Intolerance of uncertainty, experiential avoidance, and trust in physician: a moderated mediation analysis of emotional distress in advanced cancer.

We tested whether patients' trust in physician moderated the hypothesized indirect association between intolerance of uncertainty (IU; inability to tolerate the unknown) and emotional distress through the mediator, experiential avoidance (EA; efforts to avoid negative emotions, thoughts, or memories), in patients with advanced cancer. The sample included 108 adults with Stage III or IV cancer (53% female; Mage = 63 years) recruited from a metropolitan cancer center. All constructs were measured by standardized self-report instruments. The PROCESS macro for SPSS tested the moderated mediation model. IU evidenced significant direct and indirect relationships with anxiety and depressive symptoms. Trust in physician moderated the indirect relationship between IU and anxiety (not depressive symptoms), albeit in an unexpected direction. Specifically, the indirect relationship between IU and anxiety symptoms through EA was significant for those with moderate to high physician trust but not low trust. Controlling for gender or income did not change the pattern of findings. IU and EA may be key intervention targets, particularly in acceptance-or meaning-based interventions for patients with advanced cancer.

Relationships between Intolerance of Uncertainty, Worry, Rumination, and Distress in College Students During the Coronavirus Pandemic: the Role of COVID-19 Threat Appraisals.

BACKGROUND: In two conditional process models, we examined whether intolerance of uncertainty (IU) had both direct and indirect effects on coronavirus anxiety (through worry) and depressive symptoms (through rumination) among college students; these associations were hypothesized to be more likely among students who appraised COVID-19 as highly threatening. METHOD: Data were collected during the COVID-19 pandemic from September 2020 to November 2020 in the USA. Participants (n = 134) completed measures of IU, COVID-19 specific threat appraisal, rumination, worry, coronavirus anxiety, and depressive symptoms. The PROCESS macro (Model 8) was used for analyses with gender as a covariate. RESULTS: IU had a direct positive effect on coronavirus anxiety and the effect was strongest among students who perceived COVID-19 as more threatening. Threat appraisal did not moderate the IU-depressive symptoms relationship. IU had an indirect effect on depressive symptoms through rumination at all levels of threat appraisal. Unexpectedly, this indirect effect was strongest among students who perceived the pandemic as less threatening. CONCLUSION: Results may inform interventions that address IU, threat appraisals, and repetitive negative thinking to mitigate symptoms of coronavirus anxiety and depression.

The indirect influence of 'invisible' support on pulmonary function among adults with chronic obstructive pulmonary disease.

Individuals living with chronic obstructive pulmonary disease (COPD) often require support from family or friends. We examined whether invisible support - support that is provided but goes unnoticed - is related to pulmonary function, and whether this association is mediated by depressive symptoms and illness perceptions. Sixty-six dyads of individuals with COPD and their informal caregivers reported on receipt and provision of support, respectively. Those with COPD completed measures of depressive symptoms, illness perceptions and pulmonary function. Although invisible support was not directly related to pulmonary function, mediation analyses revealed a combined indirect effect through lower depressive symptoms and less negative illness perceptions. Interventions teaching skillful delivery of support to caregivers may reduce depressive symptoms and threatening illness cognitions, which may contribute to improvements in symptom burden among patients with COPD.

Coping self-efficacy, perceived helpfulness of coping, and distress: a longitudinal investigation of breast and gynecologic cancer patients undergoing chemotherapy.

We examined changes in coping self-efficacy (CSE) pre- and post-chemotherapy and whether these changes predicted depressive symptoms and perceived stress after chemotherapy among women breast and gynecological cancers. We further tested whether perceived helpfulness of coping strategies used during chemotherapy influenced these effects. In a longitudinal design, participants (n = 79) provided data on CSE, depressive symptoms, and perceived stress pre-chemotherapy, post-chemotherapy (~ 4 months later), and at 8 and 12-month follow-up. During chemotherapy, participants completed a one-week daily diary on use and helpfulness of coping strategies in managing side effects. CSE decreased during chemotherapy, returning to baseline levels at follow-up. Higher problem-focused CSE pre- and post-chemotherapy predicted increases in distress among women who appraised their coping strategies as low or average in helpfulness during chemotherapy; problem-focused CSE was unrelated to changes in distress at high levels of perceived helpfulness. Increases in coping self-efficacy without concomitant helpful coping strategies may be markers for poor adjustment post-chemotherapy and identify patients who could benefit from psychosocial services. Combined education and skills-based interventions to align self-efficacy beliefs with coping strategies may reduce psychological burden.

Tolerating Uncertainty in the Dark: Insomnia Symptoms, Distress, and Well-Being Among Parents of Adolescents and Young Adults with Cancer.

BACKGROUND: Given the need to better understand mechanisms linking poor sleep and psychological distress in the context of chronic illness, we explored a novel factor, intolerance of uncertainty (IU), in relation to insomnia among parents of adolescents and young adults (AYAs) with cancer. We hypothesized that parents with higher IU would report greater insomnia symptoms, which would be associated with higher anxiety and depressive symptoms. These greater levels of anxiety and depressive symptoms are hypothesized to mediate the relationship between insomnia symptoms and subjective well-being (SWB). METHOD: Surveying 59 parents of AYAs with cancer, we computed a parallel-serial mediational analysis using bootstrapping techniques for ordinary least squares regression to test two pathways (adjusting for whether the AYA currently resided with the parent). The first serial pathway was IU→insomnia symptoms→anxiety symptoms→SWB. The second pathway was IU→insomnia symptoms→depressive symptoms→SWB. RESULTS: Although the first pathway involving sleep and anxiety as serial mediators was nonsignificant, the second pathway with sleep and depressive symptoms was significant. The relationship between IU and SWB was mediated through insomnia and depressive symptoms. An alternative serial mediation analysis wherein depressive symptoms preceded sleep was not significant, lending support to study findings. CONCLUSION: This study provides preliminary evidence that IU's detrimental influence on depression and SWB may operate through its influence on insomnia symptoms. Given implications for parents' well-being and, likely, their subsequent capacity to care for the AYA with cancer, interventions addressing IU and disturbed sleep among this underserved population deserve attention.

Emotional adjustment among parents of adolescents and young adults with cancer: the influence of social constraints on cognitive processing and fear of recurrence.

Parents of adolescents and young adults (AYAs) with cancer experience distress comparable to other caregiver populations, but remain understudied. This study tested the social cognitive processing model of emotional adjustment to cancer. We hypothesized that social constraints on emotional disclosure would inhibit cognitive processing and be related to greater fear of cancer recurrence (FCR), potentially negatively influencing psychological adjustment. Data were collected through an online cross-sectional survey study of 66 parents of AYAs with cancer (aged 15-39) and analyzed using bootstrapping techniques for ordinary least squares regression. One-third of the parents reported moderate to severe depressive symptoms. Serial mediation analyses indicated that greater social constraints were related to poorer cognitive processing and higher FCR, and, ultimately, greater depressive symptoms. Alternative models were tested and were not significant. Future psychosocial interventions for parents of AYAs with cancer should include improving cancer-related communication between parents and their social network.

Development of a Canadian Medical Assistance in Dying Curriculum for Healthcare Providers.

Objectives: Medical Assistance in Dying (MAiD) was legalized in Canada in 2016, necessitating greater education and training in MAiD for physicians and nurse practitioners. To meet this need, the Canadian MAiD Curriculum (CMC) was developed to offer a nationally accredited, comprehensive, bilingual, hybrid (synchronous and asynchronous) educational program to support and enhance the practice of MAiD in Canada. Methods: This work describes the process of developing the CMC, including its guiding principles and framework. The CMC was guided by constructivism and adult learning theory, preliminary literature review, 5 key principles based on a needs assessment survey, as well as consultation with diverse partners. Results: Seven modules were developed: (1) foundations of MAiD in Canada, (2) clinical conversations that includes MAiD, (3) how to do an MAiD assessment, (4) capacity and vulnerability, (5) providing MAiD, (6) navigating complex cases with confidence, and (7) MAiD and mental disorders. An eighth topic on clinician resilience and reflection was woven into each of the 7 modules. Conclusion: This curriculum ensures that consistent information is available to healthcare providers concerning the practice of MAiD in Canada. To ensure sustainability, the CMC will continue to be updated alongside the evolution of MAiD policy and services in Canada.

Screening for Distress and Health Outcomes in Head and Neck Cancer.

Head and neck cancers (HNC) have higher rates of emotional distress than other cancer types and the general population. This paper compares the prevalence of emotional distress in HNC across various distress screening measures and examines whether significant distress or distress screening are associated with cancer-related survival. A retrospective observational cohort design was employed, with data collected from the Distress Assessment and Response Tool (DART) and linkages to administrative databases from 2010 to 2016. Descriptive and prevalence data were reported using multiple concurrently administered distress tools, including the Patient Health Questionaire-9 (PHQ-9), Generalized Anxiety Disorders-7 (GAD-7), Edmonton Symptom Assessment Scale-revised (ESAS-r), and MD Anderson Symptom Index-Head and Neck module (MDASI-HN). Across measures, 7.8 to 28.1% of the sample reported clinically significant emotional distress, with PHQ-9 and GAD-7 identifying lowest prevalence of moderate/severe distress, and the ultrashort distress screens within ESAS-r and MDASI-HN performing equivalently. Cox hazards models were used in univariate and multivariate survival analyses. ESAS depression (≥4), but not anxiety, was associated with increased risk of cancer-related mortality and patient completion of DART was associated with greater cancer-related survival. The findings underscore the importance of implementing routine distress screening for HNC populations and the utility of ultra-brief screening measures.

Biomarker opportunities in the treatment of cancer-related depression.

Depression comorbid with cancer is common and associated with a host of negative health outcomes. The inflammatory basis of depression is a growing area of research in cancer, focused on how stressors transduce into inflammation and contribute to the emergence of depression. In this review, we synthesize inflammatory biomarker associations with both depression and the currently available pharmacotherapies and psychotherapies in cancer, underscoring the need for expanding research on anti-inflammatory agents with antidepressant effects. Modulation of inflammatory neuroimmune pathways can slow tumor progression and reduce metastases. Biomarkers associated with depression in cancer may help with diagnosis and treatment monitoring, as well as inform research on novel drug targets to potentially improve cancer survival.

Recent trends in the management of depression in persons with cancer.

PURPOSE OF REVIEW: Depression is a prevalent comorbidity in cancer that significantly increases the risk for numerous negative health outcomes. This review updates the current evidence base for management of depression in cancer, highlighting new research directions based on the inflammatory hypothesis of depression. RECENT FINDINGS: Research on pharmacotherapy and psychotherapy for depression in cancer has shown mixed efficacy partly because of methodological issues arising from the phenomenology of depression in cancer. After decades of stagnancy, more recent high-quality clinical trials are beginning to provide an evidence base to guide treatment. Inflammatory cytokine-associated depression is a subtype of depression that may have particular relevance in cancer, opening new avenues to explore therapeutic targets and biobehavioral impacts of interventions, which may improve cancer outcomes. SUMMARY: The continuum of severity in cancer-related depression is important to consider in management approaches. Choice of treatment should be personalized to the patient and their symptom profile as there is currently insufficient evidence to recommend any particular medication or psychotherapy over another. Psychological interventions should be considered first line for mild-to-moderate depression, and pharmacological treatment added for more severe depression, which can be optimally delivered within a collaborative care model. VIDEO ABSTRACT: http://links.lww.com/YCO/A62.

Emotion regulation therapy for cancer caregivers-an open trial of a mechanism-targeted approach to addressing caregiver distress.

Informal caregivers (ICs) are integral to care provided to patients facing life-threatening or incurable illnesses. This responsibility causes considerable burden, as approximately one half of ICs report clinically significant symptoms of depression and/or anxiety that persist when left untreated. Psychosocial interventions containing efficacious treatment principles (e.g., cognitive behavior therapy [CBT]) show disappointing results in reducing anxiety and depression in ICs. This may reflect failure of these interventions to specifically target crucial mechanisms underlying the central feature of distress caused by the patient's illness-notably, perseverative negative thinking (PNT). Emotion Regulation Therapy (ERT) is an efficacious CBT developed to explicitly target mechanisms underlying PNT and the emotional concomitants that arise in response to stressful situations. This open trial was conducted to evaluate the acceptability and initial efficacy of ERT adapted to the experience of cancer ICs (ERT-C). Thirty-one ICs provided informed consent and completed eight weekly individual sessions of ERT-C. Participants completed self-report measures of depression and anxiety symptoms, PNT, emotion regulation deficits, and caregiver burden before and after treatment. ERT-C was well tolerated as indicated by 22 treatment completers and feedback provided in exit interviews. ICs demonstrated reduced depression and anxiety symptoms, PNT, and emotion regulation deficits with moderate to large effect sizes (Hedge's g range: 0.36-0.92). Notably, caregiver burden was not reduced but ICs expressed more ability to confront caregiving-related challenges. Findings offer promising but preliminary support for ERT-C as a conceptual model and treatment modality for distressed cancer ICs.

Illness Uncertainties Tied to Developmental Tasks Among Young Adult Survivors of Hematologic Cancers.

PURPOSE: Young adulthood is a period of building autonomy, relationships, and careers. Experiencing cancer as a young adult (YA) is an "off-time" event in the normative adult life cycle and may interrupt age-specific goals. The majority of prior research on illness uncertainty centers on medical concerns about recurrence or mortality. The current study identifies how YA survivors of hematologic cancers, an understudied group, experience illness uncertainties related to the developmental tasks of young adulthood. METHODS: This is a qualitative study of 53 YA hematologic cancer survivors, ages 20-39. Participants completed hour-long semistructured interviews about psychological, social, and treatment-related aspects of their cancer experience. Interviews were transcribed and coded using an abductive approach to qualitative analysis. RESULTS: Most participants (80%) spontaneously described at least one illness uncertainty tied to developmental tasks. Fertility was the most commonly reported type of uncertainty (55%), with more women than men reporting it, followed by family and intimate relationships (43%), peers and social life (36%), and academic or career goals (26%). These uncertainties were described with reference to the off-time nature of illness. Example excerpts are provided and interpreted. CONCLUSIONS: These findings have the potential to advance our understanding of the cancer experience of YA survivors by expanding on the notion of illness uncertainty in this population. Given the extent to which uncertainties related to developmental tasks were reported, tailored interventions targeting these concerns may improve quality of life among YAs with hematologic cancers.