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Multidisciplinary approach may better detect, treat depression among patients with cancer
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Major depression is common among patients with cancer — particularly those with lung cancer — yet it often goes untreated, according to a series of studies published by The Lancet.
A multidisciplinary collaborative treatment program can effectively relieve symptoms of depression, reduce anxiety and improve quality of life among patients with cancer who have favorable prognoses, as well as among individuals with lung cancer who have poor prognoses, results showed.
“Clinicians who see patients with cancer knew that depression was an important problem that significantly affects quality of life,” Jane Walker, MBChB, MSc, PhD, MRCPsych, senior clinical researcher in the department of psychiatry at the University of Oxford, told HemOnc Today. “But [prior to this research], we did not know exactly how common it was in people with different cancers, how many depressed cancer patients were getting treatment for their depression and which approach to treatment was best.”
Incidence and treatment
Jane Walker
Walker, along with Michael Sharpe, MD, professor of psychological medicine at the University of Oxford, and other colleagues conducted three studies to assess the prevalence of depression among patients with cancer and the likelihood that those individuals receive adequate treatment.
In one study, the researchers evaluated data from 21,151 patients in Scotland with breast (40%), lung (20%), colorectal (16%), gynecologic (14%) or genitourinary (9%) cancers. The mean age of patients was 64.4 years (range, 19-100), and 71% were women.
All patients were screened for depression between 2008 and 2011 using the Hospital Anxiety and Depression Scale and the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. Most patients were screened during a return appointment (84%), and the median time since cancer diagnosis was 1 year (interquartile range [IQR], 0.3-3.2).
Researchers diagnosed 1,599 patients (7.5%) as having major depression. Individuals with lung cancer had the greatest prevalence (13.1%; 95% CI, 11.9-14.2).
“Patients with lung cancer often have a poor prognosis,” Walker said in a press release. “If they also have major depression, that can blight the time they have left to live.”
The prevalence of major depression for the remaining cancer types ranged from 10.9% (95% CI, 9.8-12.1) among those with gynecologic cancer to 5.6% (95% CI, 4.5-6.7) among those with genitourinary cancer.
Major depression was more common in younger patients (P=.0038 for genitourinary cancer; P<.0001 for all other cancer types) and among patients who had lower social deprivation scores (P<.0001 for all cancer types).
Women with lung (P<.0001) and colorectal (P=.031) cancers also were more likely to have major depression than men.
Researchers evaluated patient-reported treatment data from 96% of patients identified as having major depression. Of these patients, 73% (n=1,130) were not receiving treatment for depression, 24% (n=370) reported receiving an antidepressant and 5% (n=74) reported seeing a mental health professional.
Model for care
These results compelled Walker, Sharpe and colleagues to conduct a second study designed to evaluate the effectiveness of a collaborative care depression program comprised of cancer nurses, consultation-liaison psychiatrists, primary care physicians and the patient’s oncology team.
“We found that a systematic treatment program for depression that is integrated into cancer care — Depression Care for People with Cancer — was very much more effective than the usual care in reducing depression and improving quality of life, and was relatively inexpensive to deliver (about $1,000 per patient),” Walker told HemOnc Today. “Now that we know that it is effective, we need to work out how best to implement Depression Care for People with Cancer into cancer services.”
Walker, Sharpe and colleagues assigned 253 patients with cancer and major depression to the depression care program, and 247 patients to usual care provided by primary care physicians.
All patients had favorable cancer prognoses, or at least a 12-month estimated survival, and 90% of patients in both groups were women. Other characteristics were similar between the study arms; however, the length of the current depressive episode was longer in the depression care cohort (P<.05).
Eighty-seven percent of patients in the depression care cohort attended at least four sessions, and a majority of patients in both arms were prescribed antidepressant medication.
Thirty-four cancer-related deaths occurred during the study, and 231 patients in each arm were evaluable at the time of the analysis.
A significantly higher percentage of patients assigned depression care responded to treatment with at least a 50% reduction in their Symptom Checklist Depression Scale (SCL-20) score (62% vs. 17%; adjusted OR=8.5; 95% CI, 5.5-13.4).
Patients who received depression care reported less depression, anxiety, pain and fatigue than those assigned usual care (P<.05 for all). Depression care also was associated with improved functioning, health, quality of life and perceived quality of depression care (P<.05 for all).
Researchers noted one patient was admitted to the psychiatric ward, and one patient attempted suicide during the study. Both of these patients were in the depression care cohort, but researchers deemed these events unrelated to the study’s treatments or procedures.
“The huge benefit that Depression Care for People with Cancer delivers for patients with cancer and depression shows what we can achieve for patients if we take as much care with the treatment of their depression as we do with the treatment of their cancer,” Sharpe said in a press release.
Focus on lung cancer
Due to the higher prevalence of major depression in patients with lung cancer, Walker, Sharpe and colleagues also conducted a randomized trial to assess the efficacy of depression care in patients with lung cancer.
The program was modeled after the Depression Care for People with Cancer but focused on patients with lung cancer who had poor prognoses, or at least a 3-month estimated survival.
The analysis included 131 patients with lung cancer and major depression, 59 of whom received depression care and 72 of whom received usual care.
Fifty-five patients (93.2%) assigned depression care attended at least four sessions, and the median number of sessions was eight (IQR, 7-10). A greater proportion of patients assigned depression care were prescribed antidepressant medication (85% vs. 63%).
Median follow-up was 219 days (IQR, 118-224).
The mean SCL-20 score for patients who received depression care was 1.24, which was significantly lower than the mean score of 1.61 among patients who received usual care (difference, –0.38; 95% CI, –0.58 to –0.18).
Patients with lung cancer who received depression care also experienced improved self-rated depression (P<.0001), perceived quality of care (P<.0001), quality of life (P=.018), role functioning (P=.0019) and anxiety (P=.046).
A greater proportion of patients who received depression care demonstrated a treatment response by 12 weeks than those who received usual care (51% vs. 15%; OR=5.88; 95% CI, 2.42-14.33).
“This trial shows that we can effectively treat depression in patients with poor prognosis cancers like lung cancer and really improve patients’ lives,” Walker said in the press release. – by Alexandra Todak
References:
Sharpe M. Lancet. 2014;doi:10.1016/S0140-6736(14)61231-9.
Walker J. Lancet Oncol. 2014;doi:10.1016/S1470-2045(14)70343-2.
Walker J. Lancet Psychiatry. 2014;doi:10.1016/S2215-0366(14)70313-X.
For more information:
Jane Walker, MBChB, MSc, PhD, MRCPsych, can be reached at University of Oxford Department of Psychiatry, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX, United Kingdom; email: jane.walker@psych.ox.ac.uk.
Perspective
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William Pirl, MD, MPH
The recent set of important articles by Walker, Sharpe, and colleagues are very timely as cancer centers prepare to meet the new American College of Surgeons Commission on Cancer standard that requires the implementation of systems to screen all patients for psychosocial distress starting in 2015. The goal of this screening is to identify patients with psychosocial distress, like depression, and treat or refer them to appropriate services.Systematic screening presents a tremendous opportunity to improve cancer care by addressing untreated depression in patients. Untreated depression can result from either not recognizing depression or inadequately treating depression once it has been identified. Previous research primarily has focused on the under-recognition of depression in oncology. Although the article by Walker and colleagues in Lancet Psychiatry does not parse the rates of under-recognition vs. under-treatment in the 73% of depressed patients with cancer classified as not receiving effective treatment, the other two articles demonstrate that both are likely contributing to the problem.
At baseline, about a quarter of the mixed-cancer sample and a third of the lung cancer sample were prescribed antidepressants at any dose, regardless of whether the dose was judged to be effective. In the usual care groups, rates of antidepressant prescriptions more than doubled after medical providers were informed that their patients met criteria for depression. This supports that under-recognition may lead to depression going untreated in patients with cancer.
However, merely informing the medical providers that a patient was depressed in the usual care group resulted in less than half the patients receiving at least the minimally effective dose of antidepressants, and 10% to 17% having mental health consultations at follow-up. Patients in the intervention group had greater rates of both antidepressant prescriptions and antidepressants prescribed at minimally effective doses, suggesting that under-treatment also is contributing.
Further, patients in the intervention group received counseling sessions from nurses trained in evidence-based therapies, while only a small portion of patients in the usual care groups received specialized mental health treatment. These data support the need for both screening and treatment protocols triggered by the screening.
The treatment protocol intervention — a collaborative care model for the treatment of depression — has now had decades of trials proving its effectiveness in primary care and chronic illness populations. These two trials add to the existing evidence for its effectiveness in patients with cancer. With all of this evidence, collaborative care for depression — which starts with screening — should become the standard of care. Depression can be devastating with its effects on quality of life, functioning, adherence to treatments, risk of suicide and possibly even survival. Collaborative care, designed with minimizing the need for sometimes scarce psychiatric resources, should be implemented along with screening for distress.
Fewer trials formed the basis of the ASCO recommendation that all patients with metastatic cancer receive early palliative care. Although ASCO released guidelines for the treatment of depression and anxiety in patients with cancer in 2014, these guidelines are for treatment at the individual level and do not address the best models to deliver this care. Collaborative care would be one way to deliver care consistent with these guidelines.
These articles indirectly highlight the potential benefits of implementing the new American College of Surgeons standard, as well as its limitations. Fulfilling the standard may only result in improved care if effective treatment protocols, such as collaborative care, also are implemented.
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