Effect of Inpatient Palliative Care on Quality of Life 2 Weeks After Hematopoietic Stem Cell Transplantation: A Randomized Clinical Trial.

Importance: During hospitalization for hematopoietic stem cell transplantation (HCT), patients receive high-dose chemotherapy before transplantation and experience significant physical and psychological symptoms and poor quality of life (QOL). Objective: To assess the effect of inpatient palliative care on patient- and caregiver-reported outcomes during hospitalization for HCT and 3 months after transplantation. Design, Setting, and Participants: Nonblinded randomized clinical trial among 160 adults with hematologic malignancies undergoing autologous/allogeneic HCT and their caregivers (n = 94). The study was conducted from August 2014 to January 2016 in a Boston hospital; follow-up was completed in May 2016. Interventions: Patients assigned to the intervention (n=81) were seen by palliative care clinicians at least twice a week during HCT hospitalization; the palliative intervention was focused on management of physical and psychological symptoms. Patients assigned to standard transplant care (n=79) could be seen by palliative care clinicians on request. Main Outcomes and Measures: Primary: change in patient QOL from baseline to week 2; secondary: patient-assessed mood, fatigue, and symptom burden scores at baseline, 2 weeks, and 3 months after HCT and caregiver-assessed QOL and mood at baseline and 2 weeks after HCT. Results: Among 160 enrolled patients (mean age, 60 [SD, 13.3] years; 91 women [56.9%]; median hospital stay, 21 days) and 94 caregivers, 157 (98.1%) and 89 (94.7%), respectively, completed 2-week follow-up, and 149 patients (93.1%) completed 3-month follow-up. Patients in the intervention group reported a smaller decrease in QOL from baseline to week 2 (mean baseline score, 110.26; week 2 score, 95.46; mean change, -14.72) compared with patients in the control group (mean baseline score, 106.83; week 2 score, 85.42; mean change, -21.54; difference between groups, -6.82; 95% CI, -13.48 to -0.16; P = .045). Among the secondary outcomes, from baseline to week 2, patients in the intervention group vs those in the control group had less increase in depression (mean, 2.43 vs 3.94; mean difference, 1.52; 95% CI, 0.23-2.81; P = .02), lower anxiety (mean, -0.80 vs 1.12; mean difference, 1.92; 95% CI, 0.83-3.01; P < .001), no difference in fatigue (mean, -10.30 vs -13.65; mean difference, -3.34; 95% CI, -7.25 to 0.56; P = .09), and less increase in symptom burden (mean, 17.35 vs 23.14; mean difference, 5.80; 95% CI, 0.49-11.10; P = .03). At 3 months after HCT, intervention patients vs control patients had higher QOL scores (mean, 112.00 vs 106.66; mean difference, 5.34; 95% CI, 0.04-10.65; P = .048) and less depression symptoms (mean, 3.49 vs 5.19; mean difference, -1.70; 95% CI, -2.75 to -0.65; P = .002) but no significant differences in anxiety, fatigue, or symptom burden. From baseline to week 2 after HCT, caregivers of patients in the intervention group vs caregivers of patients in the control group reported no significant differences in QOL or anxiety but had a smaller increase in depression (mean, 0.25 vs 1.80; mean difference, 1.55; 95% CI, 0.14-2.96; P = .03). Conclusions and Relevance: Among adults at a single institution undergoing HCT for hematologic malignancy, the use of inpatient palliative care compared with standard transplant care resulted in a smaller decrease in QOL 2 weeks after transplantation. Further research is needed for replication and to assess longer-term outcomes and cost implications. Trial Registration: clinicaltrials.gov Identifier: NCT02207322.

Measurement equivalence of seven selected items of posttraumatic growth between black and white adult survivors of Hurricane Katrina.

This study examined the equivalence or comparability of the measurement properties of seven selected items measuring posttraumatic growth among self-identified Black (n = 270) and White (n = 707) adult survivors of Hurricane Katrina, using data from the Baseline Survey of the Hurricane Katrina Community Advisory Group Study. Internal consistency reliability was equally good for both groups (Cronbach's alphas = .79), as were correlations between individual scale items and their respective overall scale. Confirmatory factor analysis of a congeneric measurement model of seven selected items of posttraumatic growth showed adequate measures of fit for both groups. The results showed only small variation in magnitude of factor loadings and measurement errors between the two samples. Tests of measurement invariance showed mixed results, but overall indicated that factor loading, error variance, and factor variance were similar between the two samples. These seven selected items can be useful for future large-scale surveys of posttraumatic growth.

Application of yoga in residential treatment of traumatized youth.

BACKGROUND: The Trauma Center at Justice Resource Institute has adapted a form of Hatha yoga into a trauma-sensitive adjunctive component of intervention for use with complexly traumatized individuals exhibiting chronic affective and somatic dysregulation and associated behavioral, functioning, and health complaints. OBJECTIVES: This article explores the use of yoga with traumatized youth (aged 12-21 years) in residential treatment. DESIGN: A review of the literature on the somatic impact of trauma exposure provides a rationale for the use of yoga with this population and highlights an emerging evidence base in support of this practice. Case vignettes illustrate the integration of structured, gentle yoga practices into residential programming for youth with severe emotional and behavioral problems. RESULTS: Anecdotal data and clinical observation underscore the promise of yoga as a viable approach to build self-regulatory capacity of traumatized youth. CONCLUSIONS: Future directions in the development and evaluation of trauma-informed yoga practices for youth are discussed.

Effect of Inpatient Palliative Care During Hematopoietic Stem-Cell Transplant on Psychological Distress 6 Months After Transplant: Results of a Randomized Clinical Trial.

Purpose Inpatient palliative care integrated with transplant care improves patients' quality of life (QOL) and symptom burden during hematopoietic stem-cell transplant (HCT). We assessed patients' mood, post-traumatic stress disorder (PTSD) symptoms, and QOL 6 months post-transplant. Methods We randomly assigned 160 patients with hematologic malignancies who underwent autologous or allogeneic HCT to inpatient palliative care integrated with transplant care (n = 81) or transplant care alone (n = 79). At baseline and 6 months post-transplant, we assessed mood, PTSD symptoms, and QOL with the Hospital Anxiety and Depression Scale and Patient Health Questionnaire, PTSD checklist, and Functional Assessment of Cancer Therapy-Bone Marrow Transplant. To assess symptom burden during HCT, we used the Edmonton Symptom Assessment Scale. We used analysis of covariance while controlling for baseline values to examine intervention effects and conducted causal mediation analyses to examine whether symptom burden or mood during HCT mediated the effect of the intervention on 6-month outcomes. Results We enrolled 160 (86%) of 186 potentially eligible patients between August 2014 and January 2016. At 6 months post-transplant, intervention participants reported lower depression symptoms on the Hospital Anxiety and Depression Scale and Patient Health Questionnaire (adjusted mean difference, -1.21 [95% CI, -2.26 to -0.16; P = .024] and -1.63 [95% CI, -3.08 to -0.19; P = .027], respectively) and lower PTSD symptoms (adjusted mean difference, -4.02; 95% CI, -7.18 to -0.86; P = .013), but no difference in QOL or anxiety. Symptom burden and anxiety during HCT hospitalization partially mediated the effect of the intervention on depression and PTSD at 6 months post-transplant. Conclusion Inpatient palliative care integrated with transplant care leads to improvements in depression and PTSD symptoms at 6 months post-transplant. Reduction in symptom burden and anxiety during HCT partially accounts for the effect of the intervention on these outcomes.

Yoga for Adult Women with Chronic PTSD: A Long-Term Follow-Up Study.

INTRODUCTION: Yoga-the integrative practice of physical postures and movement, breath exercises, and mindfulness-may serve as a useful adjunctive component of trauma-focused treatment to build skills in tolerating and modulating physiologic and affective states that have become dysregulated by trauma exposure. A previous randomized controlled study was carried out among 60 women with chronic, treatment-resistant post-traumatic stress disorder (PTSD) and associated mental health problems stemming from prolonged or multiple trauma exposures. After 10 sessions of yoga, participants exhibited statistically significant decreases in PTSD symptom severity and greater likelihood of loss of PTSD diagnosis, significant decreases in engagement in negative tension reduction activities (e.g., self-injury), and greater reductions in dissociative and depressive symptoms when compared with the control (a seminar in women's health). The current study is a long-term follow-up assessment of participants who completed this randomized controlled trial. METHODS: Participants from the randomized controlled trial were invited to participate in long-term follow-up assessments approximately 1.5 years after study completion to assess whether the initial intervention and/or yoga practice after treatment was associated with additional changes. Forty-nine women completed the long-term follow-up interviews. Hierarchical regression analysis was used to examine whether treatment group status in the original study and frequency of yoga practice after the study predicted greater changes in symptoms and PTSD diagnosis. RESULTS: Group assignment in the original randomized study was not a significant predictor of longer-term outcomes. However, frequency of continuing yoga practice significantly predicted greater decreases in PTSD symptom severity and depression symptom severity, as well as a greater likelihood of a loss of PTSD diagnosis. CONCLUSIONS: Yoga appears to be a useful treatment modality; the greatest long-term benefits are derived from more frequent yoga practice.

Claiming peaceful embodiment through yoga in the aftermath of trauma.

The purpose of this study was to describe the experiences of practicing yoga and its role within processes of healing for adult women with complex trauma histories. Using a hermeneutic phenomenological method, data were analyzed from interviews with 39 women. Results showed that the core meaning of participants' experience of healing through yoga is claiming peaceful embodiment. This is an ongoing process occurring on a continuum whereby women experienced improved connections with and sense of ownership and control over their bodies, emotions and thoughts, and a greater sense of well-being, calmness, and wholeness in their bodies and minds. A number of interconnected essential themes related to this core meaning were also identified, illuminating processes that supported claiming peaceful embodiment and capabilities that were enabled by being more peacefully embodied. Additional themes were identified highlighting factors that facilitated or impeded participants' engagement with yoga and their experiences of healing through yoga.

A hermeneutic phenomenological understanding of men's healing from childhood maltreatment.

PURPOSE: To describe and interpret men's experience of healing from childhood maltreatment. DESIGN: Hermeneutic phenomenological. METHOD: In-depth interviews. Community-based purposive, maximum variation sampling approach. Recruitment occurred through posting flyers and advertisements. Verbatim data were analyzed and themes of the meaning of healing were identified. FINDINGS: The meaning of healing was interpreted as "moving beyond suffering." Five themes were identified to capture the multidimensional nature of the phenomenon: (a) breaking through the masculine veneer, (b) finding meaning, (c) choosing to live well, (d) caring for the self using holistic healing methods, and (e) engaging in humanizing relationships. CONCLUSIONS: Men who survived childhood maltreatment have needs to heal holistically mind, body, and spirit. Meeting their needs requires the provision of highly compassionate humanistic healing environments and healing-promotive nursing care.

Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial.

BACKGROUND: More than a third of the approximately 10 million women with histories of interpersonal violence in the United States develop posttraumatic stress disorder (PTSD). Currently available treatments for this population have a high rate of incomplete response, in part because problems in affect and impulse regulation are major obstacles to resolving PTSD. This study explored the efficacy of yoga to increase affect tolerance and to decrease PTSD symptomatology. METHOD: Sixty-four women with chronic, treatment-resistant PTSD were randomly assigned to either trauma-informed yoga or supportive women's health education, each as a weekly 1-hour class for 10 weeks. Assessments were conducted at pretreatment, midtreatment, and posttreatment and included measures of DSM-IV PTSD, affect regulation, and depression. The study ran from 2008 through 2011. RESULTS: The primary outcome measure was the Clinician-Administered PTSD Scale (CAPS). At the end of the study, 16 of 31 participants (52%) in the yoga group no longer met criteria for PTSD compared to 6 of 29 (21%) in the control group (n = 60, χ²1 = 6.17, P = .013). Both groups exhibited significant decreases on the CAPS, with the decrease falling in the large effect size range for the yoga group (d = 1.07) and the medium to large effect size decrease for the control group (d = 0.66). Both the yoga (b = -9.21, t = -2.34, P = .02, d = -0.37) and control (b = -22.12, t = -3.39, P = .001, d = -0.54) groups exhibited significant decreases from pretreatment to the midtreatment assessment. However, a significant group × quadratic trend interaction (d = -0.34) showed that the pattern of change in Davidson Trauma Scale significantly differed across groups. The yoga group exhibited a significant medium effect size linear (d = -0.52) trend. In contrast, the control group exhibited only a significant medium effect size quadratic trend (d = 0.46) but did not exhibit a significant linear trend (d = -0.29). Thus, both groups exhibited significant decreases in PTSD symptoms during the first half of treatment, but these improvements were maintained in the yoga group, while the control group relapsed after its initial improvement. DISCUSSION: Yoga significantly reduced PTSD symptomatology, with effect sizes comparable to well-researched psychotherapeutic and psychopharmacologic approaches. Yoga may improve the functioning of traumatized individuals by helping them to tolerate physical and sensory experiences associated with fear and helplessness and to increase emotional awareness and affect tolerance. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00839813.

Posttraumatic growth among men with histories of child sexual abuse.

Despite an increased risk of long-term mental health problems, many survivors of child sexual abuse (CSA) experience positive changes in areas such as appreciation for life, personal strength, and interpersonal relationships. Drawing on life course theory, this study examined factors related to posttraumatic growth among a sample of men with CSA histories (N = 487). Using multiple linear regression (i.e., ordinary least squares), we found that men who had a better understanding of the sexual abuse experience, who ascribed to less traditional masculine norms, and who experienced a turning point reported greater growth. To promote growth, practitioners can help survivors understand the meaning and impact of the abuse on their lives and deconstruct rigid gender norms. More research on growth is needed with male survivors, especially on the nature of turning points in the recovery process.

A conceptual model of the psychological health system for U.S. active duty service members: an approach to inform leadership and policy decision making.

The influence of individual-level factors such as pretraumatic risk and protective factors and the availability of unit-level and enterprise-level factors on psychological health outcomes have been previously considered individually, but have not been considered in tandem across the U.S. Military psychological health system. We use the existing literature on military psychological health to build a conceptual system dynamics model of the U.S. Military psychological health system "service-cycle" from accession and deployment to future psychological health screening and treatment. The model highlights a few key observations, challenges, and opportunities for improvement for the system that relate to several topics including the importance of modeling operational demand combined with the population's psychological health as opposed to only physical health; the role of resilience and post-traumatic growth on the mitigation of stress; the positive and negative effects of pretraumatic risk factors, unit support, and unit leadership on the service-cycle; and the opportunity to improve the system more rapidly by including more feedback mechanisms regarding the usefulness of pre- and post-traumatic innovations to medical leaders, funding authorities, and policy makers.