The Cancer Financial Experience (CAFÉ) study: randomized controlled trial of a financial navigation intervention to address cancer-related financial hardship.

BACKGROUND: There is an urgent need for evidence on how interventions can prevent or mitigate cancer-related financial hardship. Our objectives are to compare self-reported financial hardship, quality of life, and health services use between patients receiving a financial navigation intervention versus a comparison group at 12 months follow-up, and to assess patient-level factors associated with dose received of a financial navigation intervention. METHODS: The Cancer Financial Experience (CAFÉ) study is a multi-site randomized controlled trial (RCT) with individual-level randomization. Participants will be offered either brief (one financial navigation cycle, Arm 2) or extended (three financial navigation cycles, Arm 3) financial navigation. The intervention period for both Arms 2 and 3 is 6 months. The comparison group (Arm 1) will receive enhanced usual care. The setting for the CAFÉ study is the medical oncology and radiation oncology clinics at two integrated health systems in the Pacific Northwest. Inclusion criteria includes age 18 or older with a recent cancer diagnosis and visit to a study clinic as identified through administrative data. Outcomes will be assessed at 12-month follow-up. Primary outcomes are self-reported financial distress and health-related quality of life. Secondary outcomes are delayed or foregone care; receipt of medical financial assistance; and account delinquency. A mixed methods exploratory analysis will investigate factors associated with total intervention dose received. DISCUSSION: The CAFÉ study will provide much-needed early trial evidence on the impact of financial navigation in reducing cancer-related financial hardship. It is theory-informed, clinic-based, aligned with patient preferences, and has been developed following preliminary qualitative studies and stakeholder input. By design, it will provide prospective evidence on the potential benefits of financial navigation on patient-relevant cancer outcomes. The CAFÉ trial's strengths include its broad inclusion criteria, its equity-focused sampling plan, its novel intervention developed in partnership with clinical and operations stakeholders, and mixed methods secondary analyses related to intervention dose offered and dose received. The resulting analytic dataset will allow for rich mixed methods analysis and provide critical information related to implementation of the intervention should it prove effective. TRIAL REGISTRATION: ClinicalTrials.gov NCT05018000 . August 23, 2021.

Developing home-based telemental health services for youth: Practices from the SUAY Study.

INTRODUCTION: There are no published procedural or safety guidelines for home-based telemental health (TMH) therapy with youth, despite the unique challenges and risks of providing services to this population outside of a traditional clinic setting. We developed clinical, logistical, and safety procedures for home-based TMH with youth in the context of a large clinical trial. METHODS: A Targeted Approach to Safer Use of Antipsychotics in Youth (SUAY) study identifies youth ages 3-17 who are prescribed second-generation antipsychotic medication for non-psychotic disorders within large healthcare systems. Prescribing physicians receive psychopharmacology consultation. Patients receive a "navigator" to coordinate treatments and access to TMH if they do not have a local therapist. We optimized access by allowing TMH sessions to take place in the family's home, while providing guidelines for privacy, safety, and in-session crises. RESULTS: Clinical issues included providing flexibility in the treatment modality and engaging families. Logistical issues included remote consenting for treatment and troubleshooting technological problems. Safety issues included crisis and safety planning with the youth and family before and during treatment. DISCUSSION: The provision of home-based TMH therapy for youth requires adaptations to existing TMH procedural and safety guidelines to optimize clinical care, technology coordination, and safety.Trial registration number and trial register: Clinicaltrials.gov: NCT03448575.

Concerns of Older Veteran Callers to the Veterans Crisis Line.

When the Veterans Crisis Line (VCL) was implemented, it was uncertain if veterans, and particularly older male veterans, would utilize the service. We examined VCL use by a growing group of veterans at increased risk for suicide: those aged 60 and older. Real-time clinical data were gathered from a weekly random sampling of calls. Approximately 25% of calls were from veterans aged 60 or older; over 80% reported benefit from the call. Several significant differences in presenting concerns between older and younger callers were found. Targeted outreach to encourage older veterans to use the VCL is suggested.

Sleep and Suicide in Older Adults: An Opportunity for Intervention.

Whether as a standalone disorder or as a symptom associated with existing pathology, the prevalence of sleep disturbance increases with age. Older adults also experience a myriad of risk factors for suicide, including depression, and have elevated rates of suicide. There is now significant evidence linking sleep disturbances to suicidal thoughts and behaviors. The use of pharmacologic means to treat insomnia (e.g., sedative hypnotics) is also commonplace among older cohorts and has been associated with suicide. Behavioral treatment of insomnia represents an efficacious alternative to pharmacotherapy among older adults, which while improving sleep, may concurrently reduce depressive symptomatology. Implications and clinical recommendations of the sleep-suicide relationship are discussed.

Spirituality attenuates the association between depression symptom severity and meaning in life.

OBJECTIVES: This cross-sectional study examined whether spirituality moderates the association between depression symptom severity and meaning in life among treatment-seeking adults. METHOD: Participants were 55 adults (≥60 years of age) newly seeking outpatient mental health treatment for mood, anxiety, or adjustment disorders. Self-report questionnaires measured depression symptom severity (Patient Health Questionnaire-9), spirituality (Spirituality Transcendence Index), and meaning in life (Geriatric Suicide Ideation Scale-Meaning in Life subscale). RESULTS: Results indicated a significant interaction between spirituality and depression symptom severity on meaning in life scores (ß = .26, p = .02). A significant negative association between depression symptom severity and meaning in life was observed at lower but not the highest levels of spirituality. CONCLUSION: In the presence of elevated depressive symptomatology, those participants who reported high levels of spirituality reported comparable levels of meaning in life to those without elevated depressive symptomatology. Assessment of older adult patients' spirituality can reveal ways that spiritual beliefs and practices can be can be incorporated into therapy to enhance meaning in life.

Adapting interpersonal psychotherapy for older adults at risk for suicide.

OBJECTIVE: To pilot a psychological intervention adapted for older adults at risk for suicide. DESIGN: A focused, uncontrolled, pre-to-post-treatment psychotherapy trial. All eligible participants were offered the study intervention. SETTING: Outpatient mental health care provided in the psychiatry department of an academic medical center in a mid-sized Canadian city. PARTICIPANTS: Seventeen English-speaking adults 60 years or older, at risk for suicide by virtue of current suicide ideation, death ideation, and/or recent self-injury. INTERVENTION: A 16-session course of Interpersonal Psychotherapy (IPT) adapted for older adults at risk for suicide who were receiving medication and/or other standard psychiatric treatment for underlying mood disorders. MEASUREMENTS: Participants completed a demographics form, screens for cognitive impairment and alcohol misuse, a semi-structured diagnostic interview, and measures of primary (suicide ideation and death ideation) and secondary study outcomes (depressive symptom severity, social adjustment and support, psychological well-being), and psychotherapy process measures. RESULTS: Participants experienced significant reductions in suicide ideation, death ideation, and depressive symptom severity, and significant improvement in perceived meaning in life, social adjustment, perceived social support, and other psychological well-being variables. CONCLUSIONS: Study participants experienced enhanced psychological well-being and reduced symptoms of depression and suicide ideation over the course of IPT adapted for older adults at risk for suicide. Larger, controlled trials are needed to further evaluate the impact of this novel intervention and to test methods for translating and integrating focused interventions into standard clinical care with at-risk older adults.

Age-related concerns of male veteran callers to a suicide crisis line.

In July 2007, the United States Department of Veterans Affairs (VA) partnered with the Department of Health and Human Services' Substance Abuse and Mental Health Service Administration (SAMHSA) to create the Veterans Crisis Line (VCL) in order to meet the unique needs of Veterans in distress. The current study utilized a mixed methods design to examine characteristics of male callers to the VCL. Results from qualitative analyses demonstrated that the majority of callers between April 1 and August 31, 2008 contacted the VCL with concerns related to mental health issues, suicide ideation, and substance abuse issues. Quantitative analyses demonstrated age differences associated with concerns presented by callers such that middle-aged and older callers were more likely to present with loneliness and younger callers were more likely to present with mental health concerns. The results of this study will help to inform future research designed to optimize the effectiveness of the VCL for suicide prevention in Veterans.

Opportunities for psychologists in palliative care: Working with patients and families across the disease continuum.

Interdisciplinary palliative care services have been rapidly expanding in health care settings over the past 10 years, particularly through the establishment of interdisciplinary palliative care teams. Relatively few of these teams formally include psychologists, although their skills of enhancing patients' and families' well-being and lessening suffering make an enormous contribution to the care provided. In this article, we define palliative care in broad terms, distinguishing it from hospice and end-of-life care. Using a case-based approach, we then explore the contribution of psychologists to the patient- and family-centered approach espoused by palliative care, including the knowledge, skills, and self-awareness needed to work effectively with these very ill patients and their families. We close with a call to action to better train and integrate psychologists into the rapidly growing field of palliative care.

Does perceived burdensomeness erode meaning in life among older adults?

BACKGROUND: Identification of risk factors for the loss of meaning in life among older adults is needed. In this article, we test hypotheses derived from the Interpersonal Theory of Suicide concerning the role of perceptions that one is a burden on others as a risk factor for lower meaning in life. METHODS: A prospective design was used to examine the temporal associations between perceptions of burdensomeness on others and perceived meaning in life among older adults (n=65) seeking mental health treatment (primarily for depression and/or anxiety) at an outpatient geriatric mental health clinic. Participants completed self-report questionnaires within a month following intake. Follow-up questionnaires were completed over the phone two months later. RESULTS: Perceived burdensomeness predicted lack of meaning in life two months later, while accounting for depression severity. In contrast, baseline levels of meaning in life did not significantly predict the levels of burdensomeness at two months. CONCLUSION: The findings suggest that burdensomeness may contribute to suicide morbidity and mortality in late-life by eroding meaning in life. Empirically supported treatments for late-life depression could be adapted to focus on perceptions of burdensomeness and its connections with meaning in life.

Trait neuroticism, depression, and cognitive function in older primary care patients.

OBJECTIVE: Prior studies on the association of trait neuroticism and cognitive function in older adults have yielded mixed findings. The authors tested hypotheses that neuroticism is associated with measures of cognition and that depression moderates these relationships. DESIGN: Cross-sectional observational study. SETTING: Primary care offices. PARTICIPANTS: Primary care patients aged > or =65 years. MEASUREMENTS: Trait neuroticism was assessed by the NEO-Five Factor Inventory. Major and minor depressions were determined by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and depressive symptom severity by the Hamilton Depression Rating Scale (Ham-D). Cognitive measures included the Mini-Mental State Examination (MMSE), Initiation-Perseveration subscale of the Mattis Dementia Rating Scale, and Trail-Making tests A and B. RESULTS: In multiple regression analyses, neuroticism was associated with MMSE score independent of depression diagnosis (beta = -0.04, chi2 = 14.2, df = 1, p = 0.0002, 95% confidence interval [CI] = -0.07 to -0.02) and Ham-D score (beta = -0.04, chi2 = 8.97, df = 1, p = 0.003, 95% CI = -0.06 to -0.01). Interactions between neuroticism and depression diagnosis (chi2 = 7.21, df = 2, p = 0.03) and Ham-D scores (chi2 = 0.55, df = 1, p = 0.46) failed to lend strong support to the moderation hypothesis. CONCLUSION: Neuroticism is associated with lower MMSE scores. Findings do not confirm a moderating role for depression but suggest that depression diagnosis may confer additional risk for poorer global cognitive function in patients with high neuroticism. Further study is necessary.

Depression predicts cognitive disorders in older primary care patients.

OBJECTIVE: To investigate whether depression is independently associated with increased risk of incident dementia or cognitive disorder not otherwise specified (NOS) in an older primary care population. METHOD: This was a prospective 3-year cohort study of 470 patients aged >or= 65 years without baseline cognitive disorders who were recruited from primary care offices. Annual assessments completed from March 2003 through December 2005 included the use of the Structured Clinical Interview for DSM-IV to diagnose major depressive disorder (MDD) and minor depression (MinD) and the Hamilton Depression Rating Scale (HDRS) for depressive symptom severity. The Mini-Mental State Exam, Mattis Dementia Rating Scale-initiation/perseveration subscale, and the Trail Making Tests A and B informed diagnoses of dementia and cognitive disorder NOS. RESULTS: 36 subjects, representing a cumulative incidence of 13%, developed dementia or cognitive disorder NOS over 3 years. Using Cox proportional hazard survival models to calculate the risk ratio of depression for development of cognitive disorders, MDD and MinD (HR = 3.68; 95% CI, 2.1-6.42 and HR = 1.84; 95% CI, 1.05-3.21, respectively) and HDRS scores (HR = 1.07; 95% CI, 1.02-1.12) predicted new onset dementia or cognitive disorder NOS, when covarying age, gender, and education. CONCLUSIONS: Depressive disorders pose increased risk of incident dementia or cognitive disorder NOS in older primary care patients. Clinicians treating depressed older adults should monitor for development of cognitive disorders.

Assessing families in palliative care: a pilot study of the checklist of family relational abilities.

Although families often play an integral role in palliative care, there are currently few measures to help clinicians gauge families' abilities to participate in this process. The Checklist of Family Relational Abilities was developed as an efficient, clinician-rated method of family assessment. Preliminary results suggest that Checklist ratings of overall family functioning and strength of family attachments were reliable across raters and associated with a well-validated self-report measure of family functioning. However, ratings of family communication and collaborative decision-making were less reliable. Based on these preliminary findings, we propose a revised version of the Checklist for further study in palliative care settings.

Adapting Interpersonal Psychotherapy for Older Adults at Risk for Suicide: Preliminary Findings.

We report preliminary findings of the first ever study testing a 16-week course of Interpersonal Psychotherapy (IPT) modified for older outpatients at elevated risk for suicide. Participants were referred from inpatient and outpatient medicine and mental health services. Psychotherapy sessions took place in a therapist's office in a teaching hospital. Twelve adults 60 years or older (M=70.5, SD=6.1) with current thoughts of suicide (suicide ideation) or a wish to die (death ideation) or with recent self-injurious behavior were recruited into weekly sessions of IPT; one was subsequently excluded due to severe cognitive impairment. Participants completed measures of suicide ideation, death ideation, and depressive symptom severity at pre-treatment, mid-treatment, post-treatment, and at 3-month follow-up periods, and measures of therapeutic process variables. Preliminary findings of this uncontrolled pre-post-treatment study support the feasibility of recruiting and retaining older adults at-risk for suicide into psychotherapy research and suggest that adapted IPT is tolerable and safe. Findings indicate a substantial reduction in participant suicide ideation, death ideation, and depressive symptoms; controlled trials are needed to further evaluate these findings. We discuss implications for clinical care with at-risk older adults.

Does depression precede or follow executive dysfunction? Outcomes in older primary care patients.

OBJECTIVE: The authors sought to test the potentially reciprocal relationships between depression and executive dysfunction in older patients over time. METHOD: In this prospective 2-year cohort study, the authors enrolled 709 patients age 65 years and older who presented for primary care on selected days and gave informed consent. Of these, 431 and 284 patients completed follow-up interviews at 1 year and 2 years, respectively. The main outcome measures included depression diagnosis, and measures assessing selected components of executive functions: the initiation-perseveration subscale of the Mattis Dementia Rating Scale, Trail Making tests A and B, and D Trails (Trails B time minus Trails A time). RESULTS: No cognitive measure was significantly independently associated with depression diagnosis concurrently or in 1-year lagged outcomes. A diagnosis of depression was independently associated with concurrent poorer Trails B time and with both Trails B and D Trails times in 1-year lagged models. In path analyses testing 2-year competing dynamic models, no baseline executive function measure predicted the score on the Hamilton Depression Rating Scale (HAM-D), but HAM-D score independently predicted poorer Trails B and D Trails times. Overall medical burden also independently predicted both depressive and cognitive outcomes, but cerebrovascular risk factors only predicted Trails B time. CONCLUSIONS: Older persons with depression are at risk of subsequent decline in at least some aspects of executive functioning. The study's findings leave open the possibility that either neurobiological or psychosocial factors play prominent roles in the mechanisms underlying the course of geriatric depression.

The clinical significance of subsyndromal depression in older primary care patients.

OBJECTIVE: Many seniors experience depressive symptoms not meeting standard diagnostic criteria. The authors sought to examine the clinical correlates of older primary care patients with "subsyndromal depression" (SSD), hypothesizing that SSD subjects have greater symptoms and functional impairment than nondepressed patients, but not as severe as those with major or minor depression, and to explore the characteristics of subjects captured by three different definitions of SSD used in prior published work. METHODS: The authors conducted a cross-sectional case comparison study that enrolled 662 primary care patients age >or=65 years. Outcomes were validated measures of psychopathology, medical illness burden, and functional status. RESULTS: All three SSD groups captured patients with greater symptoms and functional impairment than the nondepressed group. SSD subjects were as ill as those with minor or major depression on some measures (e.g., medical burden). Each SSD group definition captured some subjects unique to that group. CONCLUSIONS: Subsyndromal depression is common and associated with symptoms or impairments of clinical importance. Sole reliance on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition definitions of major or minor depression omit a substantial proportion of seniors with clinically significant depressive symptoms. Longitudinal study is needed to help clinicians identify those at greatest risk for poor outcomes, while researchers testing mechanistic models should include patients with SSD to determine whether they share pathogenetic underpinnings with more severe mood disorders.

Working with families in palliative care: one size does not fit all.

Comprehensive palliative care requires that family concerns are understood and addressed. Yet medical professionals frequently lack formal training in family systems concepts and, therefore, may be unprepared to engage in family-inclusive approaches to treatment. In order to address this problem, we selectively review the literature on working with families in end-of-life settings and offer specific recommendations for involving families as collaborators in the care process. Based on existing theory regarding the development of family communication styles and problem-solving abilities, we propose a tentative framework for understanding and responding to a range of common family dynamics encountered in palliative care and hospice settings. In light of the lack of empirical studies in this area, we conclude with recommendations for future research.

Cerebrovascular risk factors, executive dysfunction, and depression in older primary care patients.

OBJECTIVE: "Executive" cognitive functions may be of particular clinical importance in geriatric depression and may reflect underlying cerebrovascular disease. This study examined the associations of selected components of executive function with cerebrovascular risk factors, depression, and overall functional status. METHOD: Study measures were completed on 448 primary care patients aged>or=65 years based on patient interviews and medical chart review. Multiple regression techniques determined the presence of specified independent associations. RESULTS: Some but not all study hypotheses were confirmed. Cerebrovascular risk factors were associated with major depression and with some cognitive measures, but their associations with depression and with the most specific measures of executive function were limited and not independent of overall medical burden. Measures of initiation-perseveration and mental set shifting were associated with overall functional disability; these cognitive measures were not associated with depression diagnosis, or with depressive symptoms when also covarying medical burden or excluding patients with dementia. CONCLUSIONS: Clinicians should be aware of the potential functional significance of these components of cognition. Longitudinal risk factor studies and complementary techniques such as neuroimaging may help identify pathogenetically distinct subgroups of later-life depression that might respond preferentially to specific interventions.

Depression, perceived family criticism, and functional status among older, primary-care patients.

OBJECTIVE: Relatively little research has examined the role of family factors in later-life depression, particularly in the broad range of depressive conditions seen in primary care. Authors tested the hypotheses that 1) perceived family criticism is independently associated with depression, 2) that family criticism and depression are independently associated with functional disability, and 3) that perceived family criticism moderates the association between depression and functional disability. METHODS: This cross-sectional study recruited 379 adults age > or =65 years from primary-care practices. Study measures included the Structured Clinical Interview for DSM-IV, the Hamilton Rating Scale for Depression, the Family Emotional Involvement and Criticism Scale, and several measures of functional disability. Multiple regression determined independent associations, and a multiplicative interaction term tested the moderator model of the third hypothesis. RESULTS: Perceived family criticism was independently associated with depression diagnosis and depressive symptoms. Depression diagnosis, depressive symptoms, and perceived family criticism were each independently associated with functional status. Perceived family criticism did not moderate the association between depressive symptoms and functional status in the overall study group, although it did moderate the association between depression diagnosis and instrumental activities of daily living when only early-onset depressed patients were included. CONCLUSIONS: Authors confirmed the first and second hypotheses; however data did not support the third hypothesis. These results provide support for clinicians to attend to quality of primary family relationships and perceived criticism in depressed older adults and for researchers to consider aspects of family functioning as covariates or potential targets for intervention studies.