Friday, 21 August 2020

The Effect of Depression on Self-Care Maintenance in Lung Transplant Recipients

The Effect of Depression on Self-Care Maintenance in Lung Transplant Recipients 

Carmen Tung

High Acuity Registered Nurse,
Vancouver General Hospital,
British Columbia, Canada

Commentary on Iovino, P., De Maria, M., Matarese, M., Vellone, E., Ausili, D., & Riegel, B. (2020). Depression and self‐care in older adults with multiple chronic conditions: A multivariate analysis. Journal of Advanced Nursing, 76 (7), pp. 1668-1678.

Having worked with the lung transplant team at Vancouver General Hospital for most of my career, I wanted to integrate my clinical experiences with the recent literature on self-care maintenance (SCM) to recommend ways to improve our posttransplant education program.  To me, SCM is a vital first step to maintaining a patient’s quality of life.  When properly executed, SCM helps our transplant recipients reduce their risk for complications, decreases the rate of hospital readmission, and most importantly, enables these individuals to live richer lives than was possible prior to transplant.  The role of SCM has become particularly evident during the COVID-19 pandemic, where access to resources has been limited and patients have been managing more of their own care. 

Living with an organ transplant is a complex chronic condition, especially since many individuals find themselves trading one chronic disease for another.  At our site, patients require a lung transplant because they have underlying chronic obstructive pulmonary disease, interstitial lung disease, pulmonary hypertension, or cystic fibrosis.  After transplant, many unfortunately develop secondary chronic diseases, such as diabetes mellitus and Chronic Lung Allograft Dysfunction (CLAD).  While I agree with Iovino et al. (2020) that having multiple chronic conditions can make self-care difficult, I also believe that my population is unique because many of these patients have already practiced SCM for years prior to transplant.  As such, they bring with them a wealth of knowledge and experience.  What they require from health care providers is education, access to resources, and solutions to barriers so that they can engage in new SCM skills tailored for the posttransplant lifestyle. 

Using the definition proposed in Riegel et al. (2012), SCM includes the actions that preserve physical and emotional health.  In the context of lung transplantation, this includes smoking cessation, maintaining a healthy weight, engaging in healthy dietary and exercise habits, and most importantly, adhering to the antirejection medication regimen.  Based on my clinical experiences, depression is a major obstacle that limits SCM in the posttransplant population.  Similar findings are reported in the current literature.  Notably, Chu et al. (2020) found that up to 30% of transplant recipients experienced symptoms of major depressive disorder within two years of transplant.  When left untreated, depression can lead to medication nonadherence, which remains the biggest risk factor for CLAD, rehospitalization, and death (Costa et al., 2017).  I was thrilled to learn that the rigorous study published by Iovino et al. (2020), who conducted their investigation on individuals similar to my population, also came to the same conclusion and provided concrete suggestions to remedy this problem. 

Iovino et al. (2020) discovered that 65.6% of their patients with multiple chronic illnesses (N = 366) have mild to very severe depression, and even those who suffered from mild depression exhibited impaired SCM behaviours.  Based on these findings, Iovino et al. (2020) recommended systematic screening for depression in adults with multiple comorbidities and prioritizing the assessment of SCM behaviours.  We currently assess for depression prior to transplant, but not again unless a clinician detects symptoms during follow-up visits.  As such, I would like to conduct a similar study at our site to confirm that depression predominantly affects SCM.  If I discover similar findings, I would propose the use of a valid and reliable psychometric scale, such as the 9-Item Patient Health Questionnaire used by Iovino et al. (2020), to screen routinely for depression during posttransplant clinic visits, as well as during all hospital readmissions, especially if the reason for admission is medication nonadherence.  We currently test the blood serum level of the antirejection medication Tacrolimus at each posttransplant encounter.  This level is an established proxy for medication nonadherence and could serve as additional evidence that depression is linked to problems in this area of self-care (Chu et al., 2020).  Hopefully, with regular screening, we can detect depression early and provide interventions to help patients engage in conducive SCM behaviours.

I was surprised that Iovino et al. (2020) did not find an association between depression and the other two components of self-care.  In terms of self-care monitoring, the authors suggested that caregivers might have assisted patients with these tasks and thus masked the effects of depression.  I think this is a valid point and merits further investigation, especially since self-care monitoring is imperative to our population.  Specifically, a criterion for discharge is that our patients can monitor their vital signs, weight, spirometry, and blood glucose level daily without assistance from their support persons.  In terms of self-care management, we teach our patients how to recognize the signs and symptoms of infection and rejection, and how to respond to abnormal changes in any of their monitoring parameters.  Many of our interventions involve carrying out a predetermined action plan, such as self-administering insulin or notifying the transplant clinic of rapid weight gain.  It is crucial that our patients can perform these tasks independently, especially now during the COVID-19 pandemic.  To put things into perspective, geographically distant patients have been experiencing delays when trying to fly to our site.  For others, hospitalization poses a significant financial burden and these patients prefer to manage their health in the community.

In summary, Iovino et al. (2020) found that many individuals with multiple chronic conditions suffer from depression, and even those with mild symptoms showed deficits in SCM.  As such, the authors recommend routine depression screening.  In terms of my population, this translates to depression screening at posttransplant visits and upon hospital readmissions, and analyzing the results along with antirejection drug serum levels to detect for medication nonadherence.  In the future, I would like to investigate the relationship between depression and self-care monitoring and management while controlling for caregiver support.


Iovino, P., De Maria, M., Matarese, M., Vellone, E., Ausili, D., & Riegel, B. (2020). Depression and self‐care in older adults with multiple chronic conditions: A multivariate analysis. Journal of Advanced Nursing, 76 (7), pp. 1668-1678.

Chu, M.C., Smith, P.J., Reynolds, J.M., Palmer, S.M., Snyder, L.D., Gray, A.L., & Blumenthal, J.A. (2020). Depression, Immunosuppressant Levels, and Clinical Outcomes in Postlung Transplant Recipients. International Journal of Psychiatry in Medicine, pp. 1-16.

Costa, J., Benvenuto, L.J. & Sonett, J.R. (2017). Long-term outcomes and management of lung transplant recipients. Best Practice & Research Clinical Anaesthesiology, 31 (2), pp. 285-297.

Riegel, B., Jaarsma, T., & Stromberg, A. (2012). A middle-range theory of self-care of chronic illness. Advances in Nursing Science, 35 (3), pp. 194–204.

Editorial note: entries to JAN interactive are not reviewed and are published at the discretion of the Editor-in-Chief and may be subject to editing or removal by Wiley. We welcome replies, rejoinders, comments and debate on all entries provided they are not offensive or personal.

Friday, 7 August 2020

Monday, 3 August 2020

Effectiveness of executive function training on mental set shifting: one study reported across two papers or two trials with the same registration number?

Dear Editor
I write to highlight potential issues with the reporting of the randomised controlled trial by Chiu et al., (2018) that was published in the Journal of Advanced Nursing.

Our group have undertaken a series of reviews that have determined nursing trials compliance with ICMJE (De Angelis et al., 2004) requirement for prospective registration (Gray et al., 2017, 2019). Consistently, nursing has done poorly and has one of the lowest rates of trial registration of any clinical discipline (Gray, Brown, et al., 2019; Gray et al., 2017; Gray, Gray, et al., 2019). For example, In a review of the 151 nursing science trials published in 2017, just 17 (11%) were prospectively registered (Gray et al., 2019). The Journal of Advanced Nursing editorial team has taken the issue of prospective registration seriously and we are aware that they have put in place policies and procedures to ensure that the trials they publish are appropriately registered.

One of the practices that trial registration is intended to prevent is selective outcome reporting, where authors only publish a subset of the outcomes measured in order to inflate the magnitude of the treatment effect (Chan et al., 2004). In our previous reviews, we have not reconciled registration entries with published manuscripts to determine if there was any evidence of selective outcome reporting; this has been an acknowledged limitation of our methodology (Gray et al., 2019). We are in the process of completing our second yearly review of trial registration in nursing science (studies published in 2018) and have extended our methodology to address this deficit. Our review has identified a number of discrepancies between what authors have stated in the trial registry entry and reported in the published manuscript. We feel it is incumbent upon us to alert Journal editors about the discrepancies we have observed.

One of the trials included in our review was published in the Journal of Advanced Nursing and authored by Chiu et al., (2018). Several issues relate to this (Chiu et al., 2018) and another – seemingly related – trial by the same group (Kao et al., 2018), published in the International Journal of Nursing Studies (IJNS) and also included in our review. We have written to the IJNS separately about this paper.

Chiu et al., (2018) report a randomised controlled trial of 24 sessions of Executive Function Training on mental set shifting (determined using the Wisconsin Card Sorting Test) in healthy adults aged 65 years or older. The authors concluded that executive function training might be an effective preventative strategy in older adults. When we reconciled the manuscript with the registry entry (Chi-CTR-IOR-14005490), we noted that the authors were vague in their description of the intervention under investigation (described as cognitive training) and primary outcome (cognitive function). In our view, this apparent inconsistency warranted further investigation. We used the trial registration number to search (using Google) for any related publications (such as a trial protocol). A second paper was identified using the same trial registration number and published in BMC Geriatrics (Chan et al., 2019). In this paper, Chan et al., (2019) report the effect of 24 sessions of Interactive Cognitive-Motor Training on eye-hand coordination in older adults. According to the authors, there were no differences between the groups against the primary outcome at the end of the trial.  Our initial thought was that the authors were reporting a single trial across multiple papers (so-called salami-slicing) (Gray & Baker, 2016). This does not seem to be the case: the interventions described in the two papers seem entirely different. In the JAN paper, the authors state that that the Executive Function Training Group “…underwent process-based training using the Chinese version of the Rehacom computer training software (Hasomed GmbH, Magdeburg, Germany). Rehacom is a set of cognitive training software modules that have been proven effective by empirical research for improving the cognitive functions of older adults, including healthy older adults and patients with head injury, stroke and Alzheimer disease…” [sic] (Chiu et al., 2018). The interactive cognitive-motor training (ICMT) intervention in the BMC Geriatrics paper is described as follows “ICMT was performed on the Hot Plus interactive health service system. When using the system, the participants received information visually or acoustically and performed suitable physical responses based on their judgment. Through feedback, coordination between the brain and body can be improved to adjust responses” [sic] (Chan et al., 2019). Outcome measures in the two papers are also different. Mental set-shifting, working memory and inhibition were reported in the JAN paper (Chiu et al., 2018), and visual-motor integration, visual perception, motor coordination and cognitive function in the BMC Geriatrics manuscript (Chan et al., 2019). It seems that, apart from the trial registration number, the papers are reporting different studies. One possible explanation might therefore be that the authors reported the wrong registration number in one of the manuscripts. However, we checked the ethics committee reference number (201312037) which is the same in both papers. And both studies involved 62 participants. The demographic characteristics of the control groups in both papers are also essentially identical; mean age, MMSE score, gender, educational level is precisely the same (to two decimal places). However, the demographic profile of subjects in the experimental group subtly differs between the two studies.

The confusion deepens when a third – seemingly related paper – was reported in the IJNS is considered (Kao et al., 2018). The manuscript also reports a trial of interactive cognitive-motor training in 62 older adults. The primary outcome in this trial was gait performance. Although the Kao et al., (2018) trial has a different trial registration number (ChiCTR-IOR-17013812) to that reported in the Chan et al., (2019) paper (Chi-CTR-IOR-14005490), the demographic profile of participants in both papers match. We have written to the editors of the IJNS about our specific concerns with the paper they published.

In summary, we are unclear if the authors have reported a single trial of the same intervention that is reported across multiple papers. If this is the case the authors need to explain why the interventions are apparently different. Alternatively, the authors may have reported two separate trials and inadvertently used the same registration number. If this is the case, the authors need to explain why the demographic characteristics of control participants are identical in both studies. There may be a justification for the observed discrepancies that we have not considered.  We look forward to a response from the study authors.

Professor Richard Gray PhD
Research Focus Area Director
La Trobe University
Melbourne, VIC 3086