A randomized controlled trial of a digital cognitive-behavioral therapy program (COMPASS) for managing depression and anxiety related to living with a long-term physical health condition

BACKGROUND

To evaluate the clinical efficacy of COMPASS, a therapist-supported digital therapeutic for reducing psychological distress (anxiety/depression) in people living with long-term physical health conditions (LTCs).

METHODS

A two-armed randomized-controlled trial recruiting from LTC charities. Participants with anxiety and/or depression symptoms related to their LTC(s) were randomized (concealed allocation via independent administrator) to COMPASS (access to 11 tailored modules plus five thirty-minute therapist support sessions) or standard charity support (SCS). Assessments were completed online pre-randomization, at 6- and 12-weeks post-randomization. Primary outcome was Patient Health Questionnaire Anxiety and Depression Scale; PHQ-ADS measured at 12-weeks. Analysis used intention-to-treat principles with adjusted mean differences estimated using linear mixed-effects models. Data-analyst was blinded to group allocation.

RESULTS

194 participants were randomized to COMPASS (N = 94) or SCS (N = 100). At 12-weeks, mean level of psychological distress was 6.82 (95% confidence interval; CI 4.55-9.10) points lower (p < 0.001) in the COMPASS arm compared with SCS (standardized mean difference of 0.71 (95% CI 0.48-0.95)). The COMPASS arm also showed moderate significant treatment effects on secondary outcomes including depression, anxiety and illness-related distress and small significant effects on functioning and quality-of-life. Rates of adverse events were comparable across the arms. Deterioration in distress at 12-weeks was observed in 2.2% of the SCS arm, and no participants in the COMPASS arm.

CONCLUSION

Compared with SCS, COMPASS digital therapeutic with minimal therapist input reduces psychological distress at post-treatment (12-weeks). COMPASS offers a potentially scalable implementation model for health services but its translation to these contexts needs further evaluating.

TRIAL REGISTRATION

NCT04535778.

Retrospective Assessment of Surface Imaging Set up Accuracy for Intensity Modulated Proton Therapy of Comprehensive Breast Irradiation

PURPOSE/OBJECTIVE(S)

The purpose of this work is to retrospectively assess differences in pretreatment set-up between x-ray-based alignment (kV pair and/or CBCT) and the CatalystPT Surface Imaging System (C-RAD) to quantify accuracy and determine maximum deviation of intra-fractional motion in breast patients treated with proton therapy.

MATERIALS/METHODS

Breast patient setup differences were evaluated for ninety-seven patients (n = 97) treated by proton therapy between 2019 and 2022 at our institution. Each patient was initially aligned using C-RAD followed by orthogonal planar x-rays and/or CBCT to finalize pre-treatment localization. The couch coordinates from C-RAD immediately after patient positioning were captured and compared with the finalized couch coordinates using x-ray-based alignment. Additionally, the maximum 6D deviation of patient position recorded by C-RAD during the course of treatment was captured. Patient BMI and age were correlated with setup differences between C-RAD and x-ray imaging and evaluated using Pearson Correlation Coefficients (PCC) and Analysis of Variance (ANOVA) test.

RESULTS

The absolute mean displacement was calculated over the entire course of treatment and reported by comparing the absolute difference between C-RAD and x-ray setups for each patient. The absolute mean displacement difference calculated by the mean of all the patients was found to be 2.5±1.1 mm (lateral), 2.8±1.2 mm (longitudinal), 2.5±1.0 mm (vertical), 1.2±0.5° (Yaw), 1.0±0.5°(Pitch) and 1.0±0.5°(Roll). The relative mean displacement difference with respect to the couch coordinate finalized by x-ray imaging was calculated by the mean of all the patients and was found to be 3.9±1.8 mm (lateral), 4.8±1.7 mm (longitudinal), 3.1±1.6 mm (vertical), 1.2±0.7° (Yaw), 1.6±0.7°(Pitch) and 1.3±0.6°(Roll). The mean maximum deviation for the entire course of treatment reported by C-RAD for all the patients was calculated to be 3.3±0.9 mm. Statistically, there are no significant correlations between BMI or age for mean displacement difference (BMI: PCC = 0.18, p-value = 0.075, Age: PCC = 0.004, p-value = 0.80705) and maximum deviation (BMI: PCC = 0.023, p-value = 0.72, Age: PCC = -0.089, p-value = 0.37).

CONCLUSION

C-RAD was able to position breast patients to within 3 mm of the isocenter and monitor the intra-fractional motion of patients which was found to be 3.3±0.9 mm.

Dosimetric Evaluation of a Novel Non-Metallic Dual Port Expander for Proton Therapy

PURPOSE/OBJECTIVE(S)

This study evaluates a novel non-metallic (plastic) dual port expander and clinically utilized single/dual port metallic expanders for intensity modulated proton therapy (IMPT) in order to quantify the dosimetric implications in clinical treatment plans.

MATERIALS/METHODS

Four previously treated breast cancer patients (3 left sided, 1 right sided) with tissue expanders were retrospectively planned for IMPT utilizing a treatment planning system. Utilizing the existing CT data sets, models of three Sientra tissue expanders (dual port plastic (DPP), dual port metal (DPM) and single port metal (SPM)) were inserted into the 3D dataset and aligned using the existing patient anatomy. Each patient was planned to a total dose of 50.4 Gy in 28 fractions using 3 incident proton fields and Monte Carlo calculation algorithm. A 5 mm expansion was placed around the metallic portion of the expander to define a beam avoidance region which no proton spots traversed or were placed to minimize dosimetric error. Robust optimization (5mm setup uncertainty, 3.5% range uncertainty) was employed to a total target volume which comprised the CTV chest wall, IMN, axilla and supraclavicular nodes. The subsequent treatment plans were evaluated for target and OAR coverage.

RESULTS

Due to the non-metallic construction of the DPP expander, the metallic structure avoidance region was significantly smaller at 4.4cc on average than either the SPM (45cc average) or DPM (63.5cc average). This allowed the IMPT plans to be significantly less modulated, delivering a more uniform dose to the implant volume (SPM 47.1Gy; DPM 45.2 Gy; DPP 50.9 Gy) and thus enabling these plans to be inherently more robust to setup uncertainties. The additional benefit of the reduced avoidance region size is that the hinge angle of the lateral proton beams can be reduced for DPP plans thus reducing dose to the heart and contralateral breast. Average mean heart dose across the four cases presented is 0.68 Gy, 1.03 Gy, and 0.93 Gy, for the DPP, DPM and SPM cases respectively, while average contralateral breast/CW dose is 0.38 Gy, 0.58 Gy and 0.63 Gy. The V20 for the ipsilateral lung was, on average, reduced for the DPP expander at 14.3% across the 4 cases, while 18.8% and 17.0% for the DPM and SPM cases respectively.

CONCLUSION

The minimization of metal in the DPP expander allows for a significantly smaller beam avoidance region, in-turn enabling creation of a more homogeneous plan that can be potentially more robust while also reducing dose to surrounding OARs. Additional work is underway to expand the study to include a larger patient cohort, while also evaluating the impact of different robustness goals on OAR sparing.

The Anatomy and Evolution of a Quality Proton Therapy Plan Check Process: An Institutional Review

PURPOSE/OBJECTIVE(S)

There exists limited standard guidance from the physics community on the optimal way to ensure high-reliability proton therapy treatments. Following the guidance of AAPM MPPG 4a/4b and Task Groups 100/275, our institution has developed, implemented, and maintained strategies over the last five years to streamline workflows, enable more complex treatments, standardize procedures, and manage risk from slip or omission type errors in proton therapy. The evolution and success of that is observed from an institutional analysis of past operations data.

MATERIALS/METHODS

From the outset, standard care paths were used to sequence our workflows. These chains of tasks were well-defined and timestamped upon completion for every patient. Over five years, additional multiple interventions were implemented including clinical site standardization, checklists, root cause analysis, and failure mode identification. These were used to counter environmental variables with potential to disrupt timelines like growing patient volume, staffing demands, and new technique adoptions. These interventions went through extensive design, validation, and continuous improvement phases by the entire clinical team. Using ARIA v15.5, task timestamp data from the past 5 years were mined for physics proton-specific planning tasks and used to compute how early/late each task was in comparison to the expected due time. Average and standard deviation data were computed and used to create control charts. This coupled with the average time per year was cross-referenced with interventions to determine the impact on plan preparation timelines.

RESULTS

Over 5 years, the standard care path length reduced from 16 to 13 business days. The greatest impact on timelines was observed from standardizing clinical site guidelines. This minimized variability in task times and allowed the creation of checklists. By standardizing, we identified slack as well the need for new tasks. Overall, the average days late or early went from on-average late to on-average early (Table 1). The control charts indicate that many tasks stabilized in recent years. Furthermore, these interventions allowed us to safely increase the complexity of our proton plans using Monte Carlo dose calculations, 4D-optimization, robustness standards, repainting, and increased beams with no slippage in overall timelines.

CONCLUSION

Clinical site standardization, checklists, consistent process re-evaluation, and a team attitude of continuous improvement allowed us to improve control of our processes while simultaneously expanding treatment complexity and meeting the goals of our quality management plan.

Clinical efficacy of COMPASS, a digital cognitive-behavioural therapy programme for treating anxiety and depression in patients with long-term physical health conditions: a protocol for randomised controlled trial

INTRODUCTION

Approximately 30% of people with long-term physical health conditions (LTCs) experience mental health problems, with negative consequences and costs for individuals and healthcare services. Access to psychological treatment is scarce and, when available, often focuses on treating primary mental health problems rather than illness-related anxiety/depression. The aim of this study is to evaluate the clinical efficacy of a newly developed, therapist-supported, digital cognitive-behavioural treatment (COMPASS) for reducing LTC-related psychological distress (anxiety/depression), compared with standard charity support (SCS).

METHODS AND ANALYSIS

A two-arm, parallel-group randomised controlled trial (1:1 ratio) with nested qualitative study will be conducted. Two-hundred adults with LTC-related anxiety and depression will be recruited through national LTC charities. They will be randomly allocated to receive COMPASS or SCS only. An independent administrator will use Qualtrics randomiser for treatment allocation, to ensure allocation concealment. Participants will access treatment from home over 10 weeks. The COMPASS group will have access to the digital programme and six therapist contacts: one welcome message and five fortnightly phone calls. Data will be collected online at baseline, 6 weeks and 12 weeks post-randomisation for primary outcome (Patient Health Questionnaire Anxiety and Depression Scale) and secondary outcomes (anxiety, depression, daily functioning, COVID-19-related distress, illness-related distress, quality of life, knowledge and confidence for illness self-management, symptom severity and improvement). Analyses will be conducted following the intention-to-treat principle by a data analyst blinded to treatment allocation. A purposively sampled group of COMPASS participants and therapists will be interviewed. Interviews will be thematically analysed.

ETHICS AND DISSEMINATION

The study is approved by King's College London's Psychiatry, Nursing and Midwifery Research Ethics Subcommittee (reference: LRS-19/20-20347). All participants will provide informed consent to take part if eligible. Findings will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT04535778.

Combined Effects of Low-Dose Proton Radiation and Simulated Microgravity on the Mouse Retina and the Hematopoietic System

The purpose of the current study was to characterize the effects of simulated microgravity and radiation-induced changes in retina and retinal vasculature, and to assess the accompanying early changes in immune cells and hematological parameters. To better understand the effects of spaceflight, we used a combination of treatments designed to simulate both the radiation and low-gravity aspects of space conditions. To simulate the broad energy spectrum of a large solar particle event (SPE) and galactic cosmic ray (GCR) radiation, male C57BL/6J mice were exposed to whole-body irradiation using fully modulated beams of 150-MeV protons containing particles of energy from 0 to 150 MeV and a uniform dose-vs.-depth profile. The mice were also hindlimb-unloaded (HLU) by tail suspension. Mice were unloaded for 7 days, exposed to 50 cGy, unloaded for an additional 7 days and then sacrificed for tissue isolation at days 4 and 30 after the combined treatments. Increases in the number of apoptotic cells were observed in the endothelial cells of mice that received radiation alone or with HLU compared to controls at both days 4 and 30 (P < 0.05). Endothelial nitric oxide synthase (eNOS) levels were significantly elevated in the retina after irradiation only or combined with HLU compared to controls at the 30-day time point (P < 0.05). The most robust changes were observed in the combination group, suggesting a synergistic response to radiation and unloading. For hematopoietic parameters, our analysis indicated the main effects for time and radiation at day 4 after treatments (day 11 postirradiation) (P < 0.05), but a smaller influence of HLU for both white blood cell and lymphocyte counts. The group treated with both radiation and HLU showed greater than 50% reduction in lymphocyte counts compared to controls. Radiation-dependent differences were also noted in specific lymphocyte subpopulations (T, B, natural killer cells). This study shows indications of an early effect of low-dose radiation and spaceflight conditions on retina and immune populations.

Development and Evaluation of a Cognitive Behavioural Intervention for Chronic Post-Stroke Insomnia

BACKGROUND

Cognitive behavioural therapy for insomnia (CBTI) has been successfully applied to those with chronic illness. However, despite the high prevalence of post-stroke insomnia, the applicability of CBTI for this population has not been substantially researched or routinely used in clinical practice.

AIMS

The present study developed a 'CBTI+' protocol for those with post-stroke insomnia and tested its efficacy. The protocol also incorporated additional management strategies that considered the consequences of stroke.

METHOD

A single-case experimental design was used with five community-dwelling individuals with post-stroke insomnia. Daily sleep diaries were collected over 11 weeks, including a 2-week baseline, 7-week intervention and 2-week follow-up. The Insomnia Severity Index, Dysfunctional Attitudes and Beliefs About Sleep Scale, Epworth Sleepiness Scale, Fatigue Severity Scale and Stroke Impact Scale were administered pre- and post-treatment, as well as at 2-week follow-up.

RESULTS

At post-treatment, three participants no longer met diagnostic criteria for insomnia and all participants showed improvements on two or more sleep parameters, including sleep duration and sleep onset latency. Three participants showed a reduction in daytime sleepiness, increased quality of life and reduction in unhelpful beliefs about sleep.

CONCLUSIONS

This study provides initial evidence that CBTI+ is a feasible and acceptable intervention for post-stroke insomnia. Furthermore, it indicates that sleep difficulties in community-dwelling stroke populations are at least partly maintained by unhelpful beliefs and behaviours. The development and delivery of the CBTI+ protocol has important clinical implications for managing post-stroke insomnia and highlights directions for future research.

Cognitive behaviour treatment of co-occurring depression and generalised anxiety in routine clinical practice

Background

Anxiety and depression are closely associated. However, they are typically treated separately and there is a dearth of information on tackling them together.

Aims

The study’s purpose was to establish how best to treat co-occurring anxiety and depression in a routine clinical service—specifically, to compare cognitive behaviour therapy (CBT) focusing only on depression (CBT-D) to a broader CBT focusing on both depression and anxiety (CBT-DA).

Method

Case notes of 69 patients with equally severe clinical levels of depression and anxiety seen in a routine clinical service were randomly selected to review from a pool of 990 patients. The mean age was 44.61 years (SD = 12.97). 65% of the sample were female and 88% reported their ethnicity white. The content of electronic records reporting techniques used and scores on a measure of depression (The Patient Health Questionnaire) and anxiety (The Generalized Anxiety Disorder Assessment) were reviewed to categorise therapy as CBT-D or CBT-DA.

Results

Results indicated significant overall improvement with CBT; 70% and 77% of the sample met criteria for reliable improvement on The Patient Health Questionnaire and The Generalized Anxiety Disorder Assessment respectively. Fewer patients who received CBT-DA met The Generalized Anxiety Disorder Assessment recovery criteria at the end of treatment than those who received CBT-D. Mean post treatment PHQ-9 and GAD-7 scores remained above threshold for those receiving CBT_DA but not those receiving CBT-D. There was no evidence suggesting CBT-DA was superior to CBT-D.

Conclusions

In patients with equally severe clinical levels of depression and anxiety, a broader treatment addressing both anxiety and depression does not appear to be associated with improved outcomes compared to treatment focused on depression.

Acute Effect of Low-Dose Space Radiation on Mouse Retina and Retinal Endothelial Cells

There is concern that degradation of vision as a result of space flight may compromise both mission goals and long-term quality of life after space travel. The visual disturbances may be due to a combination of intracerebral pressure changes and exposure to ionizing radiation. The retina and the retinal vasculature play important roles in vision, yet have not been studied extensively in relationship to space travel and space radiation. The goal of the current study was to characterize oxidative damage and apoptosis in retinal endothelial cells after whole-body gamma-ray, proton and oxygen (¹⁶O) ion radiation exposure at 0.1 to 1 Gy. Six-month-old male C57Bl/6J mice were whole-body irradiated with 600 MeV/n ¹⁶O ions (0, 0.1, 0.25, 1 Gy), solar particle event (SPE)-like protons (0, 0.1, 0.25, 0.5 Gy) or ⁶⁰Co gamma rays (0, 0.1, 0.25, 0.5 Gy). Eyes were isolated for examining endothelial nitric oxide synthase (eNOS) expression and characterization of apoptosis in retina and retinal endothelial cells at two weeks postirradiation. The expression of eNOS was significantly increased in the retina after proton and ¹⁶O ion exposure. ¹⁶O ions induced over twofold increase in eNOS expression compared to proton exposure at two weeks postirradiation ( P < 0.05). TUNEL assays showed dose-dependent increases in apoptosis in the retina after irradiation. Low doses of ¹⁶O ions elicited apoptosis in the mouse retinal endothelial cells with the most robust changes observed after 0.1 Gy irradiation ( P < 0.05) compared to controls. Data also showed that ¹⁶O ions induced a higher frequency of apoptosis in retinal endothelial cells compared to protons ( P < 0.05). In summary, our study revealed that exposure to low-dose ionizing radiation induced oxidative damage and apoptosis in the retina. Significant changes in retinal endothelial cells occur at doses as low as 0.1 Gy. There were significant differences in the responses of endothelial cells among the radiation types examined here.

Helping patients to reach decisions regarding their treatment: Do 'non-directive' approaches cause systematic bias?

OBJECTIVES

Many patients want help in considering medical information relevant to treatment decisions they have to make or agree to. The present research investigated whether focussing on particular issues relevant to a medical treatment decision (using an apparently non-directive procedure) could systematically bias a treatment decision.

DESIGN AND METHODS

In a randomized design, participants (community volunteers, n = 146) were given standard information about treatment of cardiac risk factors by medication (statins). There were four experimental interventions in which the participants focussed on the likely personal relevance of subsets of the information previously given (positive, negative, or mixed aspects) or on irrelevant information. Participants were asked to rate their anticipated likelihood of accepting treatment before and after the experimental intervention.

RESULTS

The rating of acceptance of treatment was significantly increased by positive focussing; negative focussing did not significantly alter the decision rating.

CONCLUSIONS

The results partially replicate similar studies in health screening decisions. Reasons for the differences in results from those obtained in screening studies are considered. It is suggested that negative focussing may have less effect in decisions in which there are few risks. Statement of contribution What is already known on this subject? Decision-making in the context of health behaviour change has been widely described, but there are few experimental studies testing hypothesised strategies. 'Non-directiveness' is often regarded as desirable because it supposedly allows exploration of the decision without influencing it. Previous studies on health screening (but not treatment) have shown that health decision outcomes can be systematically influenced by the way in which a 'non-directive' intervention is implemented. This can be accounted for by a modified subjective expected utility theory previously applied to both health screening and child vaccination decisions. What does this study add? The hypothetical decision about whether or not, in future, to take statins for elevated cholesterol levels was influenced by positive but not by negative focussing. Results were consistent with the theoretical framework. This study extends previous work on influences on the decision to undertake health screening and vaccination to treatment offered as secondary prevention. 'Non-directive' approaches to helping facilitate decisions can modify those decisions, and as such cannot be regarded as non-directive.

SU-E-T-232: Proton Source Modeling for Geant4 Monte Carlo Simulations

PURPOSE

To investigate the effect of initial proton beam source placement, distribution and angle on the proton dose distribution in a therapeutic nozzle using Geant4.

METHODS

We performed Geant4 Monte Carlo simulations of a passively scattered proton treatment nozzle. Accurate geometry including all elements in the treatment room was used. Protons were generated just inside the vacuum pipe using one of two models. First, a standard two dimensional Gaussian distribution of proton starting position was used with a small random angle added to the initial direction. The size of the Gaussian distribution and the random angle were set to match measured beam spot size and angular spread at the exit window. Second, a point source of protons further back in the vacuum pipe with a small random angle was used. The distance of the point source to exit window and the random angle were set to match the spot size and angular deviation used for the Gaussian distribution. Depth dose curves and orthogonal beam profiles were examined to determine changes between the two models.

RESULTS

Orthogonal beam profiles for large apertures showed changes of up to 6.5% between the two models with the point source showing much better agreement with measured data. Depth dose curves and orthogonal profiles for small apertures were unaffected. For large apertures, the average difference compared to measured data was of 1.9% and 0.7% and the max difference was 5.0% and 1.6% for Gaussian and point sources, respectively.

CONCLUSIONS

The point source more realistically models the proton distribution in the vacuum pipe by correlating the proton position with the direction. For certain scattering setups and large apertures point source modeling is necessary to accurate match measured data with Monte Carlo simulations.

Ion-counting nanodosemeter with particle tracking capabilities

An ion-counting nanodosemeter (ND) yielding the distribution of radiation-induced ions in a low-pressure gas within a millimetric, wall-less sensitive volume (SV) was equipped with a silicon microstrip telescope that tracks the primary particles, allowing correlation of nanodosimetric data with particle position relative to the SV. The performance of this tracking ND was tested with a broad 250 MeV proton beam at Loma Linda University Medical Center. The high-resolution tracking capability made it possible to map the ion registration efficiency distribution within the SV, for which only calculated data were available before. It was shown that tracking information combined with nanodosimetric data can map the ionisation pattern of track segments within 150 nm-equivalent long SVs with a longitudinal resolution of approximately 5 tissue-equivalent nanometers. Data acquired in this work were compared with results of Monte Carlo track structure simulations. The good agreement between 'tracking nanodosimetry' data acquired with the new system and simulated data supports the application of ion-counting nanodosimetry in experimental track-structure studies.