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


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.

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Available from: Jesse R Fann, Mar 20, 2014
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    • "Treatment effects are repeatedly evaluated and patients who do not respond to one level of support are transferred to another level and receive more intensive support [21]. Stepped care has successfully been used for treatment of anxiety and depression in the elderly and patients with cancer [22,23]. The initial level of stepped care for psychological problems may comprise education about common symptoms and effective self-help strategies (psycho-education), counselling, and support from other patients. "
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    ABSTRACT: Approximately 20--30% of patients with cancer experience a clinically relevant level of emotional distress in response to disease and treatment. This in itself is alarming but it is even more problematic because it is often difficult for physicians and nurses to identify cancer patients who experience clinically relevant levels of anxiety and depression symptoms. This can result in persistent distress and can cause human suffering as well as costs for individuals and to the community. Applying a multi-disciplinary and design-oriented approach aimed at attaining new evidence-based knowledge in basic and applied psychosocial oncology, this protocol will evaluate an intervention to be implemented in clinical practice to reduce cancer patient anxiety and depression. A prospective randomized design will be used.The overarching goal of the intervention is to promote psychosocial health among patients suffering from cancer by means of self-help programmes delivered via an Internet platform. Another goal is to reduce costs for individuals and society, caused by emotional distress in response to cancer.Following screening to detect levels of patient distress, patients will be randomized to standard care or a stepped care intervention. For patients randomized to the intervention, step 1 will consist of self-help material, a chat forum where participants will be able to communicate with each other, and a Frequently Asked Questions (FAQ) section where they can ask questions and get answers from an expert. Patients in the intervention group who still report symptoms of anxiety or depression after access to step 1 will be offered step 2, which will consist of cognitive behavioral therapy (CBT) administered by a personal therapist. The primary end point of the study is patients' levels of anxiety and depression, evaluated longitudinally during and after the intervention. There is a lack of controlled studies of the psychological and behavioral processes involved in this type of intervention for anxiety and depressive disorders. Since anxiety and depressive symptoms are relatively common in patients with cancer and the availability of adequate support efforts is limited, there is a need to develop evidence-based stepped care for patients with cancer, to be delivered via the Internet.Trial registration: Identifier: NCT01630681.
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    • "UK Fann et al. 2009 "
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    ABSTRACT: Background: Despite some clinical guidelines for incorporating integrated psychosocial care (combining psychological screening and psychological intervention, including adequate collaboration with mental health specialists) into routine oncology practice, definitive empirical evidence regarding the effectiveness of such care remains unavailable. Here the findings of recent experimental studies are reviewed to provide guidance regarding this issue. Methods: Comparative studies examining integrated psychosocial care were reviewed. Results: Studies examining interventions that include both screening and psychological care have produced contradictory results regarding effectiveness, but all the studies that have examined the effect of psychological care after the identification of distress using systematic screening have shown positive results. Conclusions: Integrated psychosocial care may affect patients with significant distress, but the adequacy of introducing such care into routine oncology practice remains debatable.
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    • "). For example, cancer treatments alone are associated with increased risks of depressive symptoms; prior to medical treatment about 10% of patients diagnosed with various cancers show depressed mood or anhedonia, two hallmark symptoms of depression, whereas during treatment over 20% endorse one of these symptoms (Fann et al., 2009). Importantly, one large-scale prospective study suggests that cancer diagnosis and treatment provokes depression leading to a 4-fold increase in depression occurrence during the first two years after diagnosis as compared those who remain medically healthy. "
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    ABSTRACT: Over two-thirds of the 11.4 million cancer survivors in the United States can expect long-term survival, with many others living with cancer as a chronic disease controlled by ongoing therapy. However, behavioral co-morbidities often arise during treatment and persist long-term to complicate survival and reduce quality of life. In this review, the inter-relationships between cancer, depression, and sleep disturbance are described, with a focus on the role of sleep disturbance as a risk factor for depression. Increasing evidence also links alterations in inflammatory biology dynamics to these long-term effects of cancer diagnosis and treatment, and the hypothesis that sleep disturbance drives inflammation, which together contribute to depression, is discussed. Better understanding of the associations between inflammation and behavioral co-morbidities has the potential to refine prediction of risk and development of strategies for the prevention and treatment of sleep disturbance and depression in cancer survivors.
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