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Stress Management Intervention for Caregivers of Patients Undergoing Bone Marrow Transplant (BMT)

This study has been completed.
Sponsor:
Collaborator:
Information provided by (Responsible Party):
University of Colorado, Denver
ClinicalTrials.gov Identifier:
NCT00833898
First received: January 30, 2009
Last updated: October 31, 2013
Last verified: October 2013
  Purpose

RATIONALE: A stress management intervention may be more effective than usual care in improving quality of life in caregivers of patients undergoing bone marrow transplant.

PURPOSE: This randomized phase III trial is studying a stress management intervention for caregivers of patients undergoing bone marrow transplant.


Condition Intervention Phase
Hematopoietic/Lymphoid Cancer
Device: Paced respiration as part of PEPRR
Behavioral: PEPRR
Phase 3

Study Type: Interventional
Study Design: Allocation: Randomized
Endpoint Classification: Efficacy Study
Intervention Model: Parallel Assignment
Masking: Single Blind (Investigator)
Primary Purpose: Treatment
Official Title: Psychoeducation For BMT Caregivers: Biobehavioral Markers and Outcome

Resource links provided by NLM:


Further study details as provided by University of Colorado, Denver:

Primary Outcome Measures:
  • Behavioral - Stress level as measured by the Perceived Stress Scale (PSS) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    Caregiver stress will be assessed with the Perceived Stress Scale (PSS) (Cohen et al., 1983), identifying the degree to which situations in life are perceived as stressful. Items on the PSS measure the degree to which the subjects feel their lives are unpredictable, uncontrollable and overwhelming on a 5 point Likert scale. The shorter 10-item scale was validated in 2,387 respondents across demographic characteristics (i.e. age, gender, socioeconomic status, race) (Cohen, Kessler, & Gordon, 1995) with superior psychometric properties (reliability alpha of 0.84).

  • Physiological - Cortisol awakening response (CAR) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    Saliva will be collected using SPIT booklets containing four separate filter papers corresponding to collection times separated by waxed paper. Subjects will be asked to moisten a filter paper 1) immediately after waking, 2) 30 min later, 3) before lunch and 4) 10 hours after waking. They will be asked to collect these samples on three days typical for their schedules at each phase of the. They will indicate the time of each collection. Filters will dry in the booklet. Saliva samples will be aggregated across the three sampling days at each study phase to better reflect the typical pattern for each subject (see Smyth et al, 1997). The change from awakening to 30 minutes in cortisol (CAR) will be characterized by the change between waking and 30 min.


Secondary Outcome Measures:
  • Stress as measured by caregiver burden using the Caregiver Reaction Assessment (CRA) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    Burden may not shift with intervention. However we will include an accepted measure of caregiver burden, the Caregiver Reaction Assessment (CRA) developed by (Given et al., 1992) and highly recommended in a recent metanalysis (Deeken et al., 2003). The CRA includes 24 items scored on a 5 point Likert scale with subscales of esteem, family support, finances, schedule, and health. It has excellent test-retest reliability of .9 and responsiveness to change of .81. This reflects a convergent assessment of overall stress

  • Stress as measured by the Impact of Events Scale (IES) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    Caregiving for a cancer patient is also associated with posttraumatic stress (PTS)-like symptoms. We will assess BMT caregivers with the Impact of Events Scale (IES) (Horowitz, Wilner, & Alvarez, 1979), a widely accepted scale for evaluating intrusive thoughts regarding an event or situation. The scale consists of 15 items (7 measuring intrusive thoughts and 8 measuring avoidance) scored on a 5 point Likert Scale. Scores over 20 indicate significant levels of PTS-like symptoms. Scores on the IES decline with age in individuals following a natural disaster as indicated above, making age adjustments critical in analyses. The morning rise in salivary cortisol is blunted following trauma (Wessa et al., 2006). The IES will be anchored to the caregiving experience.

  • Depression measured by the Center for Epidemiological Studies Depression Scale (CESD) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    Depression scores are the most frequently measured dependent variables in caregiver research (Schulz et al., 2002). Subjects will complete the CES-D (Radloff, 1977), a measure developed for the general population with a long history of use in research (Fleming, Cook, Nelson, & Lai, 2005; Gaskin & Mitchell, 2005; Amirkhanyan & Wolf, 2003; Carter, 2002; Gallicchio, Siddiqi, Langenberg, & Baumgarten, 2002; Raveis, Karus, & Siegel, 1998; Dura, Haywood-Niler, & Kiecolt-Glaser, 1990; Glaser et al., 2001; Kiecolt-Glaser et al., 1987). The 20 item scale includes reference to sleep disruption, appetite disturbance, overall fatigue, and depressed affect. Scores range from 0-60 with scores over 16 viewed as reflecting significant depressive symptomatology. Test retest validity ranges from .51 to .67 over 2-8 weeks with an internal validity of .85 for a normal population (Radloff, 1977). This scale will also be used for monitoring caregiver mental health.

  • State Anxiety as Measured by the Spielberger State-Trait Anxiety Inventory (STAI) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    Subject anxiety will be assessed using the State/Trait Anxiety Inventory (STAI) (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). The STAI is a 40 item scale on which the subjects will indicate how they feel "right now" (state) and how they "generally feel" (trait) on a 4 point Likert scale. Internal consistency ranges from .89 to .91. The STAI has been used to effectively assess trait anxiety in caregiver populations (Claar et al., 2005; Raveis et al., 2006.)

  • Sleep as assessed by the Pittsburgh Sleep Quality Inventory (PSQI) total score [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    The PSQI is a widely used questionnaire (Berger et al., 2005) that provides acceptable reliability and validity with diagnostic sensitivity of 89.6% and specificity of 86.5% (Buysse et al., 1991; Buysse, Reynolds, III, Monk, Berman, & Kupfer, 1989). The PSQI provides information regarding sleep efficiency.

  • Physical scale via the Health Survey Version 2.0(SF-36P) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    SF-36 Health Survey Version 2.0 has extensive psychometric testing (Beusterien, Steinwald, & Ware, 1996; Ware, 2000; Ware, & Sherbourne, 1992). Subjects will respond to 32 items indicating extent of limitations in a number of physical activity domains (from walking to dressing oneself) to pain and general health. All items now appear in a common format unlike the earlier version with mixed response formats (Ware, 2000). The scale is highly reliable (> .85) and easily administered. Patients and caregivers will complete the SF-36 at each phase.

  • Total mood disturbance (TMD) score using the Profile of Mood States (POMS) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    Mood will be assessed using the POMS, a list of feelings that the patient will identify as experiencing on a five point Likert scale. Although it has six subscales (Tension, Anger, Vigor, Fatigue, Confusion, and Depression) we will use the total mood disturbance score (TMD). It has adequate internal consistency with test-retest reliability somewhat lower due to the sensitivity of the scale to mood changes. It been used in caregiver studies (Cunningham, et al, 1999; Hosaka et al., 2003; McNair et al., 1971; Miaskowski et al., 1997; Schumacher et al., 1993).

  • The slope of the diurnal decline (SlopeD) in salivary dehydroepiandrosterone (DHEA) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    The SlopeD has been noted to be affected by affective disorders such as depression. From diurnal saliva collections at each phase we will fit curves between 30 min after waking and 10 hours after waking to characterize the diurnal change in salivary DHEA.

  • Area under the curve for salivary cortisol (AUCc) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    The AUCc will be determined between 30 min after waking and 10 hours after waking from saliva samples collected using a special filter collection device applied in this study. This area will be an estimate of total cortisol released during this time period.

  • The slope of the diurnal decline in salivary Cortisol (SlopeC) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    The SlopeC has been noted to be affected by stressful experiences. From diurnal saliva collections at each phase we will fit curves between 30 min after waking and 10 hours after waking to characterize the diurnal change in salivary cortisol (SlopeC).

  • Area under the curve for salivary DHEA (AUCd) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    The AUCd will be determined between 30 min after waking and 10 hours after waking from saliva samples collected using a special filter collection device applied in this study. This area will be an estimate of total DHEA released during this time period.

  • Plasma inflammatory marker interleukin 1 beta (IL-1 beta) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    Inflammatory markers increase in association with stress. IL-1 beta is an inflammatory marker that will be determined in plasma using multiplex array technology.

  • Plasma inflammatory marker interleukin 6 (IL-6) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    Inflammatory markers increase in association with stress. IL-6 is an inflammatory marker that will be determined in plasma using multiplex array technology.

  • Plasma inflammatory marker interleukin 4 (IL-4) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    Inflammatory markers increase in association with stress. IL-4 is an anti inflammatory marker that will be determined in plasma using multiplex array technology.

  • Plasma inflammatory marker interleukin 10 (IL-10) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    Inflammatory markers increase in association with stress. IL-10 is an anti inflammatory marker that will be determined in plasma using multiplex array technology.

  • Plasma inflammatory marker tumor necrosis factor (TNF) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    Inflammatory markers increase in association with stress. TNF is an inflammatory marker that will be determined in plasma using multiplex array technology.

  • Plasma C-reactive protein (CRP) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    Plasma c-reactive (CRP) is an acute phase reactant that has been found to be predictive of cardiovascular disease. Is is also an inflammatory marker that will be assessed using high sensitivity CRP assays.

  • Mental scale via the Health Survey Version 2.0(SF-36M) [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    SF-36 Health Survey Version 2.0 has extensive psychometric testing (Beusterien, Steinwald, & Ware, 1996; Ware, 2000; Ware, & Sherbourne, 1992). Subjects will respond to 32 items indicating extent of limitations in a number of physical activity domains (from walking to dressing oneself) to pain and general health. All items now appear in a common format unlike the earlier version with mixed response formats (Ware, 2000). The scale is highly reliable (> .85) and easily administered. Patients and caregivers will complete the SF-36 at each phase.

  • Host defense assessed by natural killer (NK) cell cytotoxicity [ Time Frame: Baseline (prior to transplant), 1, 3, 6, 12 post transplant ] [ Designated as safety issue: No ]
    The activity of natural killer (NK) cells is modified by psychosocial and behavioral states (Cacioppo et al., 1998; Irwin et al., 1991; Kiecolt-Glaser et al., 1991; Kiecolt-Glaser, 1999; Kiecolt-Glaser, McGuire, Robles, et al., 2002a; Kiecolt-Glaser, McGuire, Robles, et al., 2002b). Natural cytotoxicity will be determined toward K562 target cell lines as previously described (Laudenslager et al., 1998; Scanlan, et al., 1995). Percent lysis at each effector to target ratio will be found from the median value of each triplicate determination and from which the percent lysis/NK + cell will be determined for 20% lysis (lytic units/NK+ cell).


Enrollment: 298
Study Start Date: November 2008
Study Completion Date: June 2013
Primary Completion Date: June 2013 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
No Intervention: Caregiver Control
Orientation class; laboratory biomarker analysis; questionnaire administration; survey administration; treatment as usual psychosocial care.
Experimental: Caregiver Intervention
Orientation class; laboratory biomarker analysis; questionnaire administration; survey administration; Psychoeducation Paced Respiration and Relaxation (PEPRR), which included one-on-one psychoeducation, stress management intervention, with paced respiration.
Device: Paced respiration as part of PEPRR
The FDA approved RESPeRATE™ is the size of a portable compact disk (CD) player with a visual display, an elastic belt-type respiratory sensor, and a set of headphones. During a relaxation session, the device analyzes respiratory pattern of the subject and creates a melody of pleasant tones selected by the subject (one for inhalation and one for exhalation). The subjects can observe a cartoon figure on the screen of the device that indicates their inhalation and exhalation. The subject synchronizes their breathing to these tones as the exhalation tone is gradually increased in duration with a target of less than 10 breaths/minute. Subjects were encouraged to use RESPeRATE 3-5 times a week for 20 minutes.
Other Name: RESPeRATE™
Behavioral: PEPRR
PEPRR consist of 8 sessions, each lasting approximately 60min. The first 4 sessions are weekly, followed by biweekly mtgs for the remaining 4 sessions. Sessions begin the week that the patient receives the transfusion of donor cells. Session 1-4 are conducted at the hospital where the patients receive their transplant. Once discharged from the hospital, sessions will be conducted at the outpatient BMT clinic to coincide with patients' post-transplant visits. Sessions are devoted to a separate topic with the goal of assisting the caregiver in development & application of various stress-mgmt techniques such as effective problem-solving, identifying & challenging cognitive distortions, relaxation techniques, coping skills training, effective use of social support & goal setting.
Other Names:
  • Psychoeducation & Paced Respiration/Relaxation
  • PEPRR

Detailed Description:

Specific Aims

  • Further validate a unique saliva collection device in a randomized controlled study of a psychoeducation, paced respiration, and relaxation (PEPRR) intervention for caregivers of patients undergoing bone marrow transplantation.
  • Evaluate the suitability of paced respiratory training using RESPeRATE™ for these caregivers.
  • Determine the efficacy of a PEPRR intervention on behavioral (stress level, mood and overall health) and physiological (neuroendocrine function, immune function, and sleep) outcomes of these caregivers.

OUTLINE: Caregivers are randomized to 1 of 2 groups.

  • Group I (treatment as usual [TAU]): Caregivers and patients attend a 2-hour orientation class that provides an overview of the transplant process, information regarding financial issues and resources that may be available to the patient and caregiver, a review of caregiver duties, dietary restrictions post-transplantation, a brief introduction to stress and stress management, and hands-on training of how to care for a central venous catheter. Patients also receive information in the form of a written manual that provides in-depth information about transplant, including how the transplant works, what to expect, caregiver duties, graft-vs-host disease, and when to contact medical staff for assistance. A voluntary 1-hour weekly caregiver support group is offered on the inpatient BMT unit.
  • Group II (psychoeducation, paced respiration, and relaxation [PEPRR]): Caregivers and patients attend a 2-hour orientation class identical to group I. Caregivers also participate in the PEPRR intervention comprising an individualized stress management component and educational component that addresses the psychosocial needs of the caregivers. It also provides self-care and adaptive coping skills. The stress management component addresses caregivers' perception of potential stressors (primary appraisal); perceived ability to control or manage the stressor (secondary appraisal); ability to exert control and cope with the stressor (coping effort); and ongoing evaluation of the stressor and their perceived ability of managing the stressor (reappraisal) and applies coping strategies such as relaxation, prioritizing, goal setting, pacing, and communicating needs. The PEPRR intervention consists of 8 sessions (4 weekly 60-minute sessions followed by 4 biweekly 60-minute sessions) that cover the 100-day period of caregiving post-transplantation. Caregivers also undergo paced respiratory (RESPeRATE™) training for 15 minutes once daily over 12 weeks that measures caregiver adherence and compliance to the relaxation program.

Caregivers and patients undergo psychosocial assessments at approximately 1-3 months prior to randomization and transplantation and again at 1, 3, 6, and 12 months after transplantation. Caregivers also complete questionnaires to assess their stress (PSS, CRA, and IES), mood (POMS, CES-D, and STAI), sleep (PSQI), and health (SF-36).

Caregivers undergo blood and saliva sample collection at baseline and periodically during study for biomarker analysis (e.g., neuroendocrine and immune markers). Caregivers wear an activity watch (actimeter) during each saliva sample collection period.

  Eligibility

Ages Eligible for Study:   18 Years and older
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   Yes
Criteria

Inclusion Criteria:

  • DISEASE CHARACTERISTICS (Meets all of the following criteria):

    • Patient undergoing allogeneic bone marrow transplantation (BMt)
    • Primary caregiver of a BMT patient
    • Has provided care for the patient for at least 50 days of the required 100 days of caregiving following transplant (e.g., 50% of the total time)
  • PATIENT CHARACTERISTICS:

    • Able to read and speak English
    • Has telephone access
    • No serious medical condition likely to influence immune and neuroendocrine parameters (caregiver)
    • Alcohol consumption limited to < 2 drinks/day (caregiver)
    • No history of a psychiatric illness unrelated to the experience as a caregiver within the past 18 months (caregiver)
    • No history of a psychiatric illness unrelated to the BMT within the past 18 months (patient)

Exclusion Criteria:

- PRIOR CONCURRENT THERAPY:

• No concurrent steroid medications (caregiver)

  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT00833898

Locations
United States, Colorado
University of Colorado Cancer Center at UC Health Sciences Center
Aurora, Colorado, United States, 80045
Presbyterian/St. Luke's Medical Center (PSLMC) - Denver Midtown
Denver, Colorado, United States, 80218
Sponsors and Collaborators
University of Colorado, Denver
Investigators
Principal Investigator: Mark Laudenslager, PhD University of Colorado, Denver
  More Information

Additional Information:
No publications provided by University of Colorado, Denver

Additional publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
Responsible Party: University of Colorado, Denver
ClinicalTrials.gov Identifier: NCT00833898     History of Changes
Other Study ID Numbers: 08-0303, 1R01CA126971-01A1
Study First Received: January 30, 2009
Last Updated: October 31, 2013
Health Authority: United States: Institutional Review Board

Keywords provided by University of Colorado, Denver:
depression
stress
caregiving
anxiety
psychoeducation intervention
psycho-oncology

ClinicalTrials.gov processed this record on November 20, 2014