Complex intervention improved depressive symptoms

Treatment effect was still present six months after therapy ended.

Depression is a well-known comorbidity of chronic disease. Despite the potential threat the condition poses, treatment of depression in some patients has yet to catch up with that knowledge.

Results from a survey conducted by the World Health Organization of 245,404 adults in more than 60 countries indicated that an average of 9.3% to 23% of respondents with at least one chronic physical disease also had comorbid depression.

According to the results of the SMaRT oncology 1 study, patients with a variety of cancers who had been diagnosed with a major depressive disorder improved with intervention by cancer center nurses. The results were published in The Lancet.

Researchers from Psychological Medicine Research in the University of Edinburgh in Scotland enrolled 200 patients in the study. Eligible participants had a cancer prognosis of at least six months, a major depressive disorder for at least one month, and a minimum score of 1.75 on the Symptom Checklist-20 scale (range of zero to four).

Patients were randomly assigned to either usual care (n=99) or usual care plus intervention (n=101). Patients in the intervention arm were offered up to 10 one-on-one sessions during three months with one of three nurses who had no prior experience with psychiatry.

Depression Care for People With Cancer

The nurses were trained to deliver the Depression Care for People With Cancer intervention. The program consisted of education about depression and its treatment, including antidepressant medication and coping strategies designed to help patients overcome feelings of helplessness. The nurses also communicated with each patient’s oncologist and primary care doctor about management of major depressive disorder.

The nurses called patients once monthly for three months after the treatment sessions ended and monitored their progress using the nine-item Patient Health Questionnaire. Patients did not receive any further intervention.

At three months after randomization, the researchers found that depression scores on the SCL-20 depression scale (range 0 to 4) had declined in both groups, but the drop was greater for patients in the intervention arm.

The mean reduction in the study arm compared with the control arm was 0.34 (95% CI, 0.13-0.55).

Depression scores in the intervention arm stayed lower than those in the usual care arm at six months (1.03 vs. 1.51) and also at 12 months (1.12 vs. 1.43).

The researchers indicated that they were surprised that the improvement lasted as long as it did for patients in the intervention arm since treatment and follow-up only lasted six months.

Lasting effect

Michael Sharpe, MD, a professor at the school of molecular and clinical medicine at the University of Edinburgh, Scotland and leader of the research team, said the researchers expected to find the greatest improvement in mental health right after treatment ended at three months and to find that improvement would taper off over time.

“Although there was an effect at three months, the effect was biggest at six months,” Sharpe told HemOnc Today. “The treatment effect was still very clear at 12 months. It was quite encouraging that this relatively modest intervention has a clear, long-term effect.”

The researchers wrote that the incremental cost for six months of intervention was $668 per patient. They concluded the cost per quality-adjusted life-year gained of $10,556 was cost-effective and compared favorably with the median cost of $20,000 per quality-adjusted life-year for anticancer treatments.

According to Sharpe, a new trial the SMaRT oncology 2 trial recently began at two large cancer centers in Scotland. It is designed to test the effects of intervention on a larger study population (n=500). The SMaRT 3 oncology 3 trial is scheduled to begin this fall and will look at whether this kind of intervention will work for patients with lung cancer.

In an accompanying editorial, Gary Rodin, MD, head of psychosocial oncology and palliative care at Toronto’s Princess Margaret Hospital, cautioned against assuming the results of this study would hold for depressed patients with more advanced cancer or for those with other psychiatric comorbidity.

However, Rodin praised the researchers for making an important addition to the knowledge of treating depression in medical populations.

“In a well-designed study, they have shown that trained nurses with no previous psychiatric experience can deliver a cost-effective collaborative psychosocial intervention for cancer patients with major depressive disorder,” he wrote. “Such multicomponent interventions are potentially feasible in cancer treatment centers and can be perceived by patients as less stigmatizing than referral to a mental health specialist.” – by Jason Harris

For more information:

• Lancet. 2008;372:40-48.