Improving Primary Care for Older Adults with Cancer
Jesse R. Fann, MD, MPH1,2,3, Ming-Yu Fan, PhD1, and Jürgen Unützer, MD, MPH1
1Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA;2Clinical Research
Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA;3Psychiatry and Psychology Service, Seattle Cancer Care Alliance,
Seattle, WA, USA.
BACKGROUND: 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
METHODS: 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 behav-
ioral activation and problem-solving treatment.
RESULTS: 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
CONCLUSIONS: The IMPACTcollaborative care program
appears to be feasible and effective for depression among
older cancer patients in diverse primary care settings.
KEY WORDS: depression; cancer; treatment; quality of life.
J Gen Intern Med 24(Suppl 2):417–24
© Society of General Internal Medicine 2009
The majority of cancer patients in the United States are
65 years and older.1Seventy-seven percent of all cancers are
diagnosed in persons 55 years or older. Among those without a
prior cancer diagnosis, 16% of males and 10% of females will
develop cancer between 60–69 years old and 39% of males and
26% of females will develop cancer between 70–79 years old.2
Rates of clinically significant depression are as high as 25% in
older adults,3,4well above the general population.5Despite the
large number of older adults with cancer and depression, there
are few studies examining treatment strategies for depression
in this population.
Depression has a substantial impact on health in patients
with comorbid medical conditions6and is associated with
increased symptom burden (e.g., pain, fatigue), decreased
cognitive and physical functioning, decreased quality of life,
impaired family functioning, decreased adherence to medical
regimens and healthy behaviors, and potentially decreased
immunity and increased mortality.7Recent comprehensive
reports show that depression often goes undetected and
untreated in cancer patients.8,9
Despite calls from the National Cancer Institute10and the
National Comprehensive Cancer Network11for systematic
detection and treatment of depression in cancer patients,
and the availability of evidence-based treatments for depres-
sion,12–16many depressed cancer patients do not receive
effective treatment.17,18This gap in care is in part due to the
lack of a system of care for depression that can be adapted
into oncology clinics and other settings caring for patients
with chronic medical illnesses.19
Oncologists do not consistently identify which of their
patients are depressed,17and there is little evidence that this
ability is improved by training alone.20Cancer patients are
often reluctant to seek help for psychiatric illness.21,22Even if
depression is detected, there are further obstacles to the
initiation of effective treatment,23including: (1) depression
being regarded as a normal reaction to cancer; (2) the stigma of
a psychiatric diagnosis; (3) reluctance by doctors to give or by
patients to accept treatments that are seen as psychiatric vs.
medical; (4) failure to maintain an active focus on depression
and to adjust treatment if it is not effective; and (5) limited
access to mental health care. Once treatment is initiated, close
monitoring and treatment adjustment are critical, especially
since studies have shown that response and tolerability to
antidepressant treatment in elderly depressed patients may be
lower than in younger patients.24Depression screening alone,
without a system of care that can effectively engage patients
Supported by grants from the John A. Hartford Foundation, the
California Healthcare Foundation, the Hogg Foundation, and the Robert
Wood Johnson Foundation.
and treat depression, has shown minimal effects on improving
depression outcomes in medical settings.25–28Elderly cancer
patients may have additional barriers to care, such as
transportation, financial, lack of caregiver support, a belief
that depression is a normal part of aging,29and having low
rates of depression care compared to younger patients.30
Reorganizing the way medical and mental health profes-
sionals work together by means of a Collaborative Care model
has been found to significantly improve depression outcomes in
primary care.31The core features of Collaborative Care include
active care management, support of medication management
prescribed by primary care providers, and mental health
specialty consultation and back-up. No studies have reported
on the effectiveness of collaborative care for depression in
primary care patients with cancer.
This study examines the effectiveness of a collaborative care
program for depression in a cohort of patients with cancer from
Project IMPACT, a multi-site study of collaborative care for
depression in older primary care patients32; www.impact-uw.
org. Project IMPACT enrolled 1,801 depressed older adults age
≥60, withanaverageofthreemedicalcomorbidities. Participants
were sociodemographically diverse and included 65% women
and 23% ethnic minorities.32,33We hypothesized that cancer
patients enrolled in IMPACT would also have significantly better
12-month depression outcomes compared with usual care,
although the effect would be slightly less than for the overall
The IMPACT trial was conducted in 18 primary care clinics at
8 diverse health-care organizations across the US from 1999 to
2001.32Institutional review boards for each organization and
the study coordinating center approved the study procedures,
and all participants provided written informed consent. De-
tailed information on this trial is provided elsewhere.32,34
Inclusion criteria were 60 years or older, current major
depression or dysthymia (chronic depression) diagnosed by the
Structured Clinical Interview for the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV),35and
plans to use one of the participating clinics as the main source
of general medical services for the coming year. Exclusions
included history of bipolar disorder or psychosis, ongoing
treatment by a psychiatrist, current alcohol use problems,36
severe cognitive impairment,37or acute risk of suicide.
For the analyses reported in this article, we focus on the 215
participants who had an ICD-938diagnosis of non-skin cancer
in claims or encounter data in the year before or the year
following randomization. These patients were randomly
assigned to the IMPACT intervention (n=112) or usual care
(n=103). The following ICD-9 codes were used to categorize
cancer diagnoses: digestive system (150.0–159.9), respiratory
system (160.0–163.9, 165.0–165.9), female breast (174.0–
174.9), female reproductive (179.0–184.9), male reproductive
(185.0–187.9), urinary system (188.0–189.9), occult (195.0–
199.9), hematologic (200.0–208.9), and other (includes oral
cavity and pharynx, bones and joints, soft tissues, male breast,
eye and orbit, brain, thyroid and other endocrine: 140.0–
149.9, 170.0–171.9, 175.0–175.9, 190.0–194.9).39
There were also 105 participants who reported a diagnosis
or treatment for cancer in the 3 years before study initiation;
75 of these were also among the aforementioned 215 subjects.
We used this cohort of patients who self-reported cancer to
perform a secondary confirmatory analysis.
Intervention patients were offered depression management by
a depression care manager (DCM; a nurse or clinical psychol-
ogist) working collaboratively with the patient and primary
care physician in the patient’s usual primary care clinic for up
to 12 months. The DCM conducted a psychosocial history,
provided education and behavioral activation (which empha-
sizes pleasant event scheduling and overcoming avoidance
behaviors), and helped patients identify treatment preferences.
Treatment options included antidepressant medicines pre-
scribed by the patients' primary care clinicians and a struc-
tured six- to eight-session psychotherapy program known as
Problem-Solving Treatment (PST) in Primary Care delivered by
the DCM.40A stepped-care pharmacotherapy algorithm34
recommending routinely available antidepressant medications
guided the acute and follow-up phases of treatment over
12 months. The DCM met weekly with a supervising psychi-
atrist and an expert primary care physician (PCP) to monitor
clinical progress and adjust treatment plans accordingly. In-
person or telephone follow-up visits occurred about every
2 weeks during acute-phase treatment, with subsequent
monthly contact during continuation and maintenance
phases. The intervention did not include routine assessment
or treatment of cancer-related issues, although patients could
choose to address cancer-related problems in PST sessions.
Patients assigned to the usual care group and their PCPs were
told that the patient met research diagnostic criteria for
clinical depression and received routinely available depression
treatment, including antidepressants and referrals to specialty
mental health services as deemed necessary by the attending
physician or patient. All study participants were followed in
usual care for an additional year after the initial 12 months.
Baseline, 3-, 6-, 12-, 18-, and 24-month follow-up data were
collected by trained research staff blind to treatment assign-
ment. A 20-item depression severity scale adapted from the
Symptom Checklist (SCL-20) was used to assess depression
severity and thoughts of death or suicide.41Depression
treatment response was measured by a 50% or greater
reduction in SCL-20 score and remission was defined by a
score of <0.5. Depression-free days were estimated following
the method developed by Lave and colleagues42using the SCL-
20. A score of 0.5 or less on the SCL-20 was used to indicate a
full depression-free day and a score of 1.7 or more was used to
indicate a 0 depression-free day. Intermediate severity scores
were assigned a value between 0 and 1 by linear interpolation.
Estimates were then summed to yield the total depression-free
days during 12- and 24-month follow-up periods. Use of
mental health services and antidepressants, and satisfaction
with depression care were also assessed. An item from the
SCL-20 was used to assess energy and fatigue. Respondents
also rated their health-related quality of life in the past month
on a scale from 0 to 10. Respondents were instructed to choose
0 if they felt their situation was about as bad as dying or 10 if
they felt in perfect health. The Sheehan Disability Scale was
Fann et al.: Improving Primary Care for Older Adults
used to assess health-related impairments in work, family, and
We examined descriptive statistics for demographic and base-
line characteristics and compared intervention and usual care
groups using logistic regression models with randomized
assignment as the dependent variable. For each outcome
variable, we made cross-sectional comparisons between the
two study groups at each follow-up time point using logistic
regression models. We also conducted a repeated measures
intent-to-treat analysis on baseline, 6-, and 12-month data
using mixed models for continuous variables and GEE method
for dichotomous variables. All models were adjusted for time,
recruitment method, and site. Due to the small sample size, we
did not test the interaction effect between time and interven-
tion. All analyses were performed using SAS 9.1 (SAS Institute
Inc., Cary, NC). Since the data were previously imputed, we
conducted all analyses on the five multiply imputed data sets
using the SAS PROC Mianalyze procedure. Descriptive statis-
tics were derived by combining the results from the five
imputed data sets following Rubin’s rule.44
Figure 1 describes the enrollment process for the IMPACT trial.
Two hundred fifteen (11.9%) of the 1,801 participants had an
ICD-9 diagnosis of cancer in the 12 months before or after
randomization. Intervention and control group comparisons
(Table 1) showed no significant differences in clinical or demo-
mental health service use in the past 3 months (14% in the
intervention group vs. 2% in the usual care group, P=0.005). The
mean number of comorbid chronic physical illnesses, selected
from a list of nine common medical conditions (cancer excluded),
was 3.28 (SD 0.11). Half of the participants met diagnostic
criteria for current major depression and dysthymic disorder.
Female breast and male reproductive (mostly prostate) cancers
were the most common cancer diagnoses, followed by occult and
digestive cancers (Fig. 2).
Depression Treatment and Outcomes
Depression treatment (pharmacotherapy or psychotherapy)
increased for both intervention and usual care groups over
the 12-month intervention (Table 2). Antidepressant use and
specialty mental health counseling or psychotherapy was
significantly greater among intervention than usual care
patients. These increases in treatment were similar to findings
in the overall study sample.32Intervention patients were about
twice as likely as those receiving usual care to experience a
depression treatment response at 12 months (39% vs. 20%;
P=0.029). Remission rates were higher in the intervention
group at 6 months (P=0.006) and at 12 months (P=0.031).
Intervention patients reported more depression-free days
compared with the usual care group in the first year [185.8
(10.9) vs. 135.0 (10.2); P<0.001] and a higher proportion of
patients reported at 12 months that their satisfaction with
depression care was ‘good or excellent’ (93% vs. 74%; P=0.015).
Thoughts of ending one’s life decreased in the intervention
group, but increased in the usual care group.
Repeated measures analyses over 12 months showed that
after adjusting for time, recruitment method, and site, the
intervention was significantly associated with response (OR
2.69, 95% CI 1.54, 4.71), remission (OR 2.44, 95% CI 1.51,
3.94), use of antidepressants (OR 2.07, 95% CI 1.45, 2.94),
and mental health utilization (OR 4.48, 95% CI 2.80, 7.10).
To further validate our results, we performed similar
analyses on the 105 patients who self-reported a cancer
diagnosis or cancer treatment in the 3 years prior to random-
ization. Similar group differences in depression and secondary
outcomes were found in this sub-sample (data not shown).
Functional and Quality of Life Outcomes
By 12 months, intervention patients reported significantly less
health-related functional impairment and higher quality of life
in the preceding month compared with usual care (Table 2).
Ratings of energy level were significantly better in the inter-
vention group than in usual care at 12 months.
Significant differences in depression treatment response rates
persisted even at 18 months, 6 months after the end of the
intervention (38% in intervention group vs. 16% in usual care;
P=0.012). Intervention patients continued to report more
depression-free days compared with the usual care group in
the 2nd year [356.5 (21.7) vs. 247.6 (19.6); P<0.001]. Thoughts
of ending one’s life remained slightly lower in the intervention
than the usual care group. Intervention patients continued to
report less health-related functional impairment and higher
quality of life at 18- and 24-months than those in usual care,
but these differences were not always statistically significant.
Ratings of energy continued to be significantly better in the
intervention group at 18, but not 24 months.
The IMPACT model of depression care was more effective than
usual care in treating depression in older primary care
patients with cancer and a mean of three comorbid conditions.
Depression outcomes among cancer patients were generally
similar to the overall IMPACT study sample, suggesting that
cancer does not reduce the relative effectiveness of the
program compared to usual care.32,45Benefits from improved
treatment of depression in patients with comorbid cancer and
depression extended beyond reducing depressive symptoms to
include improved functional outcomes and quality of life. Many
of these benefits persisted beyond the 12-month intervention
period into the subsequent year.
There are few data to guide clinicians regarding effective
models of care for depressed elderly cancer patients in primary
care. Findings from this secondary analysis of IMPACT data
provide promising evidence that collaborative depression care
may be a feasible and effective treatment model for depressed
older adults with cancer and can help guide future treatment
research for this population. Our finding that use of anti-
depressants and mental health services returned to near
Fann et al.: Improving Primary Care for Older Adults
baseline levels by 24 months suggests adding a brief relapse
prevention module during the 2nd year may be beneficial.
Energy level improved more in the intervention group than the
usual care group, illustrating the importance of treating comor-
bid depression in patients with fatigue, a common symptom in
cancer patients and survivors.46Cancer patients have twice the
rate of suicide compared with the general population, with older
age at diagnosis conferring an additional risk.47Accordingly, a
decrease in thoughts of death in this cancercohort’s intervention
group was slightly less than in the overall sample’s,48suggesting
that thoughts of death and suicide may warrant particular
attention in depressed cancer patients.
In an earlier British study, Strong and colleagues49demon-
strated the effectiveness of an oncology nurse-led collaborative
care model with a younger, more female population in a cancer
center. Ell and colleagues50found 12 months of bilingual social
worker-led collaborative care to be more effective than usual
care for depression in low-income, predominantly female (85%)
Hispanic cancer patients with probable major depression or
dysthymia at a university-affiliated county cancer clinic. In this
Figure 1. Flow diagram of IMPACT trial. IMPACT indicates Improving Mood-Promoting Access to Collaborative Treatment; SCID, Structured
Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Analyses included all other participants after
multiple imputation of unit-level missing data.
Fann et al.: Improving Primary Care for Older Adults
study, reliance on self-report without a confirmatory diagnostic
interview for depression may have led to inclusion of some
patients with minor depression and a high usual care response
in patients with poor prognostic factors, raising some question
of generalizability to older, lower functioning patients. However,
this and an earlier smaller study51increase optimism that
depressed low-income ethnic minority patients may benefit
from collaborative care within the cancer setting.
This is the first study of collaborative care for depressed older
adults with cancer in primary care settings (as opposed to cancer
of elderly, male, and chronically depressed and medically ill
patients. Late-life depressionis especially undetectedand under-
treated in men and members of racial and ethnic minority
groups.5Our study drew from 18 diverse primary care clinics in
8 health-care organizations in 5 states (including VA, HMO,
university-based, and private practice clinics), establishing the
IMPACT modelasfeasible and robustacrossa diverse set ofclinic
settings and socioeconomic groups. IMPACT also followed
patients for 12 months after treatment was completed, illustrat-
ing the long-term benefits of the intervention.
Our study shows that effective depression care can be offered
to depressed older adults with cancer in diverse primary care
settings through evidence-based programs such as IMPACT.
Cancer patients may especially benefit from collaborative care
because they are often engaged in a multidisciplinary treatment
environment that includes oncologists and other medical
specialists, social workers, nutritionists, physical therapists,
and sometimes psychologists or psychiatrists.
Several limitations warrant mentioning. Because this was a
secondary analysis, cancer patients were not prospectively
randomized to the study groups. Nevertheless, the groups were
well-balanced in demographic and clinical characteristics.
Although use of ICD-9 codes to ascertain cancer diagnoses
Table 1. Patient Characteristics of Subjects Who Have Cancer Diagnoses by ICD-9 (Excluding Skin Cancer)
Variable CategoryAll cancer patients
Married or living with partners
At least high school graduate
Prescription medication coverage
Number of cancer types
Depression status (SCID)0.379
2+ prior episodes of depression
Positive on cognitive impairment screener
Positive on anxiety screener
Chronic disease count (0–9)
Significant chronic pain
ICD-9, International Classification of Diseases, Ninth Revision
*Includes oral cavity and pharynx, bones and joints, soft tissues, male breast, eye and orbit, brain, thyroid and other endocrine cancers
Figure 2. SCL-20 depression scores in subjects who have cancer
diagnoses by ICD-9 (excluding skin cancer), N=215. SCL-20 indi-
cates a 20-item depression severity scale adapted from the Hopkins
Symptom Checklist. For depression, P<0.01 for the comparisons
between usual care and intervention groups at 3-, 6-, and 12-month
follow-up; P=0.49 at 0 months, 0.01 at 18 months, and 0.09 at
Fann et al.: Improving Primary Care for Older Adults
has been shown to be valid, some misclassification may have
occurred, such as with provisional diagnoses.52–54Moreover,
we did not have data on timing or staging of cancer diagnosis
or type of cancer treatment received.
Multiple imputation was based on the assumption that the
missing data were missing at random (MAR). If the missing
mechanism was not missing at random (NMAR), then the yielded
results are likely to be biased. Given the low rate of item-level
missing in our data and the fact that the wave-level missing was
unrelated to the depression outcomes, our analyses with the
multiple imputed data appear to be appropriate. Some of the
continuous outcomes do not seem to follow an exact normal
distribution; however, a central limit theorem has shown that a
large sample such as ours can adequately address this issue.
Future studies should test the delivery of collaborative
depression care to cancer patients at various stages in
treatment, including during the acute phase of chemotherapy
and radiation therapy. Studies should also test the feasibility
andeffectiveness ofdelivering theintervention inthecancer care
setting vs. a primary care setting, using different intervention
components (e.g., behavioral activation), adding treatment
components that focus on additional symptoms such as
cancer-related fatigue or pain,55and intervening in populations
with different cancer diagnoses and prognoses.
Table 2. Univariate Analysis of Depression and Functional Outcomes by Group Assignment in Subjects Who Have Cancer Diagnoses by ICD-9
(Excluding Skin Cancer)
Variable Time pointCancer patients (N=215) Intervention (N=112)Usual care (N=103) P-Value
Response (≥50% improvement in SCL-20)
Remission (SCL-20 <0.5)
Antidepressant use in the past 3 months
Any mental health visit in the past 3 months
Satisfaction with depression care
Sheehan disability scale
Quality of life
Feeling low energy
ICD-9, International Classification of Diseases, Ninth Revision; SCID, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition; SCL-20, 20-item depression severity scale
Fann et al.: Improving Primary Care for Older Adults
Conflict of Interest: None disclosed.
Corresponding Author: Jesse R. Fann, MD, MPH; Department of
Psychiatry and Behavioral Sciences, University of Washington
School of Medicine, Box 356560, Seattle, WA 98195, USA
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