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Key Words

Depression, collaborative care, supportive care, psychotherapy, antidepressants, low-income, Hispanics. (Definitions of many terms related to cancer can be found in the Cancer.gov Dictionary.)

Summary

A collaborative-care, multidisciplinary intervention to treat depression in cancer patients was more effective than usual care in relieving symptoms of depression in a study conducted at a community-based center serving a predominantly low-income Hispanic population. At 12 months, patients receiving the collaborative-care intervention also had significantly better social, emotional, and functional well-being.

Source

Journal of Clinical Oncology, September 20, 2008 (see the journal abstract).
(J Clin Oncol 2008 Sep 20;27:4488-96)

Background

Two in every five cancer patients will experience depression, which can worsen over the course of treatment and persist long after treatment ends. Oncologists often fail to treat or even recognize depression and its symptoms. Low-income cancer patients, and those with inadequate or no health insurance, are especially vulnerable because they lack access to mental health services.

In 2005, University of Southern California researchers conducted a pilot study at the Los Angeles County/USC Medical Center (LAC/USC) with 55 female Hispanics to see if a collaborative-care program for depression could work in public-sector oncology clinics that serve low-income Hispanic patients. (“Collaborative care” includes the involvement of mental health professionals in the primary care of patients.) Encouraged by the results, the researchers designed a larger study, whose findings are described here.

The Study

Researchers tested a collaborative-care intervention called Alleviating Depression Among Patients with Cancer (ADAPt-C). The ADAPt-C team, led by a doctorally prepared social worker, includes a psychiatrist who can prescribe antidepressant medication as requested or needed.

In addition, bilingual social workers trained as cancer depression clinical specialists (CDCSs) help patients navigate the community services available. They counsel each patient, provide educational resources, and develop a personalized treatment plan that reflects the patient’s preference for antidepressant medication or problem-solving therapy. During the 12-month intervention period, patients are followed closely by their CDCS, who looks for signs of relapse and maintains contact by telephone.

The study took place at the LAC/UCL Medical Center, whose patients are low-income and predominantly Hispanic. Cancer patients who showed symptoms of depression were interviewed and then assigned to one of two groups: 242 received the ADAPt-C intervention program, while the control group of 230 received enhanced usual care (EUC). Rather than counseling and support services, EUC patients received educational pamphlets about cancer and depression written for patients and their families. They also were provided a list of financial, social service, transportation, and childcare resources available in the center and the community.

Of the total 472 participants in the study, 415 were Hispanic, 399 were women, 239 were younger than age 50, and 300 were unmarried. One hundred and thirty two patients (28 percent) had stage III, IV, or recurrent cancer. All patients were experiencing one of two basic depressive symptoms more than half of all days. According to baseline scores from a patient health questionnaire called PHQ-9, 232 had major depression, 24 had dysthymia (a less severe form of depression), and 216 had both.

The study presents results of evaluations of depressive symptoms and quality of life that were carried out at six and 12 months. Long-term results will be published later as the patients are followed to 18 and 24 months.

The study’s lead author is Kathleen Ell, D.S.W., of the University of Southern California School of Social Work, Los Angeles.

Results

Patients in the ADAPt-C group were much more likely than those in the EUC group to receive depression treatment (antidepressant medication, problem-solving therapy, or both): 24 patients (10.4 percent) in the EUC group received depression treatment, compared to 72.3 percent of those in the ADAPt-C group.

Of 129 patients in the ADAPt-C group who completed interviews at both six and 12 months, half received problem-solving therapy, less than 1 percent received antidepressant medication alone, and 37 percent received both. Twelve percent refused treatment or did not adhere to their treatment plan.

Among patients in the ADAPt-C group, 92.3 percent of those who received problem-solving therapy reported at 12 months that they were satisfied or extremely satisfied with their treatment, compared with 42.3 percent of those who requested and received antidepressant medication.

At 12 months, 63 percent of patients in the ADAPt-C group and 50 percent of patients in the EUC group had experienced a clinically meaningful improvement in depressive symptoms (that is, a reduction of at least 50 percent in PHQ-9 score).

When evaluated for quality of life at 12 months, patients in the ADAPt-C group had statistically significantly better social, family, emotional, and functional well-being outcomes compared with those receiving EUC.

Limitations

The results of this study represent an average across both men and women, and may not accurately reflect outcomes for either group alone. Men made up only 15 percent of study participants.

“Hispanic males live in a culture that may discourage them from admitting to depression,” explained Diana D. Jeffery, Ph.D., from the Office of Cancer Survivorship at the National Cancer Institute. This means they would be less likely to be identified through routine depression screening on a study like this one. In contrast, Hispanic women “may express more symptoms associated with depression,” she said: “Nearly all [Hispanic women] newly diagnosed with cancer who are screened for depression will [say yes in response] to a question that asks if they cry every day.” Hispanic women are also less likely to have medical insurance than Hispanic men, making them more reliant on community-based health centers for oncology services and, therefore, more highly represented in the current study population.

The drop-out rate was fairly high in this study, especially between six and 12 months. “Men are also more likely to drop out of treatment,” said Jeffery, “when they realize it involves talking about how they feel.” Other factors contributing to the drop-out rate, she noted, are that low-income Hispanic populations tend to have less stable places of employment and may have difficulty getting time off work and transportation to and from the clinic. In addition, said Ell, advancing illness may have influenced some of the study participants to leave the area.

The depressive symptoms of patients in the comparison group receiving EUC may have been influenced by disappointment over not being selected for the collaborative-care intervention. Nonetheless, they showed improvement in their depressive symptoms, which Ell said “may have resulted from enhancements, particularly routine screening, notification of oncologists, and information about site and community psychosocial supportive services.”

Comments

“This is a very important study with implications for dissemination to communities with [Hispanic] individuals facing cancer,” said Jeffrey. Though Hispanics are the largest ethnic minority group in the United States, “there are very few quality-of-life studies among economically disadvantaged [Hispanic] cancer survivors, and this may be the first that explores their mental health needs in community-based healthcare setting,” she said.

Jeffery believes that the study’s success indicates that ADAPt-C and other collaborative-care models for depression treatment are likely to translate across the spectrum of cancer types, and also widely to those who are economically disadvantaged no matter their racial or ethnic group.

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