Behaviors and Mental Disorders

All Conditions

Depressive Disorder

Depression

Behavioral Symptoms

Quality of Life

Referred to a therapist and/or psychiatrist in their home town depending on the type of treatment they prefer (e.g., behavioral and/or medication)

At least biweekly contact from a care coordinator by phone and face-to- face visits occurring approximately every 2 months during the patients outpatient visits or treatment, and 24/7 access to a website that was specifically designed during the pilot study for advanced cancer patients from socioeconomically disadvantaged backgrounds.

enhanced usual care

Using website that was specifically designed for advanced cancer patient, collaborative with treatment from health professional

stepped collaborative care

Jennifer L. Steel, PhD

The proposed randomized controlled trial will test the efficacy of a stepped collaborative care intervention, versus enhanced usual care arm, to reduce depression of cancer caregivers. Biobehavioral factors will include assessment of changes in health behaviors and biomarkers of inflammation. The investigators will also include measures metabolic abnormalities and clinical markers of CVD. The investigators expect few cardiac events during the study period. The investigators will also measure other health outcomes but CVD risk factors will be the focus of the study.

The investigators expect to follow the caregivers for 12 months during the caregiving period.

Based on our prior experience and that of others, patients with clinical levels of symptoms report the greatest benefit from interventions aimed at reducing depressive symptoms. The investigators will screen caregivers for clinical levels of depression using the CES-D scale. If the caregiver screens positive for clinical levels of depressive symptoms (CES-D\>16) and the patients and caregiver consent to participation, the dyad will be randomized to the intervention or enhanced usual care arm based on block randomization and stratification by gender (male/female) to assure approximate equal gender distribution in each arm of the study. The screening will take place in UPMC Montefiore and Presbyian.

The participants of this study will be blinded to which arm of the intervention they received, either the stepped collaborative care or enhanced usual care. Prior to randomization they will be asked to provide information on the intervention that they prefer and at the end of the intervention they will be asked what intervention they think they received. The findings will be analyzed to determine if intervention preference or perception of intervention received affected the outcomes.

The care coordinators for the proposed intervention will have Master's degrees in psychology or counseling and training in cognitive-behavioral therapy and have experience working with people diagnosed with cancer and their families. The care coordinators will receive training at the University of Pittsburgh in cultural competence. The therapists will serve as a liaison between the patient and other health care professionals within the spousal and intimate partner caregivers' medical team. A psychiatrist will not be included as part of the study team as many of the spousal and intimate partner caregivers do not reside locally. The care coordinator will work with the spousal and intimate partner caregivers' PCP, psychiatrist, and other health care providers in the spousal and intimate partner caregivers' home community to manage the symptoms and medication if indicated. The care coordinators will be supervised by the PI who is a clinical psychologist who has been working with cancer patients and their caregivers for 20 years.

Patient and caregiver outcomes will be assessed using a battery of standardized questionnaires. The investigators have chosen instruments that are as brief as possible to limit burden to patient and spousal and intimate partner caregivers. All instruments have been demonstrated to be valid and reliable. The order of the instruments in the battery of questionnaires will begin with general, not emotionally laden instruments and also end with instruments which may not increase distress in a participant. The proposed time points (baseline, 4, 8, and 12 months) reflect intervals that permit the ability to capture changes in symptoms and inflammatory biomarkers while not burdening the patient or spousal/intimate partner caregivers. The proposed questionnaires were used in prior studies by this team and with advanced cancer patients and their family caregivers. The investigators have shown better adherence to completing the outcomes measures with self-reported pencil and paper questionnaires versus telephone interviews (K07CA118576; R01CA176809). However, the investigators will also offer telephone interviews for spousal and intimate partner caregivers or patients who have low levels of literacy, sensory impairments, or prefer a telephone interview. For all interviews, the research associate will be blinded to the participant's assigned treatment arm to prevent bias. The investigators have found no differences by method of administration (paper and pencil versus telephone interview). Inter-operator variability will be addressed by ensuring that the research staff performing measurement of blood pressure, and waist circumference will be trained together, tested by the PI for inter-operator consistency, and be assessed at intervals every 4 months for continued consistency in measurement of blood pressure and abdominal girth. Consistency in laboratory personnel techniques (inter operator variability) will be monitored by Dr. Butterfield.

The frequency distributions of study variables will be examined prior to statistical analyses to provide descriptive data and to identify departures from normality. If nonlinearity is detected, a transformation will be performed using the Box-Cox transformation, which finds the optimal relationship between variables. All measures have established reliability and validity similar to that from which the study sample will be drawn; however, the reliabilities of scales will be assessed using Cronbach's α.

Data will be analyzed using SAS (Version 9.3, SAS Institute, Inc., Cary, NC) to conduct preliminary exploratory analyses, missing data testing, and the analyses for the primary aims (linear mixed models). The level of significance for the analyses will be set at .05. The efficacy of the web-based stepped collaborative care intervention compared to enhanced usual care will be examined using the 'intent to treat' (ITT) approach, as well as the actual treatment received. In the ITT approach, subjects will be included in the analyses in the groups to which they were randomly assigned, regardless of treatment, adherence, withdrawal or deviation from protocol. The ITT approach minimizes the introduction of bias into the analyses and most closely aligns with clinical practice; therefore, it is strongly recommended for studies examining intervention efficacy.

Collaborative Care Intervention for Cancer Caregivers

University of Pittsburgh

Associate Professor of Surgery

The 'Stepped Collaborative Care Intervention' includes at least biweekly contact from a care coordinator by phone and face to face visits occurring approximately every 2 months, and 24 hour 7 day a week access to a website that was specifically designed during the pilot study for advanced cancer patients from socioeconomically disadvantaged backgrounds.

Patients randomized to the 'Enhanced Usual Care' arm receive their usual care from their medical team. However, if the patient scores in the clinical range on one or more of the three symptoms s/he will receive education about the symptom and be referred to the appropriate health care provider for further treatment in their community. The care coordinator will follow up with the patient after 3 weeks to assess barriers to treatment and assist further with accessing treatment if needed.

Using website that was specifically designed for advanced cancer patient, collaborative with treatment from health professional.

Stepped collaborative care intervention

Enhanced Usual Care

Jennifer L Steel, PhD

In an effort to reduce rural-urban disparities and improve the quality of cancer care for these patients, the objectives of this study will be to: (1) adapt the intervention to maximize effectiveness for rural, low-income patients, (2) test the effectiveness of the adapted intervention, and (3) prepare for implementation of the intervention in rural, low-income communities.

The purpose of the study is to reduce rural-urban disparities and improve the quality of cancer care for these patients:

(Aim 1): By using mixed methods, investigators will adapt the stepped collaborative care intervention to address the contextual needs of patients diagnosed with comorbid cancer and depression living in rural, low-income communities. Using face-to-face qualitative interviews with 30 patients diagnosed with cancer and quantitative data from our past trial, investigators will adapt the stepped collaborative care intervention for patients diagnosed with cancer from rural, low-income communities. For all quantitative data, the frequency distributions of study variables will be examined prior to statistical analyses to provide descriptive data and to identify departures from normality. If nonlinearity is detected, a transformation will be performed using the Box-Cox transformation, which finds the optimal relationship between variables. All measures have established reliability and validity similar to that from which the study sample will be drawn; however, the reliabilities of scales will be assessed using Cronbach's. Thorough exploratory data analyses will be performed to ascertain data characteristics and to screen for anomalies (i.e., outliers). The preliminary exploration of the data will be used to: (1) examine univariate and bivariate distributions; (2) identify any imbalances between treatment groups on baseline characteristics; (3) investigate the magnitude of the associations between the dependent variables and the potential covariates; (4) determine the internal consistency reliabilities of the measurement scales using Cronbach's alpha; and (5) verify the statistical assumptions of the planned primary analyses. If assumptions are violated, then alternative procedures such as data transformations or more robust statistical methods will be considered. Missing data will be examined using available data on subject characteristics. Logistic regression models will be created with SAS PROC LOGISTIC to compare the characteristics of subjects who remained in the study versus those who dropped out. If data are determined to be missing at random, likelihood estimation procedures available in SAS PROC MIXED will produce unbiased estimates and allow the retention of subjects with missing data on outcomes. If data are determined to be not missing at random, pattern mixture or selection modeling will be used to investigate attrition. If necessary, multiple imputation (SAS PROC MI) will be used to impute missing values for covariates.

(Aim 2): To test, in a randomized controlled trial, the adapted stepped collaborative care intervention for 242 patients diagnosed with comorbid cancer and depression living in rural, low-income communities. Primary hypotheses are that patients randomized to the stepped collaborative care intervention will report clinically meaningful (0.40 or greater effect size) improvements in depression and Quality of Life (QoL) at 6- and 12-months when compared to patients randomized to the screening and referral arm. The secondary hypotheses are that patients randomized to the stepped collaborative care intervention will report clinically meaningful (0.30 or greater effect size) improvements in sleep quality, perceived stress, and social support when compared to the screening and referral arm. The expectation is that caregivers of patients randomized to the intervention arm will have reductions in stress and depression when compared to caregivers of patients randomized to the screening and referral arm. Further exploration will be done of the beneficial effects of the stepped collaborative care intervention on survival.

(Aim 3): To examine the cost-effectiveness of the stepped collaborative care intervention for 242 patients diagnosed with cancer and depression. The stepped collaborative care intervention is expected to be cost-effective compared to the screening and referral arm from the health system perspective in terms of cost per quality-adjusted life year based on established benchmarks for cost-effectiveness. Given the low cost of the intervention and our preliminary data showing reductions in complications and healthcare utilization, there is a high chance that the intervention is, on average, cost saving.

(Aim 4): Guided by the Consolidated Framework for Implementation Science (CFIR), The acceptability, feasibility and actionable factors within the rural context that influence the delivery of the stepped collaborative care intervention will be assessed.. Using mixed methods, guided by the CFIR framework, Surveys will be administered and qualitative interviews performed with patients, caregivers, providers, clinical and research staff after testing the screening and adapted intervention to further refine and inform future implementation in rural, low-income communities.

In terms of relevant prior knowledge and gaps in current knowledge, over 60 million people live in rural communities in the United States. Those who develop cancer are diagnosed later, at more advanced stages, with greater physical comorbidities, poorer quality of life (QoL), and have fewer options for treatment and resources to cope with a diagnosis of cancer when compared to those living in urban communities. As a result, they suffer from greater cancer-related distress and depression. Patients diagnosed with cancer from rural Appalachia were more likely to meet the criteria for clinical levels of distress compared to 27.4% of non-rural cancer patients. Investigators have also observed higher rates of depression in patients from rural, low-income areas when compared to their urban counterparts in Appalachia. Despite the high rates of depression, people who live in rural communities are 47% less likely to receive mental health treatment and 72% less likely to receive specialized mental health treatment when compared to those living in urban communities. Depression results in poorer QoL, decreased adherence to cancer treatments, and increased risk of mortality. Pharmacological and non-pharmacological treatments that have been effective in people from urban communities have not been effective in those living in rural, low-income communities. A stepped collaborative care intervention was designed and tested for socioeconomically disadvantaged patients with comorbid cancer and depression. While the intervention was effective for patients from urban, low-income communities, subgroup analyses revealed the intervention was not effective in patients from rural, low-income communities. While preliminary, there is the belief that cognitive-behavioral therapy (CBT) may not be culturally sensitive in rural, low-income patients. In addition, predictors of depression for these patients included poor sleep, high levels of perceived stress, and lack of social support. The proposal is to adapt the intervention using problem solving therapy, rather than CBT; provide resources to reduce financial stress; and incorporate stress management, support groups, and treatment of sleep problems in the novel intervention. In effort to reduce rural-urban disparities and improve the quality of cancer care, the objectives of this study will be to: (1) adapt the stepped collaborative care intervention to maximize effectiveness for rural, low-income patients, (2) test the effectiveness of the adapted intervention, and (3) prepare for implementation of the intervention in rural, low-income communities.

Research Study Coordinators will be masked.

Intervention for Rural Cancer Patients

A Hybrid Type I Randomized Effectiveness-Implementation Trial of Remote Treatment of Depression in Rural Community Cancer Centers

Study protocol, statistical analyses plan and all de-identified data collected during the trial may be shared with appropriately credentialed investigators who request data directly from the Primary Investigator:

Jennifer Steel, PhD, University of Pittsburgh Physicians Department of Surgery Kaufmann Medical Building, Suite 601 3471 Fifth Ave. Pittsburgh, PA 15213 412-692-2041 steejl@upmc.edu.

Measure of depression questionnaire- The score is the sum of the 20 questions. Possible range is 0-60. A score of 16 points or more is considered depressed.

Measure of depression questionnaire - The score is the sum of the 20 questions. Possible range is 0-60. A score of 16 points or more is considered depressed.

Measure of quality of life questionnaire - scale is numbered from 0 to 100. 100 means the best health the participant can imagine. 0 means the worst health the participant can imagine.

A 12-item measure of perceptions for three dimensions of perceived social support.(Appraisal Support, Belonging Support, Tangible Support) Each dimension is measured by 4 items on a 4-point scale ranging from "Definitely True" to "Definitely False".

A measure of sleep quality where respondents are asked to indicate how frequently they have experienced certain sleep difficulties over the past month and to rate their overall sleep quality. Scores for each question range from 0 to 3, with higher scores indicating more acute sleep disturbances.

This questionnaire about stress is comprised of 14 items intended to measure how unpredictable, uncontrollable, and overloaded individuals find their life circumstances. Individuals rate items on a 5-point Likert scale, ranging from 0 - "Never" to 4 - "Very often." Scores range from 0-56, with higher scores indicating greater perceived stress.

National Cancer Institute (NCI)

Professor

Symptoms and General Pathology

Fatigue

Pain

Jennifer L Steel

To test the efficacy of a web-based stepped collaborative care intervention to reduce symptoms of depression, pain, and fatigue and improve health-related quality of life (HRQL) in advanced cancer patients and to reduce stress and depression, and fewer CVD risk factors in caregivers.

The intervention is designed to maintain quality of life for those in greatest need and least access to resources. This innovative and scalable web-based collaborative care intervention is expected not only to improve patients' quality of life, at the end of life, but also reduce caregiver stress and depression, and potentially health morbidity and mortality of patients and spousal and intimate partner caregivers from socioeconomically disadvantaged backgrounds. Study findings are expected to lead to research examining the dissemination and implementation of the intervention.

Collaborative Care Intervention for Cancer Patients and Their Family Caregivers -LITE

De-Identified Data may be shared with investigators who request data from the Primary Investigator

Functional Assessment for Cancer Therapy Hepatobiliary (FACT - Hep)

Center for Epidemiological Studies -Depression (CESD)

Functional Assessment for Cancer Therapy Fatigue (FACT - Fatigue)

Caregiver Quality of Life Questionnaire (CQOL)

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Collaborative Care Intervention for Cancer Caregivers	NCT02944136	Depression Advanced Cancer	enhanced usual ... stepped collabo...	21 Years -	University of Pittsburgh
Collaborative Care Intervention for Cancer Caregivers	NCT02944136	Depression Advanced Cancer	enhanced usual ... stepped collabo...	21 Years -	University of Pittsburgh
Intervention for Rural Cancer Patients	NCT05091593	Depression Quality of Life Social Support Sleep Stress	Stepped collabo... Enhanced Usual ...	21 Years - 100 Years	University of Pittsburgh
Collaborative Care Intervention for Cancer Patients and Their Family Caregivers -LITE	NCT05601206	Cancer Depression Fatigue Pain Sleep	Stepped collabo... Enhanced Usual ...	21 Years - 100 Years	University of Pittsburgh
Collaborative Care Intervention for Cancer Patients and Their Family Caregivers -LITE	NCT05601206	Cancer Depression Fatigue Pain Sleep	Stepped collabo... Enhanced Usual ...	21 Years - 100 Years	University of Pittsburgh
Intervention for Rural Cancer Patients	NCT05091593	Depression Quality of Life Social Support Sleep Stress	Stepped collabo... Enhanced Usual ...	21 Years - 100 Years	University of Pittsburgh

Spots Global Cancer Trial Database for stepped collaborative care intervention