Majority of cancer patients with depression untreated; integrated collaborative care found ‘strikingly’ effective

Approximately 75% of cancer patients with major depression are not receiving treatment for their depression, according to an analysis of data from more than 21,000 patients.

However, a novel integrated treatment program designed specifically for cancer patients was shown in two additional studies to be strikingly more effective than usual care for reducing depressive symptoms and improving quality of life – even in those with a poor prognosis.

The findings were reported online Aug. 28 in the Lancet Psychiatry, the Lancet, and the Lancet Oncology.

Of 21,151 patients (mean age, 64 years) who were attending cancer clinics in Scotland between May 2008 and August 2011, 1,538 had major depression and complete patient-reported treatment data available. Of those, 1,130 (73%) were not receiving appropriate treatment, Jane Walker, Ph.D. of the University of Oxford (England) and her colleagues reported (Lancet Psychiatry 2014 Aug. 28 [doi: 10.1016/S2215-0366(14)70313-X]).

The prevalence of major depression was highest in patients with lung cancer (13.1%), followed by those with gynecological cancer (10.9%), breast cancer (9.3%), colorectal cancer (7.0%), and genitourinary cancer (5.6%). Younger patients, those with lower social deprivation scores, and women with lung or colorectal cancer were at increased risk for major depression.

Younger patients and women were more likely than older patients and men to be receiving treatment, and those with breast cancer were most likely to receive treatment for depression (32%), while those with lung cancer were least likely to receive treatment (19%), the investigators said.

Notably, those who had been living with a cancer diagnosis for more than a year were as likely to have depression as those with a recent diagnosis, and those who had received initial curative treatment were as likely to have depression as those who received palliative treatment, they reported.

The findings suggest that major depression is substantially more common in people with cancer than in the general population, in which the estimated point prevalence is 2% and the estimated 12-month prevalence is 4%-5%.

"Perhaps our most important finding was that most cancer outpatients with depression were not in receipt of potentially effective treatment for their depression," they said, noting that major depression among cancer outpatients merits greater attention, and that systematic approaches to improving depression care for patients with cancer are urgently needed.

One such approach was evaluated by Dr. Walker and her colleagues from the Symptom Management Research Trials (SMaRT) Oncology-2 and Oncology-3 teams.

Of 231 patients with cancer and major depression who were enrolled in the SMaRT Oncology-2 randomized controlled effectiveness trial between May 2008 and May 2011 and assigned to receive integrated collaborative depression care (Depression Care for People with Cancer, or DCPC), 143 (62%) experienced at least a 50% improvement on the Symptom Checklist Depression Scale score at 24 weeks. Of 231 patients assigned to receive usual care, only 40 (17%) achieved a 50% or greater response at 24 weeks (adjusted odds ratio for treatment response, 8.5; number needed to treat, 2.24), Dr. Michael Sharpe of the University of Oxford reported on behalf of the SMaRT Oncology-2 team (Lancet 2014 Aug. 28 [doi: 10/1016/S0140-6736(14)61231-9]).

Additionally, 33% of those in the DCPC group achieved remission of their major depression, compared with 4% of those in the usual care group (odds ratio, 13.1).

Those in the DCPC group had less depression, anxiety, pain, and fatigue, and had better functioning, health, quality of life, and perceived quality of depression care at each of four time points evaluated during the course of the study, the investigators said.

DCPC is a manualized, multicomponent collaborative care treatment, delivered systematically by cancer nurses and psychiatrists, in conjunction with primary care physicians and oncologists, to provide "systematic proactive treatment and follow-up." Usual care was provided by primary care physicians and/or oncologists, who were instructed to treat the patients as they normally would, such as with antidepressants or referral for a mental health assessment.

Patients in SMaRT Oncology-2 were adults with a good prognosis who were attending cancer clinics in Scotland, and who had major depression of at least 4 weeks’ duration.

"The findings of this trial add to the accumulating evidence for the effectiveness of collaborative care approaches to the treatment of depression comorbid with medical conditions. They also provide new evidence that large and sustained treatment effects can be achieved if depression treatment is integrated with medical care, intensive, and systematically delivered by a well-trained and supervised team," the investigators concluded. The cost of DCPC as delivered in this trial was "quite modest, especially in the context of cancer treatment," they noted.

In a related trial (SMaRT Oncology-3), the investigators found that even patients with a poor prognosis respond well to DCPC. Patients in SMaRT Oncology-3 were adults with major depression attending cancer clinics in Scotland between January 2009 and September 2011. All had a diagnosis of primary lung cancer, and a predicted survival of at least 3 months.

Mean depression severity – a summary measure of each participant’s depression severity scores averaged over the course of the study (up to 32 weeks) was significantly lower in 68 patients with lung cancer who were assigned to receive DCPC than in 74 patients assigned to receive usual care (mean Symptom Checklist Depression Scale scores of 1.24 vs. 1.61; standardized mean difference, –0.62), Dr. Walker reported on behalf of the SMaRT Oncology-3 team.

In addition, significantly more patients receiving DCPC achieved at least a 50% reduction in depression severity scale scores (51% vs. 15%).

"We also recorded significant differences between the treatment groups in self-rated depression improvement, anxiety, quality of life, role functioning, and perceived quality of care, all in favor of the depression care for the people with lung cancer group," they said.

"Our findings suggest that, despite the rapid deterioration of this patient group, successful clinical trials in patients with poor-prognosis cancer and comorbid major depression are possible, through adaptation of both trial design and treatment delivery. Our results also suggest that it is possible to effectively treat major depression in this patient group. ... Large trials are now needed to estimate the effectiveness and cost-effectiveness of depression care for people with lung cancer in this population, and further adaptation of the treatment is needed to address the unmet needs of patients with major depression and a shorter life expectancy," they concluded.

The authors reported having no conflicts of interest. The Lancet Psychiatry and Lancet studies were jointly sponsored by the University of Edinburgh and NHS Lothian, and were funded by Cancer Research UK (CRUK), with additional funding from the Chief Scientist Office (CSO) of the Scottish Government and NHS Research Scotland. The Lancet Psychiatry article was also funded by CRUK and the CSO of the Scottish Government. Dr. Walker is supported by Sir Michael Sobell House Hospice, Oxford; and the NIHR Collaboration for Leadership in Applied Health Research and Care Oxford at the Oxford Health NHS Foundation Trust.

Approximately 75% of cancer patients with major depression are not receiving treatment for their depression, according to an analysis of data from more than 21,000 patients.

However, a novel integrated treatment program designed specifically for cancer patients was shown in two additional studies to be strikingly more effective than usual care for reducing depressive symptoms and improving quality of life – even in those with a poor prognosis.

The findings were reported online Aug. 28 in the Lancet Psychiatry, the Lancet, and the Lancet Oncology.

Of 21,151 patients (mean age, 64 years) who were attending cancer clinics in Scotland between May 2008 and August 2011, 1,538 had major depression and complete patient-reported treatment data available. Of those, 1,130 (73%) were not receiving appropriate treatment, Jane Walker, Ph.D. of the University of Oxford (England) and her colleagues reported (Lancet Psychiatry 2014 Aug. 28 [doi: 10.1016/S2215-0366(14)70313-X]).

The prevalence of major depression was highest in patients with lung cancer (13.1%), followed by those with gynecological cancer (10.9%), breast cancer (9.3%), colorectal cancer (7.0%), and genitourinary cancer (5.6%). Younger patients, those with lower social deprivation scores, and women with lung or colorectal cancer were at increased risk for major depression.

Younger patients and women were more likely than older patients and men to be receiving treatment, and those with breast cancer were most likely to receive treatment for depression (32%), while those with lung cancer were least likely to receive treatment (19%), the investigators said.

Notably, those who had been living with a cancer diagnosis for more than a year were as likely to have depression as those with a recent diagnosis, and those who had received initial curative treatment were as likely to have depression as those who received palliative treatment, they reported.

The findings suggest that major depression is substantially more common in people with cancer than in the general population, in which the estimated point prevalence is 2% and the estimated 12-month prevalence is 4%-5%.

"Perhaps our most important finding was that most cancer outpatients with depression were not in receipt of potentially effective treatment for their depression," they said, noting that major depression among cancer outpatients merits greater attention, and that systematic approaches to improving depression care for patients with cancer are urgently needed.

One such approach was evaluated by Dr. Walker and her colleagues from the Symptom Management Research Trials (SMaRT) Oncology-2 and Oncology-3 teams.

Of 231 patients with cancer and major depression who were enrolled in the SMaRT Oncology-2 randomized controlled effectiveness trial between May 2008 and May 2011 and assigned to receive integrated collaborative depression care (Depression Care for People with Cancer, or DCPC), 143 (62%) experienced at least a 50% improvement on the Symptom Checklist Depression Scale score at 24 weeks. Of 231 patients assigned to receive usual care, only 40 (17%) achieved a 50% or greater response at 24 weeks (adjusted odds ratio for treatment response, 8.5; number needed to treat, 2.24), Dr. Michael Sharpe of the University of Oxford reported on behalf of the SMaRT Oncology-2 team (Lancet 2014 Aug. 28 [doi: 10/1016/S0140-6736(14)61231-9]).

Additionally, 33% of those in the DCPC group achieved remission of their major depression, compared with 4% of those in the usual care group (odds ratio, 13.1).

Those in the DCPC group had less depression, anxiety, pain, and fatigue, and had better functioning, health, quality of life, and perceived quality of depression care at each of four time points evaluated during the course of the study, the investigators said.

DCPC is a manualized, multicomponent collaborative care treatment, delivered systematically by cancer nurses and psychiatrists, in conjunction with primary care physicians and oncologists, to provide "systematic proactive treatment and follow-up." Usual care was provided by primary care physicians and/or oncologists, who were instructed to treat the patients as they normally would, such as with antidepressants or referral for a mental health assessment.

Patients in SMaRT Oncology-2 were adults with a good prognosis who were attending cancer clinics in Scotland, and who had major depression of at least 4 weeks’ duration.

"The findings of this trial add to the accumulating evidence for the effectiveness of collaborative care approaches to the treatment of depression comorbid with medical conditions. They also provide new evidence that large and sustained treatment effects can be achieved if depression treatment is integrated with medical care, intensive, and systematically delivered by a well-trained and supervised team," the investigators concluded. The cost of DCPC as delivered in this trial was "quite modest, especially in the context of cancer treatment," they noted.

In a related trial (SMaRT Oncology-3), the investigators found that even patients with a poor prognosis respond well to DCPC. Patients in SMaRT Oncology-3 were adults with major depression attending cancer clinics in Scotland between January 2009 and September 2011. All had a diagnosis of primary lung cancer, and a predicted survival of at least 3 months.

Mean depression severity – a summary measure of each participant’s depression severity scores averaged over the course of the study (up to 32 weeks) was significantly lower in 68 patients with lung cancer who were assigned to receive DCPC than in 74 patients assigned to receive usual care (mean Symptom Checklist Depression Scale scores of 1.24 vs. 1.61; standardized mean difference, –0.62), Dr. Walker reported on behalf of the SMaRT Oncology-3 team.

In addition, significantly more patients receiving DCPC achieved at least a 50% reduction in depression severity scale scores (51% vs. 15%).

"We also recorded significant differences between the treatment groups in self-rated depression improvement, anxiety, quality of life, role functioning, and perceived quality of care, all in favor of the depression care for the people with lung cancer group," they said.

"Our findings suggest that, despite the rapid deterioration of this patient group, successful clinical trials in patients with poor-prognosis cancer and comorbid major depression are possible, through adaptation of both trial design and treatment delivery. Our results also suggest that it is possible to effectively treat major depression in this patient group. ... Large trials are now needed to estimate the effectiveness and cost-effectiveness of depression care for people with lung cancer in this population, and further adaptation of the treatment is needed to address the unmet needs of patients with major depression and a shorter life expectancy," they concluded.

The authors reported having no conflicts of interest. The Lancet Psychiatry and Lancet studies were jointly sponsored by the University of Edinburgh and NHS Lothian, and were funded by Cancer Research UK (CRUK), with additional funding from the Chief Scientist Office (CSO) of the Scottish Government and NHS Research Scotland. The Lancet Psychiatry article was also funded by CRUK and the CSO of the Scottish Government. Dr. Walker is supported by Sir Michael Sobell House Hospice, Oxford; and the NIHR Collaboration for Leadership in Applied Health Research and Care Oxford at the Oxford Health NHS Foundation Trust.

Approximately 75% of cancer patients with major depression are not receiving treatment for their depression, according to an analysis of data from more than 21,000 patients.

However, a novel integrated treatment program designed specifically for cancer patients was shown in two additional studies to be strikingly more effective than usual care for reducing depressive symptoms and improving quality of life – even in those with a poor prognosis.

The findings were reported online Aug. 28 in the Lancet Psychiatry, the Lancet, and the Lancet Oncology.

Of 21,151 patients (mean age, 64 years) who were attending cancer clinics in Scotland between May 2008 and August 2011, 1,538 had major depression and complete patient-reported treatment data available. Of those, 1,130 (73%) were not receiving appropriate treatment, Jane Walker, Ph.D. of the University of Oxford (England) and her colleagues reported (Lancet Psychiatry 2014 Aug. 28 [doi: 10.1016/S2215-0366(14)70313-X]).

The prevalence of major depression was highest in patients with lung cancer (13.1%), followed by those with gynecological cancer (10.9%), breast cancer (9.3%), colorectal cancer (7.0%), and genitourinary cancer (5.6%). Younger patients, those with lower social deprivation scores, and women with lung or colorectal cancer were at increased risk for major depression.

Younger patients and women were more likely than older patients and men to be receiving treatment, and those with breast cancer were most likely to receive treatment for depression (32%), while those with lung cancer were least likely to receive treatment (19%), the investigators said.

Notably, those who had been living with a cancer diagnosis for more than a year were as likely to have depression as those with a recent diagnosis, and those who had received initial curative treatment were as likely to have depression as those who received palliative treatment, they reported.

The findings suggest that major depression is substantially more common in people with cancer than in the general population, in which the estimated point prevalence is 2% and the estimated 12-month prevalence is 4%-5%.

"Perhaps our most important finding was that most cancer outpatients with depression were not in receipt of potentially effective treatment for their depression," they said, noting that major depression among cancer outpatients merits greater attention, and that systematic approaches to improving depression care for patients with cancer are urgently needed.

One such approach was evaluated by Dr. Walker and her colleagues from the Symptom Management Research Trials (SMaRT) Oncology-2 and Oncology-3 teams.

Of 231 patients with cancer and major depression who were enrolled in the SMaRT Oncology-2 randomized controlled effectiveness trial between May 2008 and May 2011 and assigned to receive integrated collaborative depression care (Depression Care for People with Cancer, or DCPC), 143 (62%) experienced at least a 50% improvement on the Symptom Checklist Depression Scale score at 24 weeks. Of 231 patients assigned to receive usual care, only 40 (17%) achieved a 50% or greater response at 24 weeks (adjusted odds ratio for treatment response, 8.5; number needed to treat, 2.24), Dr. Michael Sharpe of the University of Oxford reported on behalf of the SMaRT Oncology-2 team (Lancet 2014 Aug. 28 [doi: 10/1016/S0140-6736(14)61231-9]).

Additionally, 33% of those in the DCPC group achieved remission of their major depression, compared with 4% of those in the usual care group (odds ratio, 13.1).

Those in the DCPC group had less depression, anxiety, pain, and fatigue, and had better functioning, health, quality of life, and perceived quality of depression care at each of four time points evaluated during the course of the study, the investigators said.

DCPC is a manualized, multicomponent collaborative care treatment, delivered systematically by cancer nurses and psychiatrists, in conjunction with primary care physicians and oncologists, to provide "systematic proactive treatment and follow-up." Usual care was provided by primary care physicians and/or oncologists, who were instructed to treat the patients as they normally would, such as with antidepressants or referral for a mental health assessment.

Patients in SMaRT Oncology-2 were adults with a good prognosis who were attending cancer clinics in Scotland, and who had major depression of at least 4 weeks’ duration.

"The findings of this trial add to the accumulating evidence for the effectiveness of collaborative care approaches to the treatment of depression comorbid with medical conditions. They also provide new evidence that large and sustained treatment effects can be achieved if depression treatment is integrated with medical care, intensive, and systematically delivered by a well-trained and supervised team," the investigators concluded. The cost of DCPC as delivered in this trial was "quite modest, especially in the context of cancer treatment," they noted.

In a related trial (SMaRT Oncology-3), the investigators found that even patients with a poor prognosis respond well to DCPC. Patients in SMaRT Oncology-3 were adults with major depression attending cancer clinics in Scotland between January 2009 and September 2011. All had a diagnosis of primary lung cancer, and a predicted survival of at least 3 months.

Mean depression severity – a summary measure of each participant’s depression severity scores averaged over the course of the study (up to 32 weeks) was significantly lower in 68 patients with lung cancer who were assigned to receive DCPC than in 74 patients assigned to receive usual care (mean Symptom Checklist Depression Scale scores of 1.24 vs. 1.61; standardized mean difference, –0.62), Dr. Walker reported on behalf of the SMaRT Oncology-3 team.

In addition, significantly more patients receiving DCPC achieved at least a 50% reduction in depression severity scale scores (51% vs. 15%).

"We also recorded significant differences between the treatment groups in self-rated depression improvement, anxiety, quality of life, role functioning, and perceived quality of care, all in favor of the depression care for the people with lung cancer group," they said.

"Our findings suggest that, despite the rapid deterioration of this patient group, successful clinical trials in patients with poor-prognosis cancer and comorbid major depression are possible, through adaptation of both trial design and treatment delivery. Our results also suggest that it is possible to effectively treat major depression in this patient group. ... Large trials are now needed to estimate the effectiveness and cost-effectiveness of depression care for people with lung cancer in this population, and further adaptation of the treatment is needed to address the unmet needs of patients with major depression and a shorter life expectancy," they concluded.

The authors reported having no conflicts of interest. The Lancet Psychiatry and Lancet studies were jointly sponsored by the University of Edinburgh and NHS Lothian, and were funded by Cancer Research UK (CRUK), with additional funding from the Chief Scientist Office (CSO) of the Scottish Government and NHS Research Scotland. The Lancet Psychiatry article was also funded by CRUK and the CSO of the Scottish Government. Dr. Walker is supported by Sir Michael Sobell House Hospice, Oxford; and the NIHR Collaboration for Leadership in Applied Health Research and Care Oxford at the Oxford Health NHS Foundation Trust.