A randomized controlled trial of a distress screening, consultation, and targeted referral system for family caregivers in oncologic care.

OBJECTIVE: Distress screening is standard practice among oncology patients, yet few routine distress screening programs exist for cancer caregivers. The objective of this study was to demonstrate the feasibility, acceptability, and preliminary efficacy of Cancer Support Source-CaregiverTM (CSS-CG, 33-item), an electronic distress screening and automated referral program with a consultation (S + C) to improve caregiver unmet needs, quality of life, anxiety, depression, and distress relative to Enhanced Usual Care (EUC; access to educational materials). METHOD: 150 caregivers of patients with varying sites/stages of cancer were randomized to S + C or EUC and completed assessments at baseline, 3-months post-baseline, and 6-months post-baseline. A subset of participants (n = 10) completed in-depth qualitative interviews. RESULTS: S + C was feasible: among 75 caregivers randomized to S + C, 66 (88%) completed CSS-CG and consultation. Top concerns reported were: (1) patient's pain and/or physical discomfort; (2) patient's cancer progressing/recurring; and (3) feeling nervous or afraid. Differences between groups in improvements on outcomes by T2 and T3 were modest (ds < 0.53) in favor of S + C. Qualitative data underscored the helpfulness of S + C in connecting caregivers to support and helping them feel cared for and integrated into cancer care. CONCLUSIONS: S + C is feasible, acceptable, and yields more positive impact on emotional well-being than usual care. Future studies will examine programmatic impact among caregivers experiencing higher acuity of needs, and benefits of earlier integration of S + C on caregiver, patient, and healthcare system outcomes.

Caregiver Experiences With an Internet-Delivered Insomnia Intervention: SHUTi-CARE Trial Primary Qualitative Analysis.

BACKGROUND: Digital health interventions show potential to increase caregivers' access to psychosocial care; however, it is unclear to what extent existing interventions may need to be tailored to meet caregivers' unique needs. PURPOSE: This study aimed to determine whether-and if so, how-an efficacious Internet-delivered insomnia program should be modified for caregivers. The generalizability of these findings beyond the tested program was also examined. METHODS: Higher-intensity family caregivers (N = 100; age M = 52.82 [SD = 13.10], 75% non-Hispanic White, 66% ≥college degree) received access to an Internet-based cognitive-behavioral therapy for insomnia (CBT-I) program. Participants who completed one or more intervention "Cores" provided open-ended feedback on their experience; nonusers (completed no Cores) shared their barriers. RESULTS: Most caregivers who used the program (n = 82, 82%) found it feasible, citing its user-friendly, fully automated online format. Many reported that CBT-I strategies were helpful, although some faced challenges in implementing these strategies due to the unpredictability of their caregiving responsibilities. Opinions were divided on the utility of tailoring the program for caregivers. Nonusers (n = 18, 18%) primarily cited concerns about time burden and lifestyle compatibility as usage barriers. CONCLUSIONS: Delivering fully automated behavioral interventions through the Internet appears suitable for many caregivers. Extensive tailoring may not be required for most caregivers to benefit from an existing online CBT-I program, although additional guidance on integrating CBT-I strategies in the context of challenging sleep schedules and environments may help a subset of caregivers. Future research should explore how such tailoring may enhance digital health intervention uptake and effectiveness for caregivers.

This study examined family caregivers' experiences using an online cognitive-behavioral therapy for insomnia program. The aim was to determine if the program needed changes to better fit caregivers' needs. Researchers gave 100 caregivers with insomnia access to Sleep Healthy Using the Internet (SHUTi), an online insomnia program that had no caregiver-specific tailoring. Of the 82 caregivers who used the program, most found the program easy to use and helpful, although some struggled with behavioral strategies because of their unpredictable caregiving duties. There was no clear consensus among caregivers on whether tailoring would be helpful. The 18 caregivers who did not use the program most commonly said that they did not have enough time to use the program or that they felt it would not work well with their lifestyle. Overall, findings suggest that providing interventions via the Internet is a good fit for many caregivers. Many caregivers benefitted from an online insomnia program without being tailored specifically for caregivers, although some additional guidance on how to follow behavioral strategies may be helpful to some caregivers.

Caregivers' Internet-Delivered Insomnia Intervention Engagement and Benefit: SHUTi-CARE Trial Primary Quantitative Analysis.

BACKGROUND: Delivering insomnia treatment by the Internet holds promise for increasing care access to family caregivers, but their ability to adhere to and benefit from such fully-automated programs has not been rigorously tested. PURPOSE: This fully-powered, single-group trial tested whether characteristics of the caregiving context influence high-intensity caregivers' engagement with and benefit from an empirically validated Internet intervention for insomnia. METHODS: At baseline, caregivers providing unpaid time- and responsibility-intensive care who reported insomnia (N = 100; age M = 52.82 [SD = 13.10], 75% non-Hispanic white, 66% ≥college degree) completed questionnaires about caregiving context and sleep, then 10 prospectively-collected online daily sleep diaries. Caregivers then received access to SHUTi (Sleep Healthy Using the Internet), which has no caregiver-specific content, for 9 weeks, followed by post-assessment (questionnaires, diaries). Engagement was tracked by the SHUTi delivery system. RESULTS: Sixty caregivers completed SHUTi, 22 initiated but did not complete SHUTi, and 18 did not initiate SHUTi. Caregivers were more likely to use SHUTi (than not use SHUTi) when their care recipient (CR) had worse functioning, and were more likely to complete SHUTi when supporting more CR activities of daily living (ADL; ps < .03). Higher caregiver guilt, more CR problem behaviors, and being bedpartners with the CR related to more improved sleep outcomes, whereas supporting more CR instrumental ADL related to less improvement (ps < .05). CONCLUSIONS: Factors associated with greater caregiving burden, including greater CR impairment and caregiving guilt, were generally associated with better engagement and outcomes. Caregivers with substantial burdens can adhere to and benefit from a fully automated insomnia program without caregiver-specific tailoring.

This study examined how family caregivers, who often have trouble sleeping due to their responsibilities, used an online insomnia treatment program. The goal was to determine if certain aspects of caregiving would influence how caregivers engage with or benefit from the program. Researchers surveyed 100 caregivers with insomnia about their caregiving situation and sleep, and caregivers also kept online sleep diaries for 10 days. Afterward, caregivers used an online insomnia program with no caregiver-specific content called Sleep Healthy Using the Internet (SHUTi) for 9 weeks. Caregivers' usage was monitored, and they repeated measures of sleep outcomes and 10 online sleep diaries. Sixty caregivers completed SHUTi, 22 partially completed the program, and 18 did not initiate the program. Caregivers who cared for individuals with more severe functional limitations were more likely to use and complete SHUTi. Additionally, caregivers experiencing more guilt and those who managed more challenging behaviors from the person they cared for tended to report greater improvements in their sleep. This study suggests that caregivers, even those with significant care responsibilities, can use and benefit from an online insomnia treatment program like SHUTi, even when it has not been specifically tailored for caregivers.

Correlates of posttraumatic stress in cancer patients and their family caregivers across two years following diagnosis.

OBJECTIVE: To examine risk-factors of cancer-related PTSS in the 2-years post-diagnosis in adult colorectal cancer patients and caregivers. METHODS: Patients with colorectal cancer and their caregivers (N = 130 dyads) self-reported sociodemographic, psychosocial, and medical factors at diagnosis/treatment initiation (T1), at 1- (T2), and 2-year (T3) post-diagnosis. Cancer-related PTSS were assessed, and path analysis examined associations between proposed correlates and PTSS. RESULTS: Among patients, higher neuroticism and greater physical symptom distress were concurrently associated with higher PTSS (Bs ≥ 0.10, ps ≤ 0.02); greater physical symptom distress at T1 and greater social support at T2 were associated with higher PTSS at T3 (Bs ≥ 0.37, ps ≤ 0.04). Among caregivers, female gender, higher neuroticism (Bs ≥ 0.12, ps < 0.01), and lower social support (Bs  ≤ -0.24, ps ≤ 0.02) were associated with higher concurrent PTSS; lower patient physical symptom distress and social support at T1 (Bs  ≤ -0.27, ps ≤ 0.03) and longer hours spent caregiving at T2 (B = 0.03, p = 0.05) were associated with higher PTSS at T3. CONCLUSIONS: Findings identify cancer-specific risk factors (physical symptoms, hours caregiving), in addition to established risk factors (female, neuroticism, social support) in non-medical populations. The identified subgroups should receive ongoing screening and psychosocial referral for cancer-related PTSS.

Associations between context and affect within the daily lives of cancer caregivers.

PURPOSE: This study used ecological momentary assessment (EMA) to test the association between activity, location, and social company contexts with cancer caregivers' in-the-moment affect to identify precisely when and where to deliver psychological interventions for caregivers. METHODS: Current cancer caregivers (N = 25) received 8 EMA prompts per day for 7 consecutive days. At each prompt, caregivers reported their current positive affect and negative affect, as well as what they were doing, where they were located, and who they were with. Multilevel logistic regressions tested the associations between caregivers' contexts with their own person-mean-centered state (concurrent momentary level) and trait (overall weekly average) positive or negative affect. RESULTS: Caregivers reported lower state negative affect, as well as higher state positive affect, when socializing (ps < .001), when at a public location (ps < .03), and when around their friends, family, spouse/partner, or care recipient (i.e., person with cancer, ps < .02), relative to when not endorsing the context. Caregivers also reported lower state negative affect when eating/drinking or engaging in leisure (ps < .01; but no parallel effects for state positive affect). Caregivers reported higher state negative affect while working, when at their workplace, or when around work colleagues (ps < .001) and lower state positive affect when at home or alone (ps < .03). CONCLUSIONS: Results suggest the pertinence of a behavioral activation framework to mitigate the emotional strain of caregiving. Interventions that facilitate caregivers' ability to socialize with a range of friends and family, including their loved one with cancer, outside of the home may have the strongest positive emotional impact.

Including partners in discussions of sexual side effects from breast cancer: a qualitative study of survivors, partners, and providers.

PURPOSE: Ensuring there are clear standards for addressing cancer-related sexual side effects is important. Currently, there are differences in two leading sets of clinical guidelines regarding the inclusion of survivors' romantic partners into clinical discussions between survivors and their providers about this issue. To help refine guidelines, we examine breast cancer survivor, partner, and oncology provider perspectives about including partners in discussions about cancer-related sexual side effects in a secondary analysis of a broader qualitative study. METHODS: Partnered female breast cancer survivors (N = 29) completed online surveys, and intimate partners of breast cancer survivors (N = 12) and breast oncology providers (N = 8) completed semi-structured interviews. Themes were derived from thematic content analysis. RESULTS: Among survivors who reported a discussion with their provider, fewer than half indicated their partner had been present, despite most survivors expressing it was - or would have been - helpful to include their partner. Partners also largely indicated being included was or would have been helpful, when welcomed by the survivor. Providers similarly emphasized the importance of survivors' autonomy in deciding whether to discuss sexual concerns in the presence of a partner. CONCLUSIONS: Partners were infrequently included in conversations about cancer-related sexual side effects, even though survivors, partners, and providers alike expressed value in these discussions occurring with the couple together - when that is the survivor's preference. Findings suggest future clinical guidelines should emphasize that incorporating partners into clinical discussions about sexual concerns is important for many breast cancer patients. Soliciting and enacting patients' preferences is essential for truly patient-centered care.

Effects of an internet-delivered insomnia intervention for older adults: A secondary analysis on symptoms of depression and anxiety.

OBJECTIVE: To test whether an Internet-delivered cognitive behavioral therapy for insomnia (CBT-I) program for older adults attenuates symptoms of depression and anxiety. METHODS: Adults aged ≥ 55 with insomnia were randomized to SHUTi-OASIS (Sleep Healthy Using the Internet for Older Adult Sufferers of Insomnia and Sleeplessness; N = 207) or Patient Education (PE; N = 104). Depression and anxiety were assessed (HADS-D and HADS-A, respectively) at baseline, post-assessment, and 6- and 12-month follow-ups. RESULTS: Multilevel modeling of HADS-D showed a condition by time interaction (F[3,779] = 3.23, p = .02): SHUTi-OASIS participants reported lower symptoms than PE at post-assessment. There was no such interaction effect for HADS-A (F[3,779] = 2.12, p = .10). Generalized linear modeling showed no moderation of effects by baseline symptom severity. CONCLUSIONS: Participants randomized to Internet-delivered CBT-I showed stable depression and anxiety across time, while control participants' depressive symptoms briefly increased. CBT-I may help prevent development or worsening of psychological distress among older adults with insomnia. TRIAL REGISTRATION: [Registered at ClinicalTrials.gov; identifier removed for anonymity].

Development and feasibility of a communication training to assist caregivers with advanced care planning.

OBJECTIVE: Caregivers are critical in advanced care planning (ACP) discussions, which are difficult but necessary to carry out patients' goals of care. We developed and evaluated the feasibility and acceptability of a communication training to equip caregivers of patients with malignant brain tumors with skills to navigate ACP conversations. METHOD: Caregivers completed a 2-h virtual training addressing ACP Discussions with Your Loved One and ACP Discussions with the Medical Team. A pre-training assessment was completed at baseline and a training evaluation was completed one day post-training. A subset of participants completed semi-structured interviews 2 months post-training. RESULTS: Of 15 caregivers recruited, 9 attended the training and 4 completed qualitative interviews. Post-training, 40% felt confident in discussing ACP with loved ones and 67% felt confident doing so with healthcare professionals; 100% reported feeling confident in using skills learned in the training to facilitate these conversations. Data from qualitative interviews highlighted additional benefits of the training in empathic communication skills and fostering social support. SIGNIFICANCE OF RESULTS: Our communication skills training shows promise in supporting caregivers' skills and confidence in engaging in ACP discussions with patients and healthcare providers. A future randomized controlled trial with a larger and more diverse caregiving sample is needed to determine training efficacy.

Feasibility of ecological momentary assessment to study depressive symptoms among cancer caregivers.

OBJECTIVE: Ecological momentary assessment (EMA) may help with the development of more targeted interventions for caregivers' depression, yet the use of this method has been limited among cancer caregivers. This study aimed to demonstrate the feasibility of EMA among cancer caregivers and the use of EMA data to understand affective correlates of caregiver depressive symptoms. METHODS: Caregivers (N = 25) completed a depressive symptom assessment (Patient Health Questionnaire-8) and then received eight EMA survey prompts per day for 7 days. EMA surveys assessed affect on the orthogonal dimensions of valence and arousal. Participants completed feedback surveys regarding the EMA protocol at the conclusion of the week-long study. RESULTS: Of 32 caregivers approached, 25 enrolled and participated (78%), which exceeded the a priori feasibility cutoff of 55%. The prompt completion rate (59%, or 762 of 1,286 issued) did not exceed the a priori cutoff of 65%, although completion was not related to caregivers' age, employment status, physical health quality of life, caregiving stress, or depressive symptoms or the patients' care needs (ps > 0.22). Caregivers' feedback about their study experience was generally positive. Mixed-effects location scale modeling showed caregivers' higher depressive symptoms were related to overall higher reported negative affect and lower positive affect, but not to affective variability. CONCLUSIONS: Findings from this feasibility study refute potential concerns that an EMA design is too burdensome for distressed caregivers. Clinically, findings suggest the potential importance of not only strategies to reduce overall levels of negative affect, but also to increase opportunities for positive affect.

Effects of an Internet-Based Cognitive Behavioral Therapy for Insomnia Program on Work Productivity: A Secondary Analysis.

BACKGROUND: Cognitive-behavioral therapy for insomnia (CBT-I) may improve productivity along with insomnia symptoms, but the long-term duration of productivity gains is unknown. PURPOSE: In this secondary analysis, effects of Internet-delivered CBT-I on work-related and daily activity productivity were examined through 1 year post-treatment. METHODS: Adults with chronic insomnia (N = 303) were randomized to Internet-delivered CBT-I (Sleep Healthy Using the Internet [SHUTi]) or to patient education (PE). Participants reported interference with attendance (absenteeism) and productivity (presenteeism) at paid employment and in daily activities outside work on the Work Productivity Activity Impairment scale at baseline, 9 weeks later for postintervention assessment (post-assessment), and 6- and 12-month follow-ups. RESULTS: Participants randomized to SHUTi were about 50% less likely than those in the PE condition to report any absenteeism (logistic regression odds ratio [OR] = 0.48 [95% confidence intervals {CI} = 0.24,0.96]), total impairment (OR = 0.52 [95% CI = 0.29,0.93]), or activity impairment (OR = 0.50 [95% CI = 0.30,0.85]) at post-assessment; however, differences were not detected at 6- or 12-month follow-ups. SHUTi participants also reported lower overall levels of presenteeism (constrained longitudinal data analysis MDiff = -6.84 [95% CI = -11.53, -2.15]), total impairment (MDiff = -7.62 [95% CI = -12.50, -2.73]), and activity impairment (MDiff = -7.47 [95% CI = -12.68, -2.26]) at post-assessment relative to PE participants. Differences were sustained at 6-month follow-up for presenteeism (MDiff = -5.02 [95% CI = -9.94, -0.10]) and total impairment (MDiff = -5.78 [95% CI = -10.91, -0.65]). No differences were detected by 12-month follow-up. CONCLUSIONS: Findings suggest that Internet-based CBT-I may help accelerate improvement in work-related and daily activity impairment corroborating prior research, but did not find that CBT-I has persistent, long-term benefits in productivity relative to basic insomnia education. TRIAL REGISTRATION: NCT00328250 "Effectiveness of Internet Cognitive Behavioral Therapy Intervention for Treating Insomnia" (https://clinicaltrials.gov/ct2/show/NCT00328250).

Addressing sexual concerns of female breast cancer survivors and partners: a qualitative study of survivors, partners, and oncology providers about Internet intervention preferences.

PURPOSE: Sexual side effects after breast cancer treatment are common and distressing to both survivors and their intimate partners, yet few receive interventions to address cancer-related sexual concerns. To direct intervention development, this qualitative study assessed the perceptions of female breast cancer survivors, intimate partners of breast cancer survivors, and breast cancer oncology providers about how an Internet intervention for couples may address breast cancer-related sexual concerns. METHODS: Survivors (N = 20) responded to online open-ended surveys. Partners (N = 12) and providers (N = 8) completed individual semi-structured interviews. Data were inductively coded using thematic content analysis. RESULTS: Three primary intervention content areas were identified by the key stakeholder groups: (1) information about and strategies to manage physical and psychological effects of cancer treatment on sexual health, (2) relationship and communication support, and (3) addressing bodily changes and self-image after treatment. Survivors and partners tended to express interest in some individualized intervention private from their partner, although they also emphasized the importance of opening communication about sexual concerns within the couple. Survivors and partners expressed interest in an intervention that addresses changing needs across the cancer trajectory, available from the time of diagnosis and through survivorship. CONCLUSION: Internet intervention for couples to address cancer-related sexual concerns, particularly one that provides basic education about treatment side effects and that evolves with couples' changing needs across the cancer trajectory, was perceived as a valuable addition to breast cancer care by survivors, partners, and providers.

Fear of cancer recurrence promotes cancer screening behaviors among family caregivers of cancer survivors.

BACKGROUND: Fear of cancer recurrence (FCR) has been associated with cancer screening behaviors among cancer survivors, but to the authors' knowledge, the question of whether the same is true for caregivers is unknown. The current study investigated the extent to which FCR among caregivers predicted their cancer screening behaviors years after their relatives' cancer diagnosis. METHODS: A total of 813 caregivers (67% of whom were female, mean age of 56 years, and 92% non-Hispanic white) completed surveys 2 years (T1) and 8 years (T2) after their patients' cancer diagnosis. FCR, anxiety (Profile of Mood States-Short Form [POMS-SF]), and general mental health (Medical Outcomes Study 36-Item Short-Form Health Survey [MOS SF-36]) were reported at T1; caregivers' engagement in screening for colorectal, breast, and prostate cancers because of the patients' diagnoses were reported at T2. RESULTS: Caregivers were found to engage in cancer screening at rates similar to those of the national average. Controlling for covariates, hierarchical logistic regression modeling for each type of cancer screening demonstrated that greater FCR was linearly related to a higher likelihood of undergoing colorectal cancer screening (odds ratio [OR], 1.15) and maintaining prostate cancer screening (OR, 1.34), but a lower likelihood of maintaining breast cancer screening in an age-appropriate manner (OR, 0.27). Examining curvilinear effects demonstrated that moderate levels of FCR were associated with a higher likelihood of maintaining age-appropriate colorectal cancer screening (OR, 1.48). CONCLUSIONS: The overall FCR among caregivers uniquely promotes their engagement in cancer screening behaviors. The role of caregivers' FCR in other types of cancer preventive behaviors and ways to channel FCR concerns into promoting healthy lifestyle behaviors should be investigated.

Baseline Resilience and Posttraumatic Symptoms in Dyads of Neurocritical Patients and Their Informal Caregivers: A Prospective Dyadic Analysis.

BACKGROUND: Admission to a neuroscience intensive care unit (Neuro-ICU) is sudden and often traumatic for both patients and their informal caregivers. No prior studies have assessed prospectively risk and resiliency factors for chronic posttraumatic symptoms, as well as the potential interdependence between patients' and caregivers' symptoms over time. OBJECTIVE: To analyze the impact of baseline resiliency factors on symptoms of posttraumatic stress (PTS) longitudinally in dyads of patients admitted to the Neuro-ICU and their primary family caregivers. METHODS: We recruited dyads (M = 108) of patients admitted to the Neuro-ICU (total N = 102) and their family caregivers (total N = 103). Dyads completed self-report assessments of PTS and resiliency factors (mindfulness and coping) at baseline in the Neuro-ICU. PTS was measured again at 3- and 6-month follow-up. RESULTS: Clinically significant PTS symptoms were high at baseline in both patients (20%) and caregivers (16%) and remained high through 6 months (25% in patients; 14% in caregivers). Actor-partner interdependence modeling demonstrated that severity of PTS symptoms was predictive of PTS symptoms at subsequent time points (P < 0.001). High baseline mindfulness and coping predicted less severe PTS symptoms in patients and caregivers (P < 0.001) at all time points. Own degree of PTS symptoms at 3 months predicted worse PTS symptoms in one's partner at 6 months, for both patients and caregivers (P = 0.02). CONCLUSIONS: Findings highlight the need to prioritize assessment and treatment of PTS in Neuro-ICU patients and their informal caregivers through a dyadic approach.

Do treatment effects of a web-based cognitive behavioral therapy for insomnia intervention differ for users with and without pain interference? A secondary data analysis.

Cognitive-behavioral therapy for insomnia (CBT-I) shows treatment benefits among individuals with pain interference; however, effects of Internet-delivered CBT-I for this population are unknown. This secondary analysis used randomized clinical trial data from adults assigned to Internet-delivered CBT-I to compare changes in sleep by pre-intervention pain interference. Participants (N = 151) completed the Insomnia Severity Index (ISI) and sleep diaries [sleep onset latency (SOL); wake after sleep onset (WASO)] at baseline, post-assessment, 6- and 12-month follow-ups. Linear mixed-effects models showed no differences between pain interference groups (no, some, moderate/severe) for changes from baseline to any follow-up timepoint for ISI (p = .72) or WASO (p = .88). There was a small difference in SOL between those reporting some versus no or moderate/severe pain interference (p = .04). Predominantly comparable and sustained treatment benefits for both those with and without pain interference suggest that Internet-delivered CBT-I is promising for delivering accessible care to individuals with comorbid pain and insomnia.

Cancer Survivors' Beliefs About the Causes of Their Insomnia: Associations of Causal Attributions With Survivor Characteristics.

Objectives: Insomnia is common among cancer survivors, yet survivors' beliefs about their insomnia following cancer are largely unknown. This study describes cancer survivors' causal attributions of insomnia and whether these beliefs differ by sociodemographic characteristics. Participants: 160 cancer survivors meeting diagnostic criteria for insomnia disorder. Methods: Survivors endorsed how likely they believed 12 different factors were causally related to their insomnia and self-reported sociodemographics. Multinomial logistic regression tested associations between attribution endorsement and sociodemographics. Latent class analysis (LCA) examined patterns of attribution endorsement and whether sociodemographics were associated. Results: One hundred fifty-four survivors (96%) endorsed that at least 1 causal attribution was likely related to their insomnia. Most survivors endorsed that emotions (77%), thinking patterns (76%), sleep-related emotions (65%), and sleep-related thoughts (57%) were related to their insomnia, similar to data previously published among healthy persons with insomnia. Younger participants were more likely to endorse that biochemical factors related to their insomnia (ps < .02); females were more likely to endorse that hormonal factors related to their insomnia (ps < .001). LCA identified three classes (AIC = 3209.50, BIC = 3485.13). Approximately 40% of survivors endorsed most of the causal attributions were likely related to their insomnia; 13% frequently endorsed attributions were neither likely nor unlikely to be related. Older survivors were more likely to belong to the 47% who reported most attributions were unlikely related to their insomnia (p = .03). Conclusions: Cancer survivors with insomnia commonly endorsed that thoughts and emotions contributed to their sleep disturbance. Survivors' sociodemographic characteristics did not meaningfully explain individual differences for most causal attribution beliefs.

Dyadic Psychosocial eHealth Interventions: Systematic Scoping Review.

BACKGROUND: Dyadic psychosocial interventions have been found beneficial both for people coping with mental or physical health conditions as well as their family members and friends who provide them with support. Delivering these interventions via electronic health (eHealth) may help increase their scalability. OBJECTIVE: This scoping review aimed to provide the first comprehensive overview of dyadic eHealth interventions for individuals of all ages affected by mental or physical illness and their family members or friends who support them. The goal was to understand how dyadic eHealth interventions have been used and to highlight areas of research needed to advance dyadic eHealth intervention development and dissemination. METHODS: A comprehensive electronic literature search of PubMed, EMBASE, Cochrane, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO was conducted for articles published in the English language through March 2019. Eligible records described a psychosocial eHealth intervention that intervened with both care recipients and their support person. RESULTS: A total of 7113 records were reviewed of which 101 met eligibility criteria. There were 52 unique dyadic eHealth interventions identified, which were tested across 73 different trials. Of the unique interventions, 33 were conducted among dyads of children and their supporting parent, 1 was conducted with an adolescent-young adult care recipient population, and the remaining 18 were conducted among adult dyads. Interventions targeting pediatric dyads most commonly addressed a mental health condition (n=10); interventions targeting adult dyads most commonly addressed cancer (n=9). More than three-fourths of interventions (n=40) required some human support from research staff or clinicians. Most studies (n=64) specified one or more primary outcomes for care recipients, whereas less than one-fourth (n=22) specified primary outcomes for support persons. Where specified, primary outcomes were most commonly self-reported psychosocial or health factors for both care recipients (n=43) and support persons (n=18). Results of the dyadic eHealth intervention tended to be positive for care recipients, but evidence of effects for support persons was limited because of few studies specifying primary outcomes for supporters. Trials of dyadic eHealth interventions were most commonly randomized controlled trials (RCTs; n=44), and RCTs most commonly compared the dyadic eHealth intervention to usual care alone (n=22). CONCLUSIONS: This first comprehensive review of dyadic eHealth interventions demonstrates that there is substantial, diverse, and growing literature supporting this interventional approach. However, several significant gaps were identified. Few studies were designed to evaluate the unique effects of dyadic interventions relative to individual interventions. There was also limited assessment and reporting of outcomes for support persons, and there were no interventions meeting our eligibility criteria specifically targeting the needs of older adult dyads. Findings highlight areas of research opportunities for developing dyadic eHealth interventions for novel populations and for increasing access to dyadic care.

The Impact of Resilience Factors and Anxiety During Hospital Admission on Longitudinal Anxiety Among Dyads of Neurocritical Care Patients Without Major Cognitive Impairment and Their Family Caregivers.

BACKGROUND/OBJECTIVE: Anxiety is common in patients experiencing neurocritical illness and their family caregivers. Resilience factors like mindfulness and coping skills may be protective against symptoms of emotional distress, including anxiety. Less is known about the interplay of anxiety symptoms and resilience factors between patients and caregivers. The purpose of this study is to examine the trajectory of anxiety symptoms among dyads of neurocritical care patients without major cognitive impairment and their family caregivers and to elucidate the relationship between resiliency (e.g., mindfulness and coping) and anxiety in these dyads. METHODS: Prospective, longitudinal study of adults admitted to the neurological intensive care unit (Neuro-ICU) and their caregivers. Dyads of patients (N = 102) and family caregivers (N = 103) completed self-report measures of mindfulness (Cognitive Affective Mindfulness Scale-Revised) and coping (Measure of Current Status-Part A) during Neuro-ICU hospitalization and anxiety symptoms (anxiety subscale of the Hospital Anxiety and Depression Scale) during hospitalization and at 3- and 6-month follow-up. We used actor-partner interdependence modeling to predict the effect of one's own baseline characteristics on one's own and one's partner's future anxiety symptoms. RESULTS: Rates of clinically significant anxiety symptoms were 40% for patients and 42% for caregivers at baseline. Of these, 20% of patients and 23% of caregivers showed moderate and severe symptoms. Approximately, one-third of patients and caregivers reported clinically significant anxiety symptoms at 3- and 6-month follow-ups, with more than 20% endorsing moderate or severe symptoms. Patients' own baseline mindfulness, coping, and anxiety symptoms were associated with lower anxiety symptoms at all time points (ps < 0.001)-this was also true for caregivers. For both patients and caregivers, one's own baseline mindfulness predicted their partner's anxiety symptoms 3 months later (p = 0.008), but not at 6-month follow-up. CONCLUSIONS: Anxiety symptoms in Neuro-ICU patient-caregiver dyads are high through 6 months following admission. Mindfulness is interdependent and protective against anxiety in dyads at 3-month but not 6-month follow-up. Early, dyad-based interventions may prevent the development of chronic anxiety in patients without major cognitive impairment and caregivers.

Examining the relationship between changes in personality and depression in older adult cancer survivors.

Objectives: Despite widespread agreement that personality traits change across the lifespan into older adulthood, the association between changes in personality and depression among older adult cancer survivors is unknown. It was hypothesized that older adults with (vs. without) a past cancer diagnosis would experience an increase in neuroticism, and decreases in conscientiousness, agreeableness, openness, and extraversion, and that changes in these traits would mediate the relationship between receiving a cancer diagnosis and change in depression. Two hypotheses were tested in a cancer survivor sample. First, that increased chronic stressors and decreased physical health would mediate the link between personality change and increased depression. Second, that personality change would mediate the link between changes in chronic stressors/health and increased depression.Method: Secondary data analysis utilizing three waves of data from the Health and Retirement Study. Data was compiled from 5,217 participants, among whom 707 received a cancer diagnosis.Results: Older adults with (vs. without) a cancer diagnosis decreased in conscientiousness, which was associated with increased depression. Among cancer survivors, worsening chronic stressors/health mediated many pathways between personality change and an increased depression. Increased neuroticism mediated the link between worsening health/chronic stressors and increased depression.Conclusion: With the exception of conscientiousness, changes in personality did not mediate the link between cancer survivor status and depression. Among older adult cancer survivors, changes in personality traits may increase depression through worsening physical health and chronic stressors, potentially informing targeted interventions. Interventions that target increased neuroticism may be particularly useful in older adult cancer survivors.

Early Risk and Resiliency Factors Predict Chronic Posttraumatic Stress Disorder in Caregivers of Patients Admitted to a Neuroscience ICU.

OBJECTIVES: Informal caregivers-that is, close family and friends providing unpaid emotional or instrumental care-of patients admitted to ICUs are at risk for posttraumatic stress disorder. As a first step toward developing interventions to prevent posttraumatic stress disorder in ICU caregivers, we examined the predictive validity of psychosocial risk screening during admission for caregiver posttraumatic stress disorder at 3 and 6 months post hospitalization. DESIGN: An observational, prospective study. PARTICIPANTS: Ninety-nine caregivers were recruited as part of a longitudinal research program of patient-caregiver dyads in a neuroscience ICU. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Caregiver posttraumatic stress disorder symptoms were assessed during admission (baseline), 3 months, and 6 months post hospitalization. We 1) characterized prevalence of clinically significant symptoms at each time point 2); calculated sensitivity and specificity of baseline posttraumatic stress disorder screening in predicting posttraumatic stress disorder at 3 and 6 months; and 3) used recursive partitioning to select potential baseline factors and examine the extent to which they helped predict clinically significant posttraumatic stress disorder symptoms at each time point. Rates of caregiver posttraumatic stress disorder remained relatively stable over time (16-22%). Screening for posttraumatic stress disorder at baseline predicted posttraumatic stress disorder at 3 and 6 months with moderate sensitivity (75-80%) and high specificity (92-95%). Screening for posttraumatic stress disorder at baseline was associated with caregiver anxiety, mindfulness (i.e., ability to be aware of one's thoughts and feelings in the moment), and bond with patient. Furthermore, baseline posttraumatic stress disorder screening was the single most relevant predictor of posttraumatic stress disorder at 3 and 6 months, such that other baseline factors did not significantly improve predictive ability. CONCLUSIONS: Screening neuroscience ICU caregivers for clinically significant posttraumatic stress disorder symptoms during admission is the single most important way to identify the majority of those likely to suffer from chronic posttraumatic stress disorder following discharge. Addressing early posttraumatic stress disorder symptoms and their psychosocial correlates during admission may help prevent chronic posttraumatic stress disorder in these at-risk caregivers.

Prevalence of physical problems detected by the distress thermometer and problem list in patients with breast cancer.

BACKGROUND: Patients with breast cancer have high rates of physical symptoms that negatively impact their quality of life. The relationship between women's perceptions of these physical symptoms and patient demographic and breast cancer characteristics is less well known. This study describes physical symptoms of patients with breast cancer and their relationship with patient characteristics. METHODS: Patients (n = 125) with breast cancer (stage 0-IV) completed questionnaires in a dedicated academic medical center breast cancer clinic. Patients reported demographics (age, race/ethnicity, marital status, and employment status) and disease characteristics (surgery type, receipt of chemotherapy, or antihormonal therapy). Patients reported whether they were bothered by any of the 22 physical problem list (PPL) variables from the distress thermometer and problem list. RESULTS: The median number of physical problems endorsed by patients was 3.0 (M = 3.43, SD = 3.42). Approximately one-fourth endorsed no physical symptoms while three-fourths reported at least 1 problem, and three-fifths endorsed 2 or more problems. Fatigue (40.0%), sleep (34.7%), skin dry/itchy (22.9%), pain (19.5%), and feeling swollen (19.5%) were most commonly reported. Age, race/ethnicity, marital status, employment status, and receipt of chemotherapy were associated with certain physical problems. Problems with breathing, eating, memory/concentration, nausea, and total number of endorsed PPL variables were associated with distress. CONCLUSION: The breast cancer population demonstrates heavy physical symptom burden with multiple physical problems that are related to overall functioning. Special attention should be given to the physical symptom burden of younger, nonwhite, unmarried, and unemployed patients. Future research should investigate the PPL of the distress thermometer and problem list with other measures of symptom burden.