Can Rumination-Focused Cognitive Behavioral Therapy Reduce the Risk of Cardio-vascular Disease? (RFCBT-I)

RFCBT I - Proof of Concept Study/Single Subject Design

Many people know that a poor diet, exercise, smoking, and alcohol use cause heart disease. However, a less known factor that increases the risk of heart disease is depression. In addition, heart disease can also make depression worse. Almost half of American adults have some form of heart disease. Patients with low income are at an even greater risk. The circular relation between depression and heart disease raises the question of whether or not there are factors that lead to both. Attacking a factor that affects both depression and heart disease could help prevent them both. One such factor is rumination which is when someone tends to have repeated negative thoughts that loop without end. This loop in turn tears and wears down the body over time, making the person be at risk for heart disease and depression. Rumination-Focused Cognitive Behavioral Therapy (RFCBT) is a tool that targets rumination and, by doing so, reduces the risk for depression. While research has shown RFCBT helps to reduce or stop the loop that leads to depression, this project will further look at the effect of RFCBT on measures of heart health persons with low income.

Study Overview

• Status: Recruiting
• Conditions: Blood Pressure; Depressive Symptoms; Rumination
• Intervention / Treatment: Behavioral: Rumination-Focused Cognitive Behavior Therapy

Detailed Description

Objectives Objective #1: Determine whether RFCBT will impact blood pressure as a biomarker of cardiovascular health. The investigators hypothesize that RFCBT will lead to an improvement in blood pressure.

Objective #2: Determine whether RFCBT will impact stress biomarkers of cardiovascular health. The investigators hypothesize that RF-CBT will lead to an improvement of salivary cortisol.

Objective #3: Determine whether RFCBT will impact inflammatory biomarkers of cardiovascular health. The investigators hypothesize that RF-CBT will lead to an improvement of salivary C-Reactive Protein (h-CRP), interleukin (IL-6), and tumor necrosis factor-alpha (TNF-α).

Objective #4: Determine the acceptability of RFCBT for individuals with low income. While the investigators cannot predict the themes that will be generated, the information will have implications for the use of RFCBT with individuals with low income.

Study Design/Methodology The investigators will use a multiple baseline design - a type of Single Case Experimental Design (SCED) and collect survey, interview, and biological (blood pressure & saliva) data. Because of the study design, all participants will receive Rumination-Focused Cognitive Behavioral Training (RFCBT); the study is not blinded, and no non-intervention control group is necessary. As participants will be selected non-randomly, they will be randomly assigned to a group or in other words after how many weeks of baseline phase they will perceive RFCBT using the random number generator in the statistics package R. That is, 1/3rd of the participants will participate in 5 baseline waves of data collection, each one week apart, before starting RFCBT, another 1/3rd of participants will participate in 6 baseline waves before starting RFCBT, and the final 1/3rd of participants will participate in 6 baseline waves before starting RFCBT. Thus, all participants will participate in 5 to 7 weekly baseline waves. Next, each participant will participate with their trainer in up to 18 50-minute meetings of RFCBT. In this time, each participant will participate in 6 to 9 waves of training data collection (one wave of data collection every 2 RFCBT meetings). After completion of the training, each participant will be followed for another 10 weeks during which they participate in 5 waves of follow-up data collection (one wave of data collection every 2 weeks). Thus, each participant participates in 28 to 36 weeks in the study and takes part in 16 to 21 waves of data collection.

The investigators plan to recruit 27 adults with low income who have an elevated Response Style Questionnaire (RSQ)-Brooding score (>= 11), Patient Health Questionnaire (PHQ)-9 score (10-20), and blood pressure (systolic blood pressure [SBP]/ diastolic blood pressure [DBP]: >= 120 and/or 80) - that Have A Heart Clinic personnel administers regularly - and speak fluent English. There are no other exclusion criteria including any medical or psychological treatment. Patients who fulfill the above listed inclusion criteria are referred by Have A Heart Clinic personnel to the research team.

At each wave of data collection, the investigators will administer all the surveys listed in this report. All questions will be administered at each wave except for the questions about demographic information which will be asked during Baseline-1 only.

To measure blood pressure, the investigators will use an oscillometric measurement device. To do so, a blood pressure cuff will be placed about an inch above the elbow crease. For reliability purposes, blood pressure will be measured three-times with about 1 minute time between the measures.

To measure cortisol, h-CRP, IL-6, and TNF-α levels in saliva, participants will also be asked to provide saliva samples. Participants will be asked to avoid eating food or drinking caffeine for 3 hours prior to the saliva data collection in order to prepare for the saliva testing.

Once after the participants finish the RFCBT, they will be invited to take part in a semi-structured interview to explore their experiences in and acceptability of the training. The investigators intend to do these interviews with all participants who begin RFCBT (i.e., defined as completing at least one 50-minute meeting with their trainer), including those who drop out of the training, in-person, by phone, or a secure video platform.

The RFCBT exclusively addresses one possible mechanism underlying depression, rumination. In general, a participant and their trainer will identify when the participant ruminates in an unhelpful manner, what triggers the rumination, what function the rumination fulfills for the participant, and how the participant already does to stop ruminating. Building on this knowledge both together will change the environment to reduce the likelihood of the participant to ruminate, use consciously strategies to stop rumination when it occurs, and replace rumination by more helpful strategies. In the proposed single subject study, the participant and the trainer will meet in person or using a UofL approved video platform up to 18 times for 50-minutes.

Plan for Analysis of Results Following the best practice guidelines of the What Works Clearinghouse Standards for SCEDs, the investigators will examine consistency, intervention effect, immediacy, and auto-correlations for rumination, depressive symptoms, blood pressure, cortisol, h-CRP, IL-6, and TNF-α. The investigators will use Bayesian unknown changepoint models to estimate the parameters and model the treatment effect. A mixed effects model will be used to model the hierarchical structure of the data. The dependent variables are rumination, depressive symptoms, blood pressure, cortisol, h-CRP, IL-6, and TNF-α. The independent variable is phase. Bayesian estimation will be used to address the small sample nature of the data. For these statistical analyses the investigators will use R and "Just Another Gibbs Sampler" (JAGS). The investigators will conduct semi-structured interviews and analyze data using thematic analysis to generate themes associated with the data. The statistical program Dedoose will be utilized to facilitate this process.

• Study Type: Interventional
• Enrollment (Estimated): 9
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Patrick Possel, Dr.rer.soc.; Phone Number: 502-852-0623; Email: patrick.possel@louisville.edu

Study Locations

• United States
  • Kentucky
    • Louisville, Kentucky, United States, 40202
      • Recruiting
      • Have a Heart clinic
      • Contact: Sherry Pancost; Email: sherry.pancost@louisville.edu

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• RSQ-Brooding score: >= 11
• PHQ-9 score: 10-20
• SBP: >= 120 and/or DBP: >= 80)
• fluent in English

Exclusion Criteria:

• None besides the described inclusion criteria

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: RFCBT; This is a single subject design study. Thus, all participants receive Rumination-Focused Cognitive Behavior Therapy

Behavioral: Rumination-Focused Cognitive Behavior Therapy; The RFCBT exclusively addresses one possible mechanism underlying depression, rumination. In general, a participant and their therapist will identify when the participant ruminates in an unhelpful manner, what triggers the rumination, what function the rumination fulfills for the participant, and how the participant already does to stop ruminating. Building on this knowledge both together will change the environment to reduce the likelihood of the participant to ruminate, use consciously strategies to stop rumination when it occurs, and replace rumination by more helpful strategies. In the proposed single subject study, the participant and the therapist will meet in person or using a UofL approved video platform up to 18 times for 50-minutes.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	Baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	1 week after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	2 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	3 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	4 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	5 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	6 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	7 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	9 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	11 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	13 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	15 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	17 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	19 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	21 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	23 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	25 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	27 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	29 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	31 weeks after baseline 1
Response Style Questionnaire	sadness rumination, Score range: 5-20, higher score = more rumination	33 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	Baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	1 week after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	2 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	3 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	4 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	5 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	6 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	7 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	9 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	11 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	13 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	15 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	17 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	19 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	21 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	23 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	25 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	27 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	29 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	31 weeks after baseline 1
Patient Health Questionnaire-9	depressive symptoms, Score range: 0-27, higher score = more depressive symptoms	33 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	Baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	1 week after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	2 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	3 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	4 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	5 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	6 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	7 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	9 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	11 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	13 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	15 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	17 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	19 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	21 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	23 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	25 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	27 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	29 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	31 weeks after baseline 1
systolic blood pressure measures	systolic blood pressure; score range: 0-200+, higher score = higher blood pressure	33 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	Baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	1 week after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	2 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	3 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	4 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	5 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	6 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	7 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	9 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	11 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	13 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	15 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	17 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	19 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	21 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	23 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	25 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	27 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	29 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	31 weeks after baseline 1
diastolic blood pressure measures	diastolic blood pressure; score range: 0-200+, higher score = higher blood pressure	33 weeks after baseline 1

Collaborators and Investigators

• Sponsor: University of Louisville
• Investigators: Principal Investigator: Patrick Possel, Dr.rer.soc., University of Louisville

Study record dates

Study Major Dates

• Study Start (Actual): August 15, 2023
• Primary Completion (Estimated): August 31, 2026
• Study Completion (Estimated): August 31, 2026

Study Registration Dates

• First Submitted: June 7, 2023
• First Submitted That Met QC Criteria: August 4, 2023
• First Posted (Actual): August 7, 2023

Study Record Updates

• Last Update Posted (Actual): October 18, 2023
• Last Update Submitted That Met QC Criteria: October 16, 2023
• Last Verified: October 1, 2023

More Information

Terms related to this study

• Keywords: blood pressure; rumination; depressive symptoms; Proof of Concept Study; rumination-focused cognitive behavioral therapy; Single subject design
• Additional Relevant MeSH Terms: Behavioral Symptoms; Mental Disorders; Digestive System Diseases; Feeding and Eating Disorders; Gastrointestinal Diseases; Depression; Rumination Syndrome; Feeding and Eating Disorders of Childhood
• Other Study ID Numbers: 23.0150

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No