Improving primary care for older adults with cancer and depression.

Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Box 356560, Seattle, WA 98195, USA.
Journal of General Internal Medicine (Impact Factor: 3.42). 11/2009; 24 Suppl 2(S2):S417-24. DOI: 10.1007/s11606-009-0999-4
Source: PubMed

ABSTRACT Depression is common among older cancer patients, but little is known about the optimal approach to caring for this population. This analysis evaluates the effectiveness of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) program, a stepped care management program for depression in primary care patients who had an ICD-9 cancer diagnosis.
Two hundred fifteen cancer patients were identified from the 1,801 participants in the parent study. Subjects were 60 years or older with major depression (18%), dysthymic disorder (33%), or both (49%), recruited from 18 primary care clinics belonging to 8 health-care organizations in 5 states. Patients were randomly assigned to the IMPACT intervention (n = 112) or usual care (n = 103). Intervention patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care provider and who offered education, care management, support of antidepressant management, and brief, structured psychosocial interventions including behavioral activation and problem-solving treatment.
At 6 and 12 months, 55% and 39% of intervention patients had a 50% or greater reduction in depressive symptoms (SCL-20) from baseline compared to 34% and 20% of usual care participants (P = 0.003 and P = 0.029). Intervention patients also experienced greater remission rates (P = 0.031), more depression-free days (P < 0.001), less functional impairment (P = 0.011), and greater quality of life (P = 0.039) at 12 months than usual care participants.
The IMPACT collaborative care program appears to be feasible and effective for depression among older cancer patients in diverse primary care settings.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Background Medical conditions are often complicated by major depression, with consequent additional impairment of quality of life. We aimed to compare the effectiveness of an integrated treatment programme for major depression in patients with cancer (depression care for people with cancer) with usual care. Methods SMaRT Oncology-2 is a parallel-group, multicentre, randomised controlled effectiveness trial. We enrolled outpatients with major depression from three cancer centres and their associated clinics in Scotland, UK. Participants were randomly assigned in a 1:1 ratio to the depression care for people with cancer intervention or usual care, with stratification (by trial centre) and minimisation (by age, primary cancer, and sex) with allocation concealment. Depression care for people with cancer is a manualised, multicomponent collaborative care treatment that is delivered systematically by a team of cancer nurses and psychiatrists in collaboration with primary care physicians. Usual care is provided by primary care physicians. Outcome data were collected up until 48 weeks. The primary outcome was treatment response (≥50% reduction in Symptom Checklist Depression Scale [SCL-20] score, range 0–4) at 24 weeks. Trial statisticians and data collection staff were masked to treatment allocation, but participants could not be masked to the allocations. Analyses were by intention to treat. This trial is registered with Current Controlled Trials, number ISRCTN40568538. Findings 500 participants were enrolled between May 12, 2008, and May 13, 2011; 253 were randomly allocated to depression care for people with cancer and 247 to usual care. 143 (62%) of 231 participants in the depression care for people with cancer group and 40 (17%) of 231 in the usual care group responded to treatment: absolute difference 45% (95% CI 37–53), adjusted odds ratio 8·5 (95% CI 5·5–13·4), p<0·0001. Compared with patients in the usual care group, participants allocated to the depression care for people with cancer programme also had less depression, anxiety, pain, and fatigue; and better functioning, health, quality of life, and perceived quality of depression care at all timepoints (all p<0·05). During the study, 34 cancer-related deaths occurred (19 in the depression care for people with cancer group, 15 in the usual care group), one patient in the depression care for people with cancer group was admitted to a psychiatric ward, and one patient in this group attempted suicide. None of these events were judged to be related to the trial treatments or procedures. Interpretation Our findings suggest that depression care for people with cancer is an effective treatment for major depression in patients with cancer. It offers a model for the treatment of depression comorbid with other medical conditions. Funding Cancer Research UK and Chief Scientist Office of the Scottish Government.
    The Lancet 09/2014; 384(9948). DOI:10.1016/S0140-6736(14)61231-9 · 39.21 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Major depression is an important complication of cancer. However, it is frequently inadequately treated. There are challenges both in identifying which cancer patients are depressed, and in ensuring that these patients receive effective treatment for their depression. Integration of depression management into cancer care has been advocated as a way to address these challenges. Such integrated approaches must include both the systematic identification of cases and the delivery of treatment. We describe here a system of depression care that includes both a screening programme to identify patients with depression and a linked treatment programme, based on the collaborative care model, called 'Depression Care for People with Cancer' (DCPC). The system of care was designed to be fully integrated with specialist cancer services and has been robustly evaluated in randomized trials. We describe how the system operates and explain why it is designed as it is. We also summarize the evidence for its effectiveness and cost-effectiveness and discuss its implementation in routine clinical practice.
    International Review of Psychiatry 12/2014; 26(6):657-68. DOI:10.3109/09540261.2014.981512 · 1.80 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose: Depression, one of the most common cancer symptoms, has a profound impact on treatment retention and adherence. As such, there is an increasing need to identify simple, effective, and feasible strategies for retaining cancer patients to depression treatment. This becomes especially important in the context of a large public sector care system, where there are not only patient barriers, but also organizational/institutional barriers to delivery. This study aimed to explore strategies used by intervention trial providers to increase retention to a clinical depression treatment trial (Alleviating Depression among Patients with Cancer [ADAPt-C]), among a cohort of low-income minority cancer patients. Specifically, this study identified viable provider strategies to decrease dropout and increase retention to the depression effectiveness treatment trial. Methods: Grounded theory qualitative methods were used to analyze data from fourteen providers representing the various care roles in a randomized clinical depression treatment trial intervention. Fourteen providers included: six social work therapists, three project recruiters, two patient navigators, one psychiatrist, one project manager, and one project assistant. From May to June, 2008, strategies were elicited through in-depth, semi-structured interviews. Sensitizing concepts from the literature and dropout barriers identified by patients (who were predominately female, Latino, foreign-born, unmarried, unemployed, moderately depressed, less advanced cancer stage diagnosis, and in follow-up cancer treatment) were used to guide interview prompts. Strength of this study involved the use of data triangulation to improve analytic accuracy and rigor. Provider participants received $10 gift card incentives. Results: Of the 242 ADAPt-C patients enrolled in the ADAPt-C intervention, 152 satisfied criteria for adhering to treatment, while 90 patients met criteria for withdrawing or dropping out of treatment. Retention strategies clustered according to trial dropout barriers: 1) Depression treatment barrier strategies included patient satisfaction surveys, efforts to strengthen the therapeutic alliance (e.g., building rapport, early engagement, and active listening), and clinical motivation strategies (e.g., persistence, consistency, outcome-focused counseling, validation, family involvement, and strength identification); 2) Informational barrier strategies included education about the study and psycho-educational strategies; 3) Instrumental barrier strategies included transportation resources, consistent contact, reminder calls, phone communication, and flexibility; 4) Recruitment barrier strategies included birthday greetings and the importance of incentive types; 5) Cultural barrier strategies included patient-provider cultural and language matching; and 6) Systems’ barrier strategies included patient systems navigation strategies and the importance of provider-provider rapport and communication. The important cross-cutting thread which links all of these barrier strategies together involves the importance of mediated communication between providers and patients, and providers and patient systems. Implications: This high rate of study adherence among a hard-to-reach population suggests that socio-culturally grounded strategies can be effective in facilitating depression treatment retention among low-income, minority patients in a public sector oncology care system. Findings indicate that identification of treatment barriers can help generate culturally sensitive strategies that not only inform patient level communication interventions, but also institutional and organizational level communication efforts. This study is important to future development of evidence-based sustainability interventions and real-world mental/ health care.
    The Society for Social Work and Research 2013 Annual Conference; 01/2013

Full-text (2 Sources)

Available from
May 21, 2014