recent reviews call into question the validity of evidence for mindfulness-based interventions. A smaller number of trials using acceptance and commitment therapy, meta-cognitive therapy, dignity therapy and coaching have emerged, and whereas findings are promising, additional fully powered trials are required. Weaker evidence exists for counselling, support-based and narrative therapy interventions.

SUMMARY

Efficacious, timely and acceptable psychological interventions are a necessary component of comprehensive cancer care. There is some way to go before the evidence conclusively points towards which interventions work for which cancer groups and for which specific outcomes. Methodological limitations must be addressed in future trials; at the forefront remains the need for fully powered, head-to-head comparison trials.