Telephone-Delivered Cognitive-Behavioral Therapy for Older, Rural Veterans with Depression and Anxiety in Home-Based Primary Care.

OBJECTIVES: Rural, homebound older adults are at increased risk for anxiety and depression and have limited access to mental health services. These individuals face many barriers to receiving evidence-based mental health treatment and would benefit from interventions that increase access to and efficiency of care. The aim of this study was to evaluate use of a telephone-delivered, modular, cognitive behavioral therapy (CBT) intervention for both late-life depression and anxiety delivered to rural, homebound Veterans. METHODS: Three cases are presented to illustrate the flexible adaptation of the intervention for use among older Veterans enrolled in home-based primary care, with varying symptom presentations and functional limitations. The Veterans received 7 to 9 sessions of the CBT intervention, with ordering of skill modules based on symptom presentation and determined collaboratively between patient and therapist. RESULTS: The three Veterans showed improvement in depression and/or anxiety symptoms following treatment and provided positive feedback regarding their experiences in this program. CONCLUSIONS: These results suggest that telephone-delivered CBT is acceptable to older adults and can be tailored to individual patient needs. CLINICAL IMPLICATIONS: Clinicians should consider telephone-delivered CBT as an alternate mode of therapy to increase access to mental health care for rural, homebound individuals with depression and anxiety.

Complications of radiotherapy in laryngopharyngeal cancer: effects of a prospective smoking cessation program.

BACKGROUND: Radiotherapy (XRT) is effective as the primary treatment modality for laryngopharyngeal cancer; however, complications of XRT can result in significant morbidity. Few previous studies have examined the effect of continued smoking on complications of XRT. The authors of this report hypothesized that patients with laryngopharyngeal cancer who successfully quit smoking would have fewer complications of primary XRT. METHODS: All patients with head and neck cancer who were smokers at the time of diagnosis were referred prospectively to the Tobacco Treatment Program (TTP). From this group, the patients with laryngopharyngeal cancer who received XRT as the primary treatment modality were retrospectively selected and studied. RESULTS: Eighty-six patients were identified and were divided into 3 groups: Seventeen patients attended TTP and quit smoking before the start of XRT (Group 1), 33 patients attended TTP but continued to smoke during XRT (Group 2), and 37 patients refused TTP (Group 3). On the basis of a review of medical records for patients in Group 3, 20 patients quit smoking before starting XRT and were included in Group 1 (abstainers), 11 patients continued to smoke and were included in Group 2 (continued smokers), and 6 patients had incomplete data and were omitted from further analysis. Analyses both with and without Group 3 patients yielded similar results. Abstainers and continued smokers had similar demographic and clinical characteristics. With the exception of skin changes, all complications (mucositis, need for feeding tube, duration of feeding tube, need for hospitalization, pharyngeal stricture, and osteoradionecrosis) were more common in the patients who continued to smoke, although the only complications that were significantly more common were the need for hospitalization (P = .04) and osteoradionecrosis (P = .03). Patients who continued to smoke were more likely to develop osteoradionecrosis (relative risk [RR], 1.32; 95% confidence interval [CI], 1.09-1.6; P = .03) and to require hospitalization during treatment (RR, 1.46; 95% CI, 1.05-2.02; P = .04). CONCLUSIONS: Continued smoking during treatment appeared to increase the risk for complications of XRT for patients with laryngopharyngeal cancer and possibly increased hospitalizations. This hypothesis-generating study emphasized the importance of smoking cessation programs in the management of patients with head and neck cancer patients who receive XRT.