Improving depression management with support from close others: A thematic analysis of individuals with depression and their partners in care

OBJECTIVES

With support from others, individuals with depression can build skills and implement lifestyle changes that help them manage their illness. The objective of the current study was to understand how the CarePartners for Depression Program, a randomized clinical trial aimed at enhancing the role of caregivers in the management of depression, improved communication and shared understandings of depression among individuals with depression and their close others.

METHODS

We conducted in-depth, semi-structured interviews with individuals with depression and their caregivers who participated in the CarePartners program. Interviews were qualitatively coded using a thematic analytic framework.

RESULTS

We conducted individual interviews with 39 participants in the CarePartners program, including 18 individuals with depression, 14 out-of-home care partners, and 7 informal caregivers. Three central themes were derived from analyses: (a) The quality of interpersonal relationships influenced the management of depression; (2) having clearly defined roles for CarePartners improved communication between CarePartners and individuals with depression; and (3) shared understanding of depression improved management of depression.

DISCUSSION

Our findings established the conditions under which the management of depression was influenced in a dyadic intervention. Dyadic interventions may make it easier for individuals to support patients with depression by fostering communication and collaboration.

Clinic-based Assessment and Support for Family Caregivers of Patients With Cancer: Results of a Feasibility Study

Background

Cancer caregiving is burdensome with unique needs, highlighting the importance of assessing caregivers' distress. Caregivers often accompany patients to healthcare visits, presenting an opportunity to complete distress screening at patients' point-of-care.

Objective

To evaluate the feasibility of caregiver distress screening at patients' point-of-care and implementing a caregiver psychoeducational session.

Methods

We approached caregivers in outpatient cancer clinic waiting rooms. Participants completed depression, burden, anxiety, quality of life, and stress measures. A psychoeducational session with a psychologist was offered to those meeting clinical cutoffs for depression and/or burden. Fifty caregivers completed 1+ measure; however, due to incomplete consent documentation, findings from 23 caregivers are reported.

Results

22% of caregivers screened positive for depression, 30% burden, and 70% anxiety. More than half rated stress as moderate or higher. Mental wellbeing was slightly below that of the general population. More than 75% screened positive on 1+ distress measure. Of the 9 caregivers who met cutoffs for depression and/or burden, two (22%) accepted the psychoeducational session.

Conclusion

Caregivers were moderately receptive to distress screening during patients' visits, but were less receptive to engaging in the psychoeducational session due to time constraints and privacy concerns.

Implications for Practice

Assessing caregivers' distress can facilitate referrals for supportive services. Offering caregivers psychoeducational intervention outside of patient care may not be acceptable. Future research may evaluate the integration of routine caregiver screening within patient care to promote engagement with mental health services.

Foundational

This research offers a unique method of assessing cancer caregivers' distress.

Adapting a Telephone-Based, Dyadic Self-management Program to Be Delivered Over the Web: Methodology and Usability Testing

BACKGROUND

The COVID-19 pandemic has amplified the need for web-based behavioral interventions to support individuals who are diagnosed with chronic conditions and their informal caregivers. However, most interventions focus on patient outcomes. Dyadic technology-enabled interventions that simultaneously improve outcomes for patients and caregivers are needed.

OBJECTIVE

This study aimed to describe the methodology used to adapt a telephone-based, facilitated, and dyadic self-management program called Self-care Using Collaborative Coping Enhancement in Diseases (SUCCEED) into a self-guided, web-based version (web-SUCCEED) and to conduct usability testing for web-SUCCEED.

METHODS

We developed web-SUCCEED in 6 steps: ideation-determine the intervention content areas; prototyping-develop the wireframes, illustrating the look and feel of the website; prototype refinement via feedback from focus groups; finalizing the module content; programming web-SUCCEED; and usability testing. A diverse team of stakeholders including content experts, web designers, patients, and caregivers provided input at various stages of development. Costs, including full-time equivalent employee, were summarized.

RESULTS

At the ideation stage, we determined the content of web-SUCCEED based on feedback from the program's original pilot study. At the prototyping stage, the principal investigator and web designers iteratively developed prototypes that included inclusive design elements (eg, large font size). Feedback about these prototypes was elicited through 2 focus groups of veterans with chronic conditions (n=13). Rapid thematic analysis identified two themes: (1) web-based interventions can be useful for many but should include ways to connect with other users and (2) prototypes were sufficient to elicit feedback about the esthetics, but a live website allowing for continual feedback and updating would be better. Focus group feedback was incorporated into building a functional website. In parallel, the content experts worked in small groups to adapt SUCCEED's content, so that it could be delivered in a didactic, self-guided format. Usability testing was completed by veterans (8/16, 50%) and caregivers (8/16, 50%). Veterans and caregivers gave web-SUCCEED high usability scores, noting that it was easy to understand, easy to use, and not overly burdensome. Notable negative feedback included "slightly agreeing" that the site was confusing and awkward. All veterans (8/8, 100%) agreed that they would choose this type of program in the future to access an intervention that aims to improve their health. Developing and maintaining the software and hosting together cost approximately US $100,000, excluding salary and fringe benefits for project personnel (steps 1-3: US $25,000; steps 4-6: US $75,000).

CONCLUSIONS

Adapting an existing, facilitated self-management support program for delivery via the web is feasible, and such programs can remotely deliver content. Input from a multidisciplinary team of experts and stakeholders can ensure the program's success. Those interested in adapting programs should have a realistic estimate of the budget and staffing requirements.

CULTURALLY CONCORDANT CARE: CLINICIAN PERSPECTIVES ON PROVIDING CANCER CARE TO SOUTH ASIANS

In many South Asian (SA) cultures, cancer is stigmatized, and family members are expected to become primary caregivers. Clinicians need to be familiar with these SA needs and values to provide culturally concordant care. The South Asian Family Approaches to Disease (SAFAD) study aims to understand cultural needs of SAs managing breast cancer. We conducted semi-structured qualitative interviews with multidisciplinary clinicians at a major academic medical center about caregiver interactions, cultural dynamics affecting clinical practice, unmet patient needs, and perceptions of culturally concordant care. Participants included physicians(8), a nurse practitioner(1), a social worker(1), and a physician assistant(1) with experience in palliative care(5), hematology/oncology(4), breast cancer(3), critical care(2), and radiation oncology(1) with one to 42 years in practice. Participants identified as Caucasian/White(6), South Asian(3), African American/Black(1), and Chinese(1). Clinicians noted the following: 1)SAs have greater family involvement in care and may defer treatment decisions to family members; 2)SAs seek clinician support with cancer management and nutrition; 3)SA emotions and hesitation around sensitive topics may result in non-disclosure; 4)SAs have diverse caregiver roles; and 5)individual SA needs cannot be generalized within the diaspora. “There’s still some stigma… with breast cancer… [it] may lead a patient to not want to share their diagnosis… then set up a patient for having less support… [We can] help them feel more comfortable opening up selectively.” Understanding such cultural needs is essential to cultivating trust and providing person-centered care. Interventions and resources to promote culturally concordant cancer care can target education in these areas.

UNMET NEEDS AND PERCEIVED BARRIERS TO ACCESSING HCBS AMONG CAREGIVERS OF VETERANS OF ALL ERAS

VA has several HCBS to offset caregiver burden, facilitate caregiving, and enhance Veterans’ home-based care, but they remain underutilized. We aimed to describe: the unmet psychosocial and HCBS needs of caregivers, barriers to accessing services, and gaps in available programs. Twenty-three caregivers participated in a 1-hr semi-structured interview (62.9□13.5y; 74.0% women; 47.8% White; 17.4% Hispanic; 65.2% spouses). Caregivers provided 7.3 hrs of daily care (SD=5.5 hrs, Range=1-24); most had provided care for 1+ year. Barriers to accessing HCBS included: a) disagreement with Veterans regarding service preferences and needs; b) lack of awareness of VA and non-VA programs; c) delays in obtaining services; and d) emotional toll of caregiving on personal health and relationship with the Veteran. The VA may need to invest in advertising existing services, develop strategies to match caregivers with available services when needed, and enhancing mental health and relationship quality for Veterans and caregivers.

SOCIAL SUPPORT DYNAMICS FOR SOUTH ASIAN BREAST CANCER PATIENTS: AN ANALYSIS CONDUCTED USING ATLAS CAREMAPS

With a rise in the prevalence and a drop in mortality rates of breast cancer among South Asians (people with heritage from India, Pakistan, Nepal, Bhutan, Sri Lanka, Maldives, and Bangladesh), globally and in the US, there is an increasing number of South Asians managing breast cancer. The South Asian Family Approaches to Disease (SAFAD) study aims to better understand how South Asian breast cancer survivors are supported while managing breast cancer. We conducted semi-structured interviews to complete an adapted version of Atlas CareMaps, a visual representation of survivors' care networks at the time of the interview. Thirteen South Asian breast cancer survivors were enrolled. Survivors were on average 47y (SD=9.1y) and reported being diagnosed with stage 0 (n=1), stage 1 (n=3), stage 2 (n=6), or stage 4 (n=3) breast cancer. Analyses of the Atlas CareMaps suggest 1) South Asian breast cancer survivors received support from 13.7±3.5 individuals, while providing care to 3.3 ± 2.2 individuals; 2) at more advanced stages of breast cancer, patients provide less support to others (Stage 1=3.8±2.2, Stage 4=1.7±1.5); 3) older survivors received more support from abroad (< 40y=2.0±2.2, patients 50+=5.3±3.3). Atlas CareMaps can provide useful insights into the rich care networks of South Asian breast cancer survivors which can be used to develop clinical programs.

UNDERSTANDING THE CARE NETWORKS OF INFORMAL CAREGIVERS OF SOUTH ASIANS WITH BREAST CANCER USING ATLAS CAREMAPS

Breast cancer rates are increasing among individuals with a South Asian heritage, i.e., from India, Pakistan, Nepal, Bhutan, Sri Lanka, Maldives, and Bangladesh. Informal caregiving is vastly understudied among this population, despite being influenced by cultural mores such as collectivism, cancer-related stigma, and gender roles. The South Asian Family Approaches to Disease (SAFAD) study took a mixed-methods, observational approach to describe the care networks of informal caregivers via an adapted version of Atlas CareMaps. Thirteen caregivers (43.9+/-14.8y, 30.8% female) were interviewed and included 6 husbands, 1 wife, 2 daughters, 1 son, 1 brother, and 1 friend of the breast cancer survivors. Semi-structured interviews were designed to develop an adapted Atlas CareMap, a visual representation of the caregivers’ care network at the time of the interview. Atlas CareMaps depicted the number of people supported by caregivers, and who provide support; their relationship; the frequency, intensity, and type of care; and modes of communication used. Immediate or extended family members were the most common people included. Results indicated that: 1) caregivers reported 8.8□3.5 individuals in their care network, provided care to 3.5+/-1.8 individuals and received care from 7.3+/-3.5 individuals; 2) caregivers primarily received emotional support from others; 3) their survivors’ care teams were often included as a source of support and medical knowledge for survivors, but only three noted that the care teams supported them directly. Describing these networks is a key step to developing culturally-concordant programs that can support South Asian caregivers, even as they care for breast cancer survivors.

Patient, caregiving partner, and clinician recommendations for improving heart failure care in the Veterans Health Administration

OBJECTIVE

Heart Failure (HF) care requires substantial care coordination between patients, patients' informal caregivers, and clinicians, but few studies have examined recommendations from all three perspectives. The objective of this study was to understand and identify shared recommendations to improve HF self-care from the perspective of VA persons with HF, their caregiving partners, and clinicians.

METHODS

Secondary data analysis from a study of semi-structured interviews with 16 couples (persons with HF and their caregiving partners) and 13 clinicians (physicians, nurses, other specialists) from a large Veterans Affairs (VA) hospital. Interviews were double-coded, and analyzed for themes around commonly used or recommended self-care strategies.

RESULTS

Three themes emerged: (1) Couples and clinicians believe that improvements are still needed to existing HF education, especially the need to be tailored to learning style and culture, (2) Couples and clinicians believe that technology can facilitate better HF self-care, and (3) Couples and clinicians believe that caregiving partners are part of the self-care team, and should be involved in care management to support the person with HF.

DISCUSSION

Recommendations from couples and clinicians address barriers to HF self-care and encourage patient-centered care.

A Web-Based Self-Management Intervention for Veterans With Chronic Conditions and Their Caregivers: A Pilot Study

Web-based Self-management Using Collaborative Coping Enhancement in Diseases (Web-SUCCEED) is a dyadic intervention for patients and their caregivers designed to improve self-management through improving dyadic stress coping, dyadic relationships, and positive emotions. Veterans Affairs (VA) patients with one or more chronic conditions and positive screen for self-management distress were recruited with their informal caregiver from VA Palo Alto. Of the 17 patients and 16 caregivers recruited (62.3% of eligible), 8 patients and 8 caregivers (48.5%) completed the intervention and assessments. Twelve participants withdrew mostly citing the stress of the pandemic as their reason; 5 did not respond to multiple outreach efforts. Veterans were 66□18 y and caregivers were 58□16 y. Veterans and caregivers who completed the program rated it high on usability and acceptability. Pre-post t-tests across a psychosocial battery did not reveal significant differences; results were limited by incomplete post-intervention data. Further testing with modified retention strategies is recommended.

Caregiving Intensity and Psychosocial Impact of COVID-19 in Dementia and Non-Dementia Caregivers

COVID-19 has adversely impacted the well-being of informal caregivers (CG) due to infection risk, changes to the home environment, and changes to resource availability. CG of persons living with dementia (PLWD) may be especially vulnerable due to the intensity of care provided. We compared CG activities and well-being among CG who did and did not care for PLWD during COVID-19. We conducted an anonymous online survey from April 2020-present. Respondents self-identified as 18+ years and CG to a child or adult with mental health or medical conditions. CG answered questions regarding hours of care provision and caregiving activities, and completed measures of CG burden (Zarit Burden Inventory-4), loneliness (UCLA Loneliness Scale), depressive symptoms (Patient Health Questionnaire), and anxiety (Generalized Anxiety Disorder-2). Of the 258 respondents within the United States, 86 cared for PLWD (33%; 88% female; 56±12 years) while 172 did not (66%; 87% female; 49±14 years). Compared to non-dementia CGs, more CGs of PLWD provided 40+ hours of caregiving/week (36% vs. 49%, p<.05), performed more caregiving activities (8.5 vs. 10.5, p<.01), and assisted with more activities of daily living (55% vs. 73%, p<.01). Compared to non-dementia CG, more dementia CG reported CG burden (53% vs. 67%; p<.05) and loneliness (7.3 vs. 9.1, p<.05). No differences in depressive symptoms or anxiety were found. Results suggest that existing needs of CG of PLWD may be exacerbated by the stressors and concerns of the pandemic, necessitating higher levels of support.

Protocol for isolating young adult parvalbumin interneurons from the mouse brain for extraction of high-quality RNA

Dysfunction in the parvalbumin (PV) subclass of GABAergic interneurons is implicated in several neurodevelopmental disorders that evolve in severity with postnatal developmental stages. Understanding the molecular underpinnings of the postnatal changes in the function of PV interneurons has been limited by the difficulty in the isolation of pure adult PV interneurons and high-quality RNA. Here, we describe our protocol for the isolation of pure young adult PV interneurons and preparation of high-quality RNA from these cells. For complete details on the use and execution of this protocol, please refer to Joseph et al. (2021).

Postnatal Arx transcriptional activity regulates functional properties of PV interneurons

The transcription factor Aristaless-related X-linked gene (Arx) is a monogenic factor in early onset epileptic encephalopathies (EOEEs) and a fundamental regulator of early stages of brain development. However, Arx expression persists in mature GABAergic neurons with an unknown role. To address this issue, we generated a conditional knockout (CKO) mouse in which postnatal Arx was ablated in parvalbumin interneurons (PVIs). Electroencephalogram (EEG) recordings in CKO mice revealed an increase in theta oscillations and the occurrence of occasional seizures. Behavioral analysis uncovered an increase in anxiety. Genome-wide sequencing of fluorescence activated cell sorted (FACS) PVIs revealed that Arx impinged on network excitability via genes primarily associated with synaptic and extracellular matrix pathways. Whole-cell recordings revealed prominent hypoexcitability of various intrinsic and synaptic properties. These results revealed important roles for postnatal Arx expression in PVIs in the control of neural circuits and that dysfunction in those roles alone can cause EOEE-like network abnormalities.

How are Informal Caregivers Adapting to COVID19? Preliminary Results of an Online Survey

COVID19 may disrupt informal caregivers’ (CG) ability to support their care recipients (CR) but little is known how caregivers adapt. A 10-minute, anonymous, online survey with no geographic restrictions was fielded April-August 2020. Two screening items ensured that the respondents were at least 18y and self-identified as a CG. This English-language survey assessed: sociodemographics; reactions to COVID19; changes in CG responsibilities and abilities; depression (Patient Health Questionnaire, PHQ-2); CG burden (Zarit Burden Inventory, ZBI-4); and anxiety (Generalized Anxiety Disorder, GAD-2). Univariate analyses determined the proportion of those who screened positive on PHQ-2 (cutoff=3), GAD-2 (cutoff=3), and ZBI-4 (cutoff=8). Of the 314 respondents, 74% lived in USA; 73.5% of caregivers and 48.2% CR were women. While 63.4% were married, only 28% cared for their spouse. CG mainly cared for adults (83%), and reported that 75.0% of their CR had 2+ conditions. 49.6% CG provided >20h of care/wk. Since COVID19, 53% reported an increase in CG responsibilities; 28.0% noted a decrease in income. Many CG screened positive on the ZBI-4 (48.4%), GAD-2 (30.9%), and PHQ-2 (26.8%). 74% worried about contracting COVID19 at least some of the time. 35.0% noted limits to performing all caregiving tasks when they (N=34) or their CR (N=57) were asked to self-isolate/quarantine. 163 (51.9%) CG noted spending less time with their CR, of which 46.4% used alternate means (e.g., telephone calls). Preliminary results show that a plurality of CG had changes in their responsibilities and abilities during COVID19. A sizable proportion also reported poor well-being.

FEASIBILITY OF SCREENING AND MANAGING CAREGIVER BURDEN AND DEPRESSIVE SYMPTOMS DURING PATIENTS’ CLINIC VISITS

Half of cancer caregivers experience depression, caregiver burden, or stress, yet less than a third have discussed their needs with anyone. Identifying this vulnerable population is challenging since caregivers only interact with the healthcare system in service of the patients. Our objectives were: 1) To test the feasibility of screening cancer caregivers for burden and depressive symptoms during patients’ clinic visits; and 2) To test the feasibility of a brief counseling session for caregivers who screened positive for either. Caregivers of patients with head and neck cancers were recruited from cancer clinic waiting rooms at Palo Alto VA and Stanford. Caregivers completed the PHQ-9 (depressive symptoms), and Zarit Burden Inventory-Short Form (caregiver burden). Participants screening positive for burden (>16) and/or depressive symptoms (>9) were provided psychoeducational resources and the choice to attend 1 brief counseling session with a clinical psychologist. Of the 50 participants who completed the surveys, 36 (72%) were women and 30 (60%) were significant others. Mean scores for depressive symptoms and caregiver burden were 6.29±5.01 and 11.02±8.62, respectively. Twenty participants screened positive for depressive symptoms (n=9) or caregiver burden (n=11); 3 screened positive for both. Of those who screened positive, only 4 indicated an interest in counseling. Main reason for refusal was lack of time, or that they were already receiving mental health care. Screening caregivers at patient visits is feasible and convenient. However, connecting those in need to mental health resources may be more challenging.