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

Abstract

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

Fig 1.

CONSORT diagram. (*)Reasons for ineligibility: language barrier (n = 10), benign disease (n = 6), previous HCT (n = 15), clinician refusal (n = 2), participation in another supportive care trial (n = 8), transplant aborted within 24 h of admission (n = 6), combined solid organ and hematopoietic stem-cell transplant (n = 3), primarily outpatient transplant (n = 6).

Fig 2.

Symptom burden as a mediator of intervention effects on 6-month psychological outcomes. (A) Symptom burden during hematopoietic stem-cell transplant (HCT) hospitalization mediates the effect of the palliative care intervention on depression symptoms at 6 months post-transplant. Models control for baseline criterion scores. (B) Symptom burden during HCT hospitalization mediates the effect of the palliative care intervention on post-traumatic stress disorder (PTSD) symptoms at 6 months post-transplant; models control for baseline criterion scores. PHQ-9, Patient Hospital Questionnaire 9; SE, standard error.

Fig 3.

Anxiety symptoms as a mediator of intervention effects on 6-month psychological outcomes. (A) Anxiety symptoms during hematopoietic stem-cell transplant (HCT) hospitalization mediate the effect of the palliative care intervention on depression symptoms at 6 months post-transplant: models control for baseline criterion scores. (B) Anxiety symptoms during HCT hospitalization mediate the effect of the palliative care intervention on post-traumatic stress disorder (PTSD) symptoms at 6 months post-transplant: models control for baseline criterion scores. PHQ-9, Patient Hospital Questionnaire 9; SE, standard error.