Barbara A. Given

Burden and depression among caregivers of patients with cancer at the end of life.

PURPOSE/OBJECTIVES To examine the patient and family caregiver variables that predicted caregiver burden and depression for family caregivers of patients with cancer at the end of life. DESIGN A prospective, longitudinal study was implemented with an inception cohort of patients and their family caregivers who were followed after the diagnosis and treatment of cancer. SETTING Community oncology sites in the midwestern United States. SAMPLE 152 family caregivers of patients with cancer who died during the course of the study. METHODS Telephone interviews were conducted with patients at 6-8, 12-16, 24-30, and 52 weeks following diagnoses. In addition, patient medical records and state death certificates were reviewed. MAIN RESEARCH VARIABLES Effect of caregiver age, gender, education, relationship to the patient, employment status, reports of patient symptoms, patient cancer type, stage of cancer, time from the patients diagnosis to death, caregiver burden, and depression. FINDINGS Caregivers aged 45-54 reported the highest levels of depressive symptoms, and caregivers aged 35-44 reported the strongest sense of abandonment. Caregivers who were the adult children of patients with cancer and those who were employed reported high levels of depressive symptoms. Feeling abandoned (a portion of caregiver burden) was more prevalent in female, nonspouse, and adult children caregivers, and adult children caregivers of patients with early-stage cancer and patients with multiple symptoms reported a high perception of disruption in their schedule because of providing care. Caregivers whose patients died early following diagnosis reported the highest depressive symptoms, burden, and impact on schedule. CONCLUSIONS Caregivers reported levels of depression at thresholds for screening of clinical depression. The number of patient symptoms was related to levels of caregiver depressive symptoms. An association also was found between depression and employment status. Caregiver distress was not dependent on demands of care. IMPLICATIONS FOR NURSING Very little research exists that prospectively analyzes family caregiver experiences of burden and depression when providing end-of-life cancer care for a family member. Interventions aimed at decreasing caregiver depressive symptoms should be targeted to caregivers who are middle-aged, adult children, and employed. Interventions aimed at decreasing the burden associated with feeling abandoned and having schedules disrupted while providing care should be targeted to caregivers who are female, nonspouse, and adult children, and caregivers of patients with early-stage cancer and multiple symptoms.

Caregiver burden and depressive symptoms: analysis of common outcomes in caregivers of elderly patients.

Despite widespread use of caregiver burden and depressive symptoms in caregiving research, the relationship between these two concepts and the way in which burden and depressive symptoms are affected are not clear. Methods: The authors used structural equation modeling with an inception cohort of 488 family caregivers to examine the relationship between care recipients’ mental and functional status and recency of care demands and caregivers’ burden and depressive symptoms. Results: Care recipients’ mental and functional status and recency of care demands predicted caregiver burden; burden, in turn, was nearly significant in predicting depressive symptoms. Care recipients’ mental status and recency of care demands had a near significant indirect effect on caregiver depressive symptoms. There were no significant direct paths between care recipients’ mental status, functional status, recency of care demands, and caregivers’ depressive symptoms. Discussion: Health care practitioners should assist caregivers with new care demands stemming from care recipients’ mental and functional status to decrease burdens and should monitor caregivers with higher levels of burden for the development of depressive symptoms.

Effect of a Cognitive Behavioral Intervention on Reducing Symptom Severity During Chemotherapy

PURPOSE To describe a randomized trial of a cognitive behavioral intervention on reducing symptom severity among patients diagnosed with solid tumors and undergoing a first course of chemotherapy and to determine whether the intervention had an additive or interactive effect on symptom severity in the presence of supportive care medications. PATIENTS AND METHODS Patients (N = 237) were accrued from comprehensive and community cancer centers, interviewed, and randomly assigned to either the experimental intervention (n = 118) or conventional care (n = 119). A symptom severity index, based on summed severity scores across 15 symptoms, was the primary outcome. Each patients site of cancer, stage at diagnosis, chemotherapy protocols, and use of supportive medications were learned from medical records. RESULTS Groups were equivalent at baseline, and attrition by characteristics by group was not different. The proportion of patients not receiving chemotherapy at 10 and 20 weeks did not differ by group. At the 10- and 20-week observations, there was a significant interaction between the experimental group and baseline symptom severity. Patients in the experimental group who entered the trial with higher symptom severity reported significantly lower severity at 10 and 20 weeks. Controlling for chemotherapy treatment status at follow-up and supportive care medications did not alter the effect of the experimental intervention. CONCLUSION Compared with conventional care alone, the experimental intervention was effective among patients who entered the trial with higher levels of symptom severity. Age, sex, site or stage of cancer, and supportive medications did not modify the effect of this cognitive behavioral intervention on symptom severity.

Depression and functional status as predictors of death among cancer patients

The current study examined the extent to which depression and functional limitations contribute to the mortality of newly diagnosed cancer patients. The analysis focused on differences in survival times among cancer patients with new experiences of depressive symptoms and functional limitations and patients with a history of such limitations.

Primary Care Clinicians Treat Patients with Medically Unexplained Symptoms: A Randomized Controlled Trial

AbstractOBJECTIVE: There is no proven primary care treatment for patients with medically unexplained symptoms (MUS). We hypothesized that a long-term, multidimensional intervention by primary care providers would improve MUS patients’ mental health. DESIGN: Clinical trial. SETTING: HMO in Lansing, MI. PARTICIPANTS: Patients from 18 to 65 years old with 2 consecutive years of high utilization were identified as having MUS by a reliable chart rating procedure; 206 subjects were randomized and 200 completed the study. INTERVENTION: From May 2000 to January 2003, 4 primary care clinicians deployed a 12-month intervention consisting of cognitive-behavioral, pharmacological, and other treatment modalities. A behaviorally defined patient-centered method was used by clinicians to facilitate this treatment and the provider-patient relationship. MAIN OUTCOME MEASURE: The primary endpoint was an improvement from baseline to 12 months of 4 or more points on the Mental Component Summary of the SF-36. RESULTS: Two hundred patients averaged 13.6 visits for the year preceding study. The average age was 47.7 years and 79.1% were females. Using intent to treat, 48 treatment and 34 control patients improved (odds ratio [OR]=1.92, 95% confidence interval [CI]: 1.08 to 3.40; P=.02). The relative benefit (relative “risk” for improving) was 1.47 (CI: 1.05 to 2.07), and the number needed to treat was 6.4 (95% CI: 0.89 to 11.89). The following baseline measures predicted improvement: severe mental dysfunction (P<.001), severe body pain (P=.039), nonsevere physical dysfunction (P=.003), and at least 16 years of education (P=.022); c-statistic=0.75. CONCLUSION: The first multidimensional intervention by primary care clinicians led to clinically significant improvement in MUS patients.

Gender bias in the measurement properties of the center for epidemiologic studies depression scale (CES-D)

Confirmatory factor-analytic models are used to examine gender biases of individual items of the Center for Epidemiologic Studies Depression (CES-D) Scale. In samples containing 708 cancer patients and 504 caregivers of the chronically ill elderly, two CES-D items are identified as producing biased responses in comparisons of male and female respondents. Three additional CES-D items are excluded on the basis of other psychometric problems, yielding a subset of 15 CES-D items that capture almost all the information of the original 20-item CES-D scale but are free of any gender bias. Gender differences in mean levels of depressive symptomatology are significantly reduced, but not eliminated, when the 15-item scale is used.

Improving the quality of life of patients with prostate carcinoma: a randomized trial testing the efficacy of a nurse-driven intervention.

Treatments for clinically localized prostate carcinoma are accompanied by sexual, urinary, and bowel dysfunction and other sequelae that can result in significant distress and reduced well being. Methods capable of improving quality of life are needed that can be integrated into clinical practice. To address this need, a nurse‐driven, cancer care intervention was developed and tested.

Intervention to improve psychological functioning for newly diagnosed patients with cancer.

PURPOSE/OBJECTIVES To test the effects of a computer-based nursing intervention designed to provide patients and family caregivers with concrete, objective information on symptom management; provide education about disease and treatment; coordinate medical resources; and provide emotional support and counseling. DESIGN Two-site, randomized clinical trial. SETTINGS A large, urban, midwestern, tertiary-cancer center and a community-based cancer center in a medium-sized midwestern city. SAMPLE 109 patients newly diagnosed with breast, colon, or lung cancer who were receiving chemotherapy; 54 received standard care, and 55 participated in the intervention group. METHODS Outcome data were collected via structured telephone interviews at three time points: baseline, midway through the intervention, and one month postintervention. The intervention consisting of nine visits, five in person and four by telephone, was conducted over 18 weeks by advanced practice oncology nurses. MAIN RESEARCH VARIABLES Psychosocial functioning, anxiety, and depression. FINDINGS Patients who received the intervention had significantly less depression between baseline and the midway point, as well as less anxiety and greater improvement in the role-emotional and mental health subscales of the Medical Outcomes Study 36 Short Form. CONCLUSIONS Cancer-care nursing interventions can decrease psychosocial morbidity and improve quality of life for newly diagnosed patients with cancer undergoing treatment. Additional research is needed to understand who benefited most from the intervention. IMPLICATIONS FOR NURSING This nurse-directed intervention resulted in improved mental health for patients; however, physical subscales were not changed. Further work is needed to determine why depression and mental health were affected yet physical health and symptoms did not differ between groups. Results support the important role of nurses in addressing mental health issues in patients and families experiencing cancer.

Exploration of DSM-IV criteria in primary care patients with medically unexplained symptoms.

Objectives: Investigators and clinicians almost always rely on Diagnostic and Statistical Manual of Mental Disorder, 4th edition’s (DSM-IV) somatoform disorders (and its derivative diagnoses) to characterize and identify patients with medically unexplained symptoms (MUS). Our objective was to evaluate this use by determining the prevalence of DSM-IV somatoform and nonsomatoform disorders in patients with MUS proven by a gold standard chart review. Methods: In a community-based staff model HMO, we identified subjects for a clinical trial using a systematic and reliable chart rating procedure among high-utilizing MUS patients. Only baseline data are reported here. The World Health Organization Composite International Diagnostic Interview provided full and abridged DSM-IV diagnoses. Patients with full or abridged DSM-IV somatoform diagnoses were labeled “DSM somatoform-positive,” whereas those without them were labeled “DSM somatoform-negative.” Results: Two hundred six MUS patients averaged 13.6 visits in the year preceding study, 79.1% were females, and the average age was 47.7 years. We found that 124 patients (60.2%) had a nonsomatoform (“psychiatric”) DSM-IV diagnosis of any type; 36 (17.5%) had 2 full nonsomatoform diagnoses, and 41 (19.9%) had >2; 92 (44.7%) had some full anxiety diagnosis and 94 (45.6%) had either full depression or minor depression diagnoses. However, only 9 of 206 (4.4%) had any full DSM-IV somatoform diagnosis, and only 39 (18.9%) had abridged somatization disorder. Thus, 48 (23.3%) were “DSM somatoform-positive” and 158 (76.7%) were “DSM somatoform-negative.” The latter exhibited less anxiety, depression, mental dysfunction, and psychosomatic symptoms (all p <.001) and less physical dysfunction (p = .011). Correlates of this DSM somatoform-negative status were female gender (p = .007), less severe mental (p = .007), and physical dysfunction (p = .004), a decreased proportion of MUS (p <.10), and less psychiatric comorbidity (p <.10); c-statistic = 0.77. Conclusion: We concluded that depression and anxiety characterized MUS patients better than the somatoform disorders. Our data suggested radically revising the somatoform disorders for DSM-V by incorporating a new, very large group of now-overlooked DSM somatoform-negative patients who were typically women with less severe dysfunction. HMO = health maintenance organization DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th edition DSM-V = planned for approximately 2010, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition MUS = medically unexplained symptoms ECA = epidemiologic catchment area SD = somatization disorder SF-36 = Short-Form 36 MCS = Mental Component Summary of the SF-36 PCS = Physical Component Summary of the SF-36 SSAS = Spielberger State Anxiety Scale CES-D = Center for Epidemiological Studies Depression inventory PSC = Psychosomatic Symptom Checklist WHO-CIDI = World Health Organization Composite International Diagnostic Interview.

Putting Evidence Into Practice®: Nursing Assessment and Interventions to Reduce Family Caregiver Strain and Burden

Family caregiving often is associated with multiple rewards, yet the diversity and intensity of caregiving roles also can result in caregiver strain and burden. Using interventions to reduce the strain and burden on caregivers of patients with cancer is an important role nurses play. This article is a critical review and synthesis of the evidence regarding assessment tools and interventions aimed at reducing caregiver strain and burden in the oncology population. Although the striking finding is the limited number of interventions targeted toward oncology caregivers, suggestions from the literature are offered to support and promote healthy outcomes for family caregivers.