Laudenslager et al, Supplemental Information
A randomized control trial of a psychosocial intervention for caregivers of allogeneic
hematopoietic stem cell transplant patients: Effects on distress
Supplemental Information
Mark L. Laudenslager, PhD.,1 Teri L. Simoneau, PhD.,1
Kristin Kilbourn, PhD.,2 Crystal Natvig, BS.,1 Sam Philips, BS.,1
Janet Spradley, MSW.,3,4 Patrick Benitez, BS.,1
Peter McSweeney, MB Ch.B.,3,4 & Susan K. Mikulich-Gilbertson, PhD.1
1
University of Colorado Denver Anschutz Medical Campus
Department of Psychiatry
Aurora Colorado, 80045
2Univerity
of Colorado Denver
Department of Psychology
Denver, Colorado, 80217
3Presbyterian/St.
Luke’s Medical Center
Denver, CO 80218
4Colorado
Blood Cancer Institute
Denver, CO 80218
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Non-Caregiving Control Participants
There are no widely accepted norms for salivary cortisol and DHEA as well as natural
cytotoxicity available so we obtained a small non-caregiving control group for comparison
purposes. Healthy (by their report) non-caregiving control participants (n=32) were recruited by
campus email announcements and word of mouth in the community. Compared to the
caregivers, the control participants were younger (Mean = 43.5 years, SD = 12.4 years), of
similar sex distribution (81% female), higher education (91% college graduates), and racially
more diverse than caregivers as indicated in Supplemental Table A. Income did not differ
significantly from randomized caregivers (Table A). Biomarker means and 95% CI for noncaregiving controls and caregivers by randomization at baseline are indicated in Supplemental
Table B.
Methods Biomarker outcomes
The primary physiological outcome was the salivary cortisol awakening response (CAR)
occurring following awakening and which has been associated with behavioral indications of
acute and chronic distress (1) including caregiving (2). Using a novel collection approach
described in detail elsewhere (3), saliva samples were collected at the time of questionnaire
completion on three consecutive days at awaking, +30 min. after awaking, prior to lunch, and 10
hr. after awaking at each study phase (Baseline and 1 and 3 months post-transplant). The CAR
was defined as the average change between waking and 30 min after awaking based on natural
log transformed values over the three days at each phase. For analysis, the CAR saliva
samples were included only if they were collected by subject report within + 7.5 min of 30 min
after awaking (3). Diurnal salivary DHEA (4) was determined from the same saliva collections.
Following natural log transformation of salivary cortisol and DHEA levels (3), the slope of the
diurnal decline was determined from three samples: awaking, before lunch, and 10 hr. after
awaking samples (omitting the +30 min sample). The slope of the diurnal decline between
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awaking and 10 hr. later was determined as well as area under the curve with respect to ground
for both cortisol and DHEA since they associate with health outcomes (5) as well as short term
challenges (6). The area under the curve with respect to ground (AUCg) was computed using
the trapezoid method across mean levels noted at the three times of collection for each steroid
at each phase (7).
At baseline and one and three months post-transplant, blood was also drawn from the
caregiver during their patient’s clinic visit between 0700 and 1000 hr. for biomarker assays
which included natural cytotoxicity (8) reported as lytic units/NK cell (9). Plasma CRP and IL-6
were assessed by high sensitivity EIA (10) at baseline and 3 months. Secondary physiological
outcomes were not normally distributed but natural log transformation prior to analysis
normalized all distributions except DHEA.
Identical to psychological outcomes, caregiver physiological outcomes were
analyzed by mixed model analyses of covariance (ANCOVA) using Satterthwaite
approximation for degrees of freedom providing group estimates at each month with
fixed effects of intervention group (PEPRR, TAU), month (baseline, month1 and month
3), and their interaction while co-varying for caregiver age because older age is
associated with greater resilience in response to challenge (11). An unstructured
covariance structure was assumed for repeated measures (12). To provide some
protection for multiple comparisons (13), group effects were tested at month 3 only if the
omnibus test of the global null hypothesis (i.e. means for each group by month
combination were equal) was rejected. Effect Sizes (ESs) at month 3 were calculated as
(MTAU - MPEPRR)/SD, where MTAU and MPEPRR represents adjusted means of TAU
and PEPRR respectively at month 3 for outcomes and standard deviation (SD) was
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computed as the square root of estimated variance of each outcome at month 3.
Comparisons utilized a two-tailed, 0.05 significance level.
Results
Baseline Comparisons to Non-Caregiving Controls
Based on ANOVAs with planned post hoc comparisons (only if the overall effect of the
three groups was significant), all caregiver biomarkers for the TAU and PEPRR groups did not
differ from non-caregiving controls at baseline as indicated in Supplemental Table B. However
there was a significant effect of group for psychological outcomes when compared across
groups as expected. Depression (CESD) and Anxiety (STAI-State) were significantly elevated
in the caregivers and the score on the PSS similarly approached significance when compared to
these non-caregiving controls as show in Supplemental Table B.
Intervention Impact on Biomarkers
For baseline and 1 and 3 month collection times, 95, 95, and 80% respectfully, of blood
samples and 96, 98, and 90% of the saliva samples were available for processing from
caregivers remaining in the study. Supplemental Table C presents model estimates (Mean, 95%
CI; presented as natural logs) at baseline and at one and three months for PEPRR and TAU for
all primary and secondary physiological outcomes based on mixed model analyses of
covariance (ANCOVAs). Estimated effects sizes (ES) are only reported in Table C for month 3
comparisons when interactions were significant.
There was no effect of the PEPRR intervention on the primary biomarker outcome, CAR,
as indicated in Supplemental Table C. A similar lack of effect of the intervention was also noted
for all secondary biomarker outcomes including lytic units, the awakening level of cortisol and
DHEA, the slope of the decline in salivary cortisol and DHEA, and CRP. There was only a
single significant group by month interaction for biomarkers for the DHEA AUC (F(2,105)= 4.56; p
=0.013) such that PEPRR exceeded TAU slightly but non-significantly at baseline and TAU
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exceeded PEPRR slightly but non-significantly at three months. We view this as an anomalous
observation since neither of the other approaches (awaking level or slope) to characterization of
DHEA were significant.
For plasma IL-6, there was main effect of group (F(1,139) = 4.93, p=0.03) and plasma IL-6
increased significantly from baseline to month three (F(1,104) = 4.68, p=.03) in the absence of a
significant interaction suggesting no significant effect of the intervention on IL-6. Of note,
plasma levels predicted by the model for IL-6 were low and did not exceed 1.0 pg/ml after back
transformation.
Summary Biomarkers
For this group of 148 HSCT caregivers, we failed to establish a difference from noncaregiving controls at the time of transplant for both primary and secondary biomarkers.
However consistent with the challenges of caregiving for an Allo-HSCT patient, these caregivers
revealed significantly higher measures of depression and anxiety and a trend to greater
perceived stress compared to this group of non-caregiving controls. Biomarker observations
were consistent with caregiver subjective reports of their health falling in the normal range on
the SF36 health scores for their age group. Not surprisingly in the absence of a disturbance in
these physiological systems during the initial 100 days post-transplant, the intervention was
without an effect in spite of the presence of significant effects on the psychological outcomes.
While these caregivers have experienced numerous challenges associated with the health of
their patient prior to the transplant itself, the overall duration of caregiving is shorter when
compared to longer term caregivers of patients with cognitive disabilities for whom many studies
of biomarkers have been targeted (10, 14). An allogeneic HSCT has the promise of
improvement for patients whereas dementia patients are faced with prolonged cognitive decline
which may further contribute to their health discrepancy. Finally in order to serve in the role of
caregiver for these patients, the caregivers are pre-screened prior to transplant to ensure their
fitness for the upcoming challenge and perhaps better overall health at the outset.
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Supplemental Table A. Demographic Characteristics for Caregivers & Non-Caregiving Controls
a
Characteristics
Age, mean (CI), y
Sex
Female
Male
Race, n (%)
Caucasian
Other
Education, n (%)
College or above
Annual income $, n (%)
< 25,000
25,000-44,999
45,000-64,999
> 65,000
a
b
Caregivers
(n = 148)
53.5 (51.5, 55.5)
Non-Caregiving
b
Significance
(n = 32)
43.5 (39.0, 47.9) p=.00005
112 (75.7)
35 (23.6)
26 (81.3)
6 (18.8) p=.54
133 (89.9)
12 (8.2)
23 (71.9)
9 (28.1) p=.002
117 (79.1)
29 (90.6) p=.05
24 (16.2)
29 (19.6)
26 (17.6)
60 (40.5)
6 (18.8)
13 (40.6)
5 (15.6)
8 (25.0) p=.07
Caregiver information was not available for the following variables: age (n = 1), sex (n = 1), ethnicity (n = 3),
education (n = 4), annual income (n = 9)
Significance based on independent t-test or Pearson's Chi-square test as appropriate.
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Supplemental Table B. Baseline non-Transformed Means and 95% CIs for Caregivers & Non-Caregiving Controls
Mean (95% CI)a
Characteristics
PRIMARY OUTCOME
Cortisol Awakening Response
(nmol/L)
SECONDARY OUTCOMES
Slope
Cortisol (nmol/L)/hour
DHEA (nmol/L)/hour
Area Under the Curve
Cortisol (nmol/L)*hour
DHEA (nmol/L)*hour
% Lysis per NK+ Cells
Interleukin-6 (pg/mL)
C-reactive protein (mg/L)
TAU
PEPRR
NON- CAREGIVERS
(n = 74)
(n = 74)
(n = 32)
Significance b
0.74 (-1.40, 2.88)
1.86 (.56, 3.17)
2.16 (.25, 4.08)
p=0.815
-0.61 (-1.04, -.19)
-0.08 (-.10, -.06)
-0.55 (-.71, -.39)
-0.11 (-.13, -.08)
-0.23 (-.55, .09)
-0.11 (-.14, -.09)
p=0.428
p=0.672
57.64
5.19
0.54
1.08
2.77
47.56
6.82
0.54
0.77
3.18
45.32
6.30
0.52
0.96
1.86
p=0.471
p=0.150
p=0.999
p=0.324
p=0.317
(42.48, 72.79)
(4.24, 6.13)
(.42, .66)
(.75, 1.41)
(1.80, 3.73)
(32.13, 62.99)
(5.35, 8.29)
(.29, .79)
(.61, .92)
(2.07, 4.28)
(40.33, 50.32)
(4.96, 7.64)
(.37, .66)
(.28, 1.64)
(1.15, 2.57)
PSYCHOLOGICAL OUTCOMESc
a
PSS
23.11 (21.00, 25.23)
23.10 (21.21, 24.99)
19.38 (16.81, 21.94)
p=0.071d
CESD
15.52 (13.19, 17.85)
14.93 (12.69, 17.18)
7.88 (5.79, 9.96)
STAI-STATE
42.08 (39.40, 44.77)
39.16 (36.85, 41.48)
32.88 (29.35, 36.40)
p=0.0003d
p=0.0003d
Information was not available for TAU for the following variables: Cortisol Awakening Response (n = 15), Slope: Cortisol (n = 12), Slope: DHEA (n = 16), Area Under the Curve:
Cortisol (n = 16), Area Under the Curve: DHEA (n = 16), % Lysis per NK+ Cells (n = 8), Interleukin-6 (n = 11) and C-reactive protein (n = 7), PSS (n = 4), CESD (n = 5),
STAI-STATE (n = 3). Information was not available for PEPRR for the following variables: Cortisol Awakening Response (n = 15), Slope: Cortisol (n = 12), Slope: DHEA (n = 15),
Area Under the Curve: Cortisol (n = 14), Area Under the Curve: DHEA (n = 14), % Lysis per NK+ Cells (n = 4), Interleukin-6 (n = 4) and C-reactive protein (n = 6), PSS (n = 2),
CESD (n = 2), STAI-STATE (n = 1). Information was not available for Controls for the following variables: Cortisol Awakening Response (n = 2), Slope: Cortisol (n = 1), Slope:
b
DHEA (n = 1), Area Under the Curve: Cortisol (n = 2), Area Under the Curve: DHEA (n = 2), % Lysis per NK+ Cells (n = 2), Interleukin-6 (n = 2) and C-reactive protein (n = 2).
Significance based on ANOVA of natural log transformed values
c
Abbreviations: PSS, Perceived Stress Scale; CESD, Center for Epidemiologic Studies Depression; STAI-State, State-Trait Anxiety Inventory-State.
d
Significance based on ANOVA of non-transformed values
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Supplemental Table C. Estimates (as Natural Log Transforms) and Test Results from Mixed Model Analyses of Covariance for Primary and Secondary Physiological Outcomes
Outcome
Interventation
Mean (95% CI)
Mean (95% CI)
Mean (95% CI)
Model Tests
Model Tests
Group
Baseline
Month 1
Month 3
Main Effects
Interaction
PEPRR
0.25 (0.12, 0.37)
0.36 (0.20, 0.52)
0.52 (0.34, 0.70)
Group: F1,111 =0.32; p =0.57
Group*Month:
TAU
0.35 (0.23, 0.48)
0.33 (0.18, 0.48)
0.33 (0.15, 0.51)
Month: F2,107 =1.39; p =0.25
F2,107 = 1.97; p =0.15
PEPRR
1.84 (1.67, 2.02)
1.95 (1.73, 2.16)
1.62 (1.36, 1.88)
Group: F1,139 =1.64; p =0.20
Group*Month:
TAU
1.98 (1.80, 2.16)
1.99 (1.77, 2.21)
1.89 (1.64, 2.15)
Month: F2,117 =2.58; p =0.08
F2,117 = 0.75; p =0.48
PEPRR
0.078 (-0.11, 0.26)
0.033 (-0.16, 0.22)
0.180 (-0.04, 0.39)
Group: F1,135 =0.11; p =0.74
Group*Month:
TAU
0.021 (-0.16, 0.21)
0.068 (-0.12, 0.26)
0.079 (-0.13, 0.29)
Month: F2,108 =0.82; p =0.44
F2,108 = 0.58; p =0.56
PEPRR
-0.12 (-0.16, -0.09)
-0.12 (-0.15, -0.08)
-0.11 (-0.14, -0.09)
Group: F1,117 =0.08; p =0.78
Group*Month:
TAU
-0.12 (-0.15, -0.08)
-0.10 (-0.13, -0.07)
-0.12 (-0.15, -0.10)
Month: F2,102 =0.26; p =0.77
F2,102 = 0.61; p =0.55
PEPRR
-0.13 (-0.15, -0.10)
-0.15 (-0.18, -0.12)
-0.17 (-0.18, -0.15)
Group: F1,98 =3.21; p =0.08
Group*Month:
TAU
-0.11 (-0.14, -0.09)
-0.13 (-0.16, -0.10)
-0.13 (-0.15, -0.11)
Month: F2,69.1 =5.38; p =0.007
F2,69.1 = 1.24; p =0.30
Month 3 Groupb
Comparison
Effect Size
PRIMARY OUTCOME
CAR ln(nmol/L)
SECONDARY OUTCOMES
Wake Level ln(nmol/L)
Cortisol
DHEA
Slope ln[(nmol/L)/hour]a
Cortisol
DHEA
Area Under the Curve ln[(nmol/L)*hour]
PEPRR
Cortisol
DHEA
ln(% Lysis/NK+ Cell)
IL6 ln(pg/mL)
3.65 (3.51, 3.79)
3.80 (3.62, 3.98)
3.68 (3.45, 3.91)
Group: F1,125 =0.82; p =0.37
Group*Month:
TAU
3.85 (3.71, 3.99)
3.78 (3.61, 3.96)
3.77 (3.55, 3.99)
Month: F2,99.3 =0.40; p =0.67
F2,99.3 = 0.40 p =0.67
PEPRR
1.64 (1.46, 1.81)
1.41 (1.23, 1.59)
1.35 (1.16, 1.54)
Group: F1,123 =0.16; p =0.69
Group*Month:
TAU
1.44 (1.26, 1.62)
1.52 (1.34, 1.70)
1.56 (1.37, 1.74)
Month: F2,105 =0.92; p =0.40
F2,105 = 4.56; p =0.013 ES=0.31
PEPRR
-1.07 (-1.29, -0.86)
-1.17 (-1.37, -0.97)
-1.27 (-1.49, -1.04)
Group: F1,139 =0.76; p =0.38
Group*Month:
TAU
-1.01 (-1.23, -0.78)
-1.09 (-1.28, -0.89)
-1.09 (-1.32, -0.86)
Month: F2,110 =1.41; p =0.25
F2,110 = 0.22 p =0.80
-0.45 (-0.65, -0.25)
Group: F1,139 =4.93; p =0.03
Group*Month:
-0.13 (-0.34, 0.07)
Month: F1,104 =4.68; p =0.03
F1,104 = 0.40; p =0.53
-0.10 (-0.50, 0.30)
Group: F1,139 =0.00; p =0.94
Group*Month:
Month: F1,88.1 =6.52; p =0.012
F1,88.1 = 1.30 p =0.26
PEPRR
TAU
CRP ln(mg/L)
PEPRR
-0.56 (-0.76, -0.37)
-0.33 (-0.54, -0.13)
0.27 (-0.06, 0.61)
TAU
a
b
0.18 (-0.16, 0.51)
Cortisol and DHEA slopes were calculated using wake, before lunch, and +10 hrs.
0.03 (-0.37, 0.43)
Month 3 group post hoc t-test comparison and corresponding estimated effect size (ES) when Group*Month interaction was significant.
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t99.4 =1.56; p=0.12