Perspective from William Pirl, MD, MPH
October 01, 2014
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Multidisciplinary approach may better detect, treat depression among patients with cancer

Perspective from William Pirl, MD, MPH
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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, MBChB, MSc, PhD, MRCPsych

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).

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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.