© 2004 by Oxford University Press
2004 © Oxford University Press
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ARTICLE |
Barriers to the Treatment of Depression in Cancer Patients
Correspondence to: Donna B. Greenberg, MD, Department of Psychiatry, WRN 605, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114 (e-mail: dgreenberg{at}partners.org)
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ABSTRACT |
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 Top Abstract IntroductionMajor Depressive DisorderBarriers to Quality of...Special CategoriesStrategies To Improve Depression...Further ResearchLeadershipReferences |
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Major depressive disorder is a relapsing syndrome with grave morbidity and mortality. Much like asthma, it has a genetic predisposition and environmental triggers. Specific antidepressant medications alone, tested in randomized, placebo-controlled studies, show that this is a treatable condition with 65%-70% clinical response. Treatment guidelines written for psychiatric patients and patients in primary care clarify the role of medications and psychotherapy. Physicians are compelled to treat syndromes that are serious and treatable, but barriers to diagnosis and treatment of major depressive disorder in cancer patients include two major barriers to quality medical care generally: uncertainty and cost. Given uncertainty about diagnosis and treatment, cancer physicians with limited time avoid questions about emotions. Cases of depression are often missed. Mental health specialists often work in systems that are separated from oncologists by location, organization, and insurance. Most successful interventions to improve treatment of depressive disorders require multiple strategies: clinical education, enhanced role of nurses, and integrated oncology and specialist care. Recent strategies in oncology settings are reviewed. Research concepts to improve outcomes in treatment of depression include staging of depressive disorder in cancer to reveal prognosis, evaluation of depression outcomes in the context of one tumor type, new organizational models in the acute cancer setting, use of the cancer protocol, and assessment of access to care of depression in cancer survivors. Major depressive disorder in cancer is staged by positive past history, comorbid anxiety disorder or substance abuse, use of specific cancer medications that destabilize mood, and active cancer or no evidence of disease.
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INTRODUCTION |
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TopAbstractIntroductionMajor Depressive DisorderBarriers to Quality of...Special CategoriesStrategies To Improve Depression...Further ResearchLeadershipReferences |
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A major barrier to the treatment of depression in cancer patients comes from confusion about the morbidity of major depressive disorder compared with other sources of sadness for cancer patients. Both uncertainty and cost restraints in current models of oncology care affect the quality of mental health care given to cancer patients. This article reviews the morbidity of major depressive disorder, the documented benefits of treatment, and the ways uncertainty and cost containment limit recognition and treatment among cancer patients. The issues related to special categories like survivors, those at the end of life, the elderly, children, and patients receiving complementary treatments are considered. Strategies that improve care of major depressive disorder in oncology settings are reviewed, and further research questions are considered.
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MAJOR DEPRESSIVE DISORDER |
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TopAbstractIntroductionMajor Depressive DisorderBarriers to Quality of...Special CategoriesStrategies To Improve Depression...Further ResearchLeadershipReferences |
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Major depressive disorder is a relapsing syndrome with grave morbidity and mortality. Complications of major depressive disorder include suicide, inanition, and significant functional impairment (1). This disorder, much like asthma, has a genetic predisposition and environmental triggers. Because its clinical presentation varies, and no consistent laboratory abnormalities are known, diagnosis of the syndrome for research consensus has been based on established criteria of symptoms and signs. The lifetime prevalence of major depressive disorder is 16.2%, and the 12-month prevalence is 6.6% in adults (2). It is more common in women than men, with a risk ratio of 1.7 to 1.0 over a lifetime and 1.4 to 1.0 for 12 months. Risk factors are personal or family history of depressive disorder, prior suicide attempts, female gender, lack of social supports, stressful life events, and current substance abuse. More than 50% of those who have one episode have another (3). The second episode is often within 2 years, but the majority (75%) of recurrences occur within 10 years (4). In her article here (p. ), Massie has reviewed the literature on prevalence of depression among cancer patients in different settings (5).
Since the 1950s, multiple medications have been synthesized to treat major depressive disorder. These medications have been tested in systematic placebo-controlled, randomized studies. Overall, antidepressants have a clinical response rate of 65%-70% (6,7). A clinical response has been defined as at least 50% reduction in symptoms, whereas full remission implies that patients no longer meet criteria for the syndrome (8). The methodology for these psychopharmacologic studies includes diagnosis by a structured interview that assesses current symptoms, lifetime diagnosis, and comorbid psychiatric diagnoses. Drug response is typically assessed by a validated provider-measured scale.
Guidelines for appropriate use of medications and psychotherapy apply to specialist treatment of the disorder (9) and to the disorder as seen in primary care (3). The standard psychopharmacology treatment of depression recommended in the clinical update of the Annals of Internal Medicine in 2001 (4) is a minimum course of 6 months of treatment to reduce the risk of relapse. Long-term antidepressant therapy seems to have a prophylactic effect. For patients with two or more serious recurrences in 5 years or three serious lifetime recurrences, long-term antidepressant treatment is recommended.
In patients with medical illness, major depressive disorder, and even subthreshold depression, mortality rates are higher. Medical illness, past depression, and present depression are a predictive triad for in-hospital mortality (10,11). Over the course of a chronic illness like cancer, depression is associated with more functional impairment and poorer quality of life (12,13).
Medical morbidity of cancer and the associated disorders of an older population do not prevent treatment response (14,15). That antidepressant medication succeeds in treating major depressive disorder in cancer patients is the conclusion of the evidence-based review of treatment supported by this conference (16). A Cochrane evidence-based report on the use of antidepressants in the medically ill also finds that medical patients with depression are more likely to improve with antidepressants than with placebo (17). Two of the eight studies reviewed in this analysis specifically focused on patients with cancer; the other studies included patients with other common conditions of cancer patients, like lung and kidney disease.
Antidepressants are well tolerated even in the medically ill. In the Cochrane analysis, the authors estimated that only one of 10 patients dropped out of antidepressant treatment because of treatment with the drug rather than placebo. Response rates do not seem to differ between those with greater severity or those with lesser severity of comorbidity (18,19).
We do not know whether patients with cancer have worse depression outcomes than those without cancer. In a study of 1356 depressed patients from 46 managed primary care clinics, patients with comorbid medical disorders had worse depression outcomes than depressed patients without comorbid medical illness (20). However, the outcome was improved for those with comorbid illness with a quality-improvement program. The program included training experts and nurse specialists to provide education and assessment, access to nurse specialists for antidepressant medication follow-up, or access to psychotherapists.
Psychotherapy interventions have been developed specifically to treat major depressive disorder. Psychosocial interventions like relaxation techniques (21), hypnosis, and individual and group psychotherapy (22) have been shown to reduce distress in cancer patients, but these treatments have not been specifically focused on major depressive disorder in a cancer setting. The effectiveness of psychosocial interventions for depression in cancer patients is also discussed in this issue (16). For one prominently studied treatment, group supportive-expressive psychotherapy for breast cancer patients with metastatic disease, depressive symptoms were measured by the Profile of Mood States, an adjective checklist (23,24). The study was developed to evaluate the effect of treatment on survival rather than for treatment of depressive disorder, specifically.
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BARRIERS TO QUALITY OF CARE |
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TopAbstractIntroductionMajor Depressive DisorderBarriers to Quality of...Special CategoriesStrategies To Improve Depression...Further ResearchLeadershipReferences |
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Physicians are compelled to consider treatment for syndromes that are serious and treatable. Any barrier to the recognition of major depressive disorder in a cancer patient, when the condition is known in the general population even without the stress of a cancer diagnosis, is an impediment to quality of care. Barriers to diagnosis and treatment of major depressive disorder in cancer patients include two major barriers to quality medical care in general: uncertainty and cost (25).
Uncertainty
The anxiety and sadness that come naturally with bad news may be assumed to be appropriate to the context. The vegetative symptoms of depression overlap with the vegetative symptoms of medical illness. Like an upper respiratory infection, an episode of depression may cause discomfort, but no laboratory equivalent to the streptococcal culture identifies quickly those who warrant drug treatment to prevent more serious morbidity. Trask has reviewed (26) the complexities of structured clinical interview and self-report assessment of depression in the cancer patient in this journal. Guidelines that do not clearly delineate the role of medications or psychotherapy add to the confusion. The psychiatric diagnoses of adjustment disorder and dysthymia, as well as the multiple causes of distress in the cancer setting, cloud the recognition of major depressive disorder. The oncology staff deals with many patients unhappy about their predicament and do not always have the conviction that treating those with major depressive disorder will make a difference.
Often cancer physicians do not ask, and patients with cancer do not tell. Patients want to avoid the stigma of weakness of will or "craziness" (27,28). They may want to appear strong to the oncologist so that the oncologist will not give up on them. They may have never had cancer before and attribute dysphoria to the knowledge of the diagnosis and difficulty of treatment. Barriers to care of depression include patient worry about medication side effects, confidentiality, and stigma of treatment (29). The nature of depressive illness itself—thoughts of hopelessness and worthlessness—inhibits active pursuit of care, adherence to a treatment, and the ability to recognize what is emotional distortion rather than cancer itself.
Given the uncertainty about diagnosis, physicians with limited time avoid questions about emotions. Maguire (28) documented that British general physicians with cancer patients generally assumed that any patient who had psychological problems serious enough to warrant help would consult them and request treatment. The physicians felt a conversation would take too much time. Interviewed physicians admitted that they tended not to ask about psychological state unless patients offered that they were having difficulties. Physicians were observed to use strategies that distanced them from emotions: switching topics, ignoring cues, reassuring prematurely.
Many cases of depression are missed. Hardman et al. (30) found that only half of depressed patients on a British medical oncology service were recognized by physicians and nurses. In the only American study of oncologists' recognition of depression in their patients with cancer, Passik et al. (31) studied 25 ambulatory oncology clinics in Indiana, asking 1109 patients treated by 12 oncologists to complete the Zung Self-Rating Depression Scale. Physicians rated the patients' levels of depressive symptoms, anxiety, and pain on a numerical scale. Physicians identified patients with no affective symptoms 79% of the time, but they identified only one-third of patients who reported mild to moderate symptoms, and only 13% of those who had severe ratings on the Zung (31). In a study of depressive disorders among cancer patients in an outpatient oncology clinic of a major hospital in South Africa, only 14% of patients with major depressive disorder had been treated (32). Fallowfield's (33) study of 143 doctors in 34 cancer centers and hospitals in the United Kingdom found that psychiatric morbidity was misclassified in 35% of 800 patients. The sensitivity of their assessments (true positive rate) was 29%, and specificity (true negative rate) was 85%.
The more severe and visible symptoms are the ones more likely to arouse concern in the cancer treatment setting. Passik (31) found that oncologists were influenced by crying and depressed mood, anxiety, pain, and global dysfunction; oncology nurses followed the same pattern (34). Similarly, treatment in the primary care setting is more likely if the patient has more severe disease or comorbid anxiety, but silent symptoms like suicidal ideation are often missed (35). Screening instruments can open the conversation about more invisible depressive symptoms, or physicians could probe for more reliable cognitive symptoms of depression like anhedonia, guilt, suicidal thinking, and hopelessness (31), but the judgment as to whether they signal major depressive disorder must still be evaluated by a caregiver who can consider both medical and psychiatric syndromes and evaluate treatment efforts.
More insight about physician ability to make the diagnosis comes from the context of primary care. The primary care physician who prefers to provide counseling for depression is more apt to detect depression (36). Visit context is another determinant; depression has been more often considered during scheduled check-ups (when there may be more time to consider emotional factors) than in visits for new medical problems (35).
If oncology staff believe that the answer to the psychiatric referral question will make a difference, the referral question should be as clear as that for heart disease. Lack of provider referral and lack of patient awareness of a counseling service were among the major barriers to use of support and information services noted by patients with breast, colon, and prostate cancer in an Oregon health management organization (HMO) (37). The oncology and urology providers reported referring 70% of their patients to HMO cancer support services, but only 24% of patients reported that physicians had mentioned the counseling center. In some cases, referral meant the mention of a brochure; in others, physicians aware of patients' psychosocial concerns gave focused referrals.
The responsibility to consider and treat depression is further complicated by the burden of other psychiatric problems like substance abuse. Psychiatric problems, particularly chronic conditions that are difficult to treat, often appear to be outside the purview of the cancer effort and within the control of the patient as an individual. Quality-of-life measures often correlate with depressive scores, but these scores do not distinguish unhappiness about the complications of cancer from the presence of major depressive disorder. Although it is known that major depressive disorder impairs function and quality of life (12,13), poor quality-of-life outcomes in oncology are attributed solely to the burden of the cancer and not to comorbid untreated major depressive disorder.
Cost
Some comprehensive cancer centers have psychiatric or psychosocial oncology staff (psychiatrists, psychologists, and social workers), and other hospitals depend on the psychiatry staff, a few with consultation psychiatry services. Because mental health insurance coverage is limited, cost restricts the number of staff available. In most communities, referral for evaluation of psychiatric diagnosis or counseling depends on referral to independent mental health services not linked to oncology. In Massachusetts, for instance, progressive defunding of psychiatric services has made provision of mental health treatment in organized settings like hospitals and clinics a money-losing proposition, and some departments have closed (38). Outpatient care is delivered by a mix of private practitioners, for-profit and nonprofit clinics, and community mental health centers. Most insurance coverage for mental health treatment is administered either by "carved out" managed behavioral health care organizations or by an HMO directly. Medicare is the only traditional indemnity coverage. Medicaid, the program for the indigent, also carves out psychiatric care to a for-profit, managed behavioral health care organization. Private practitioners have fled managed plans as the fee scale has been ratcheted down. The staff working with the oncology team may not be on the carved-out panel of providers. In the community, mental health care has been less accessible to the elderly, rural, and economically disadvantaged (39). The federal view of fragmentation of care and the limitations on treatment were delineated in the President's New Freedom Commission on Mental Health in the fall of 2002 (40) and in the U.S. surgeon general's report on mental health in 1999 (41).
Oncology services are organized with a focus of specific disease management. The goal is cure of the cancer, prolonged survival, or disease-free survival. The first priority is the up-front management of the disease. A recent study of outpatient cancer drug costs in 1995 and 1998 for about 14 000 Commercial and Medicare health maintenance organization enrollees showed that supportive therapies, specifically psychotherapeutic agents and analgesics, had only a modest effect on total spending. The main burden comes from the cost of new anticancer treatments (42). Most payments for oncology practice are organized around payment for the procedures of care.
Although specialists are trained to assess and treat clinical depression, specialty staff for making psychological assessments are usually not seen as essential to the practice of oncology. Especially in the beginning, the marginal benefit of treating depression is less compelling than the urgency of treating the tumor.
In the usual course of care, the primary care physician considers or detects the cancer diagnosis and refers the patient to a surgeon or medical oncologist. A radiation oncologist may be included in the referral if appropriate to the multidisciplinary approach to the tumor. The patient's path includes the hospital, the medical oncologist's office, and the radiation treatment unit. In both the community and the cancer center, the oncology specialist who will give the bulk of care for that tumor usually organizes the medical care for the new patient with cancer. The oncology nurse, radiation treatment technician, and office support staff are more available to attend to the patients' logistical and medical needs and to hear the patient's day-to-day concerns. They are often invested in the relief of the patient's suffering, but not trained to diagnose and treat major depressive disorder. The physician's inclination to refer a patient for mental health evaluation depends on the availability of a clinician, the willingness of the patient to keep an appointment, and the patient's ability to pay.
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SPECIAL CATEGORIES |
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TopAbstractIntroductionMajor Depressive DisorderBarriers to Quality of...Special CategoriesStrategies To Improve Depression...Further ResearchLeadershipReferences |
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Survivors
Over the course of an illness, the treatment imperative changes. Initially, patients spend most of their time in oncology specialty care. At the time of diagnosis they face an existential crisis, and antitumor medical treatment is the priority. Survivors live with the fear of recurrence, the physical losses from their treatment, and conditioned anxiety associated with treatment (43). They bring their own past psychiatric history and tendency to depressive illness to the challenge of adaptation. When the patient sees the physician more frequently, the physician-patient bond may facilitate treatment for depression (36).
However, when there is no active cancer, they may lose the connection with the caretakers who can treat or refer. The survivors' emotional and physical isolation as they bear the burden of the cancer and its costs may inhibit attention to depressive symptoms (44).
As the patients become survivors, they fall back into the health services available in the primary care setting.
Overall, primary care physicians often fail to recognize depression, to prescribe an adequate treatment regimen, and to follow up the patients' treatment once it is initiated; appropriate care is more often given by mental health specialists (45). Psychologists and psychiatrists are more likely to treat patients with depression with formal interventions in longer sessions than are general medical clinicians treating patients with depressive disorder (46).
Cancer survivors do report significantly greater contact with mental health providers in the previous year (7.2% versus 5.7%) than did those patients without a cancer history in a nationally representative sample of 95 615 adults interviewed as part of the National Health Interview Survey. Mental health care was more likely for those younger, those who were formerly married, and those with other comorbid conditions. The unmet need for mental health service, which would have raised that rate to 11.7%, was greater among younger individuals, women, and those without health insurance (47).
End of Life
The will to live is quite sturdy but varies considerably during the final course of terminal illness (48). Caretakers may choose a respectful distance from the dying, not wanting to overburden them and not wanting to become too involved themselves (49).
At the end of life, when there is a burden of medical illness, depressive symptoms may seem appropriate. A patient's acknowledgement of depression is a powerful answer to a screening question for major depressive disorder (50), but the patient must be asked, "Are you depressed?"
Because depression in the terminally ill, like depression in others, is associated with hopelessness and persistent suicidal thoughts (51), untreated depression results in earlier admission to hospice or inpatient care (52). Among oncology outpatients, hoarding of drugs to prepare for a possible suicide attempt is related to depression more than pain (53). Even if depressed, patients with cancer can express a convincing benefit analysis of the burdens of continued life despite hopelessness, poor self-esteem, and pessimism (54). In a survey of Oregon psychiatrists, only 6% were very confident that they could in a single evaluation adequately assess whether a psychiatric disorder was impairing the judgment of a patient desiring assisted suicide (55). Antidepressant treatment of hospitalized depressed patients can alter the patient's outlook and, therefore, the desire for death (56).
Both medication and psychotherapy may alleviate suffering in the dying, but clinicians tend to be more worried about the side effects of antidepressant medications in the severely ill and to think that the time left to achieve benefit is too little (57). Hopelessness and humiliation may be eased by psychotherapeutic interventions that sustain dignity and meaning (58,59), but the patient's inability to sustain attention and cognitive clarity can interfere.
Elderly
The older the patients, the more apt they are to be vulnerable to dementia or to reversible cognitive impairment caused by medications, metabolic abnormality, vascular disease, and other comorbid conditions. The belief that the cognitive impairment is irreversible may limit enthusiasm for good care for depression. The cultural context of the patient determines whether he or she will be open to psychiatric treatment, and financial and logistical concerns like transportation can inhibit psychiatric care for the elderly (38). In a recent study of 1801 patients over 60 years with depression selected from 18 primary care clinics in eight organizations in California, Washington, Indiana, North Carolina, and Texas (60)—most with two or more prior depressive episodes—only about 65% had been treated for depression in their lifetime, and only 46% had undergone some treatment in the last 3 months. Rates of care for depression were lower in men, African Americans, Latinos, and those who had not had multiple episodes of depression.
Children
Barriers to care for depression in children include the ambiguity of diagnosis, minimal availability of mental health specialists and insurance to cover them, and unwillingness of the parents to obtain this care. Similar barriers to care exist for depressed parents. Pediatric assessments traditionally pay attention to psychosocial variables and developmental milestones, but the diagnosis of depressive disorder is difficult in children, who are less apt to articulate their feelings of depression. Psychopharmacological treatment of depression has come later to child psychiatry. Recent studies highlight the need for broad-based support for children and families during the first year after diagnosis and the need to be alert for early intervention when general support fails (61).
Complementary Treatments
In complementary medicine and in traditional oncological treatments, effective healers rely in part on the ability to arouse hope in vulnerable patients (62). The patient's report of treatment response is influenced by the physician's attention, interest, and concern for healing; the setting; the expectations of treatment; the reputation of the doctor; the expense; and the impressiveness of treatment (63). Placebos are all the more powerful in the patient under stress (64). In studies of antidepressant medication, placebo response rate is higher for patients with less severe depressive symptoms, shorter episodes, no prior history of chronic depression, and non-endogenous symptom features (65). Complementary medicines may augment a placebo effect and reduce depressive symptoms in those with milder forms of depression and no past history. Barriers to the treatment of emotional syndromes include the factors that work against the placebo response in a cancer treatment arena: high volume of patients, distracted caretakers, and clinical spaces that seem less friendly and respectful. By contrast, a complementary care setting may offer patients a caretaker relationship and hope.
Although complementary treatments may alleviate anxiety symptoms and bring social support closer to the patient, the use of alternative treatments may also signal the patient's distress and their efforts to bypass traditional treatment of depressive illness. Women with newly diagnosed early-stage breast cancer treated with standard therapies who started alternative medicines were more likely to have higher depressive scores, more symptoms, and lower mental health scores than women who had not started alternative medications (66). Psychologically distressed patients may seek this alternative route because they do not want the stigma of conventional psychiatric care or because they do not have access to traditional care for depressive disorder.
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STRATEGIES TO IMPROVE DEPRESSION CARE IN CANCER PATIENTS |
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TopAbstractIntroductionMajor Depressive DisorderBarriers to Quality of...Special CategoriesStrategies To Improve Depression...Further ResearchLeadershipReferences |
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In primary care settings, intensified programs of patient education and shared care among the primary care physician and psychiatrist or psychologist improved patient recovery (67-69). A cost offset was noted in those with major depressive disorder; however, improved management of depressive disorders did not last beyond the period of enhanced organizational care. The education of clinicians alone was not sufficient to maintain the improved outcome. A systematic review by Gilbody et al. (70) found that the most successful interventions combined multiple strategies: clinical education, an enhanced role of the nurse, and greater integration of primary and secondary care. Telephone medication counseling delivered by practice nurses or trained counselors also had a positive effect, but simple guideline implementation and educational strategies were not generally effective. In oncology, nursing interventions, telephone monitoring, depression screening and education, and a specific antidepressant treatment in a cancer protocol have been evaluated, and national guidelines have been developed.
Nursing Interventions and Telephone Monitoring
Nurses can help staff to detect the diagnosis of depression in cancer patients and to facilitate referral to specialty back-up services. In Manchester, England, Faulkner and Maguire (71) reported an effort to train ward nurses caring for patients after mastectomy to identify psychological problems. Training included provision of a standard assessment form, practice interviews, and audiotape feedback of performance. In a second study, 152 women with mastectomy who were assigned randomly to a specialist nurse intervention or control group, the nurse recognized and referred for help 76% of those patients who had developed an anxiety state, depressive illness, or sexual problem (72). In the group offered routine care, only 15% of patients similarly affected were referred for help. At 12-18 month follow-up, only 12% of patients in the nursing intervention group were still suffering, whereas 39% of the control group were symptomatic.
In a second nonspecialist strategy (28), ward or community nurses who detected possibly depressed cancer patients referred them to the general practitioner; patients with already evident problems were referred to a psychiatrist. After one nurse visit, patients were encouraged to call the nurse if they had concerns, but second visits were not done for patients who were not distressed. In this model the specialist nurse could turn to front-line nurses for further monitoring of the patients, and he or she could, because of his or her additional training and access to psychiatric advice, function as a resource for staff. Although ward nurses did well, district nurses and health visitors performed less well over time.
In the United States, McCorkle et al. (73) reported on a standardized nursing intervention protocol—a specific set of home-care nursing strategies designed to help older patients with cancer. It included eight scheduled contacts (three 2-hour home visits and five telephone calls) within 4 weeks. Further, a nurse was available on-call around the clock for emergency questions. Assessment of psychological symptoms occurred as one element of the protocol in the first week. Patients were made aware of referral resources. Those patients who had the nursing intervention gained a survival advantage of 7 months regardless of cancer type or stage over the control group.
Telephone monitoring facilitated treatment of depression in primary care, significantly improving outcome at modest cost (74). Telephone monitoring has also been used for psychosocial assessment of cancer patients in Cancer and Leukemia Group B and would be an adjunct to assessment and care (44).
Depression Screening and Education
Oncologists may respond to the Beck Depression Inventory (BDI) score as a "laboratory" report that alerts them that a patient has moderate to severe depressive symptoms. In Melbourne, Australia, at the Peter MacCallum Cancer Institute, McLachlan et al. (75) assessed the benefit of an effort to report immediately to the oncologist via a computer-generated patient-report the patient's cancer needs, quality-of-life measures, and psychosocial information. The goal was to develop targeted psychosocial interventions that would reduce cancer needs, improve quality of life, and increase satisfaction with care. Information was gathered via standardized questionnaires on a touch-screen computer. Of 450 patients, two-thirds were assigned randomly to the group whose computer-generated information was immediately given to the physician; for the other one-third, information was not made available to the patient's doctor. After speaking with the patient and doctor, a coordination nurse devised a management plan based on previously specified guidelines formulated by multidisciplinary experts. Only in relation to depression did this intervention lead to a significant difference in the two groups.
When the physicians were made aware of a patient's report that signaled moderate to severe depression, they were more likely to offer the patient counseling. Six months later, their level of depression was significantly reduced in comparison to patients whose BDI scores of moderate/severe depression were not made known to their physicians. For patients whose physician was not aware of the BDI score, 73% of the moderately depressed and 90% of the severely depressed were still depressed 6 months later. In the intervention group, 68% were offered counseling, and 47% accepted the offer. In this intervention group at 6 months, the rate of depression was reduced, but 58% remained moderately depressed and 45% severely depressed.
The Zung Self-Rating Depression Scale score has also been used as a laboratory test to trigger follow-up interviews of ambulatory oncology patients by oncology staff and to consider whether antidepressant treatment would be started according to an algorithm. It was suggested that cut-off scores could vary based on the resources available or the comfort of the staff in using antidepressant medications (76). Passik et al. (77), working from a hospital-based research network in an Indiana rural community where the Zung was used as a screening tool, also trained oncologists and nurses to diagnose depressive disorder in cancer patients. In a 1-hour in-service, the staff was taught to use the Mini International Neuropsychiatric Interview, a brief diagnostic interview, that could distinguish major depressive disorder, adjustment disorder with depressed mood, or no psychiatric diagnosis. Training included a videotape of the investigator using this diagnostic interview and the opportunity for staff to diagnose the two patients from the videotaped assessment. The researchers suggested this education about a semistructured interview as a training model.
Screening self-report measures may be useful to develop models of stepped care (39) that triage to specialists patients with more severe disease, suicidal ideation, or lack of improvement. At Johns Hopkins, Zabora (78) reports that their automated screening program uses clerical and support staff to distribute and retrieve the questionnaires, but professional staff are used to offer interventions. Screening is coordinated with the first or second oncology visit or the simulation appointment for radiation treatment, and a resource coordinator responds to patients' specific concerns. Patients with high distress, particularly if they have reported suicidal ideation, receive an immediate follow-up contact to arrange a referral to the Cancer Counseling Center. The center is staffed by social workers with masters degrees, psychiatric nurses, and consulting psychiatrists.
Targeted Prevention
Because the focus of oncology is anticancer treatment, oncologists are particularly sensitive to strategies that facilitate known chemotherapy treatments. The recent study of paroxetine for the treatment of interferon-related depression in the regimen for advanced malignant melanoma is a useful example (79). Interferon, the treatment itself, causes a high rate of clinical depression during treatment. Paroxetine pretreatment minimized depression induced by the treatment, and the treated group was less apt to discontinue the anticancer treatment. The study targeted a population likely to develop major depressive disorder, systematically reduced the associated suffering, and made anticancer treatment easier to tolerate.
Guidelines and Policy
Another contribution to reduce barriers to competent treatment of major depressive disorder among cancer patients has been the National Comprehensive Cancer Network Guidelines for Management of Distress led by Holland (80). The National Comprehensive Cancer Network has developed guidelines for treatment of specific tumors that serve as a state-of-the-art reference for oncologists. The Guidelines for the Management of Distress offer an algorithm for care of depressive disorder and other psychiatric/spiritual disorders in the specialty oncology setting. These include the differential diagnosis and treatment of major depressive disorder. This guideline encourages collegial interaction between psychiatrists, psychologists, social workers, and pastoral counselors who will consult each other and give feedback information to the oncology physician and nurse team. The guidelines open the conversation about patient distress, assessment of needs, and appropriate referral pathways.
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FURTHER RESEARCH |
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TopAbstractIntroductionMajor Depressive DisorderBarriers to Quality of...Special CategoriesStrategies To Improve Depression...Further ResearchLeadershipReferences |
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To reduce barriers to treatment of depression in cancer patients, the first goal is to clarify the benefit of diagnosis and treatment of depression to the oncology effort and to reduce the uncertainty in the minds of oncology staff. A second goal is to explore different methods of organizing and integrating care so that patients have the best functional outcome at the best cost.
Staging of Depressive Disorders in Cancer To Reveal Depressive Prognosis
Oncologists have used staging and grading of tumors to clarify diagnosis, prognosis, and different treatment. By analogy, depressive disorder in cancer patients can be subclassified. Patients who meet criteria for major depressive disorder can be categorized by past history of affective illness, medication-induced mood disorder, comorbid anxiety or substance abuse, severity of affective illness, and specific active cancer versus no evidence of cancer (survivor).
Patients with a known past history of major depressive disorder who develop cancer and come to attention with a depressive recurrence belong in one group. These patients happen to have cancer as well as major depressive disorder. Extensive literature supports treatment standards. Questions worthy of research include how the two disorders interact. Can the standard of treatment for major depressive disorder be maintained as the patient is treated for cancer? How does the cancer affect adherence to antidepressant treatment, and how does depression affect adherence to cancer treatment? What is the effect of inadequately treated major depressive disorder on the mortality and course of a specific cancer? How much of the health-related quality of life is affected by inadequately treated depressive disorder? The patient who has a lifetime history of depression or defined episodes of depression that predate cancer can most easily be identified as the patient with two distinct comorbid disorders.
The second category includes patients who meet criteria for affective illness in the acute setting of cancer treatment but who do not have a past history of depression. These cancer patients either have the first episode of major depressive disorder or a syndrome with medical symptoms and situational distress that meet criteria for affective illness. We do not know the natural course of this second condition. We do not know the relative role of psychotherapy or medication or the standards and duration of antidepressant treatment in this group.
A third category is the patient taking medications for cancer that destabilize mood, such as corticosteroids, interferon, or antiestrogens. What is the nature of the syndromes, and what is the appropriate treatment?
The fourth category is the cancer survivor who is no longer in active cancer treatment, who has no evidence of tumor, who develops a first episode of major depressive disorder. Does he have access to treatment for affective illness? Does he adhere to the psychiatric treatment program? How does the course of depressive disorder affect cancer course and treatment? How does the fear of recurrence complicate the presentation? Is the course different when major depressive disorder is associated with comorbid anxiety disorder or comorbid substance abuse and cancer?
This method of grouping depressed cancer patients can identify those most at risk for depressive recurrence—those who may need closer follow-up or prevention of affective illness. Programs to improve treatment of major depressive disorder in the cancer population may target those at-risk patients with anxiety disorder, past history of depression, and family history of depression to be screened, assessed, and followed more carefully.
Depression Outcome Evaluated in the Context of One Type of Cancer
Clinical research in cancer usually focuses on the management of one type of cancer. The study of depression in the context of one disease aligns the incentives, so that the oncology staff and those who focus on depression treatment are both oriented to improvements in the patient's functional outcome. In the population of head and neck tumor patients, the rate of substance abuse is high; research may focus on the assessment and treatment of depression with the dual diagnosis of substance abuse and further study of how that treatment affects oncology outcome data. Breast cancer patients in the year following adjuvant treatment have high rates of insomnia and fatigue. The best timing and duration of antidepressant treatment for those who become depressed in this setting is unclear: The general guidelines for continued treatment may or may not be applicable in this setting. Steroid-related affective disorder can occur in the setting of lymphoma or brain tumor. Can mood stabilizers prevent depression in this setting? For brain tumor patients taking anticonvulsants, what are the rate of major depressive disorder and the effectiveness of treatment?
Improving Models of Organization of Care
Continuous efforts and combined strategies: clinical education, an enhanced nursing role, and greater integration of oncology and mental health specialty care are most likely necessary to affect the care of comorbid major depressive disorder in oncology. Specialty knowledge in mental health does make a difference in the quality of care given to patients. Strategies that combine education about the diagnosis, timely screening for the diagnosis, case-managed follow-up of medication adherence, and outcome assessment must be tailored to the oncology setting. It is not clear what configuration of specialists, nurses, and social workers would best sustain improved outcomes in the treatment of affective illness. Further research should offer models of nursing, social worker, and psychiatry/psychology consultation to optimize case finding, treatment assessment, and referral of cases with resistant depression to specialists. The role of telephone monitoring as an adjunct should be defined. Psychosocial interventions already adapted for specific groups of cancer patients can also be evaluated for their benefit for the subset of cancer patients with major depressive disorder. It may be simply important to document the status of mental health care and care for depressive disorder in an oncology setting.
Capitalizing on the Cancer Protocol Model
Oncologists have a tradition of working with physicians of different disciplines to develop clinical protocols for specific diseases. Major depressive disorder impairs function, augments pain, increases anxiety, and interferes with adherence to medical treatment. More chemotherapy agents are now oral, so adherence to medical treatment is more important to achieve the clinical oncology outcome. It may be useful to study major depressive disorder within cancer treatment protocols and to investigate adherence to both chemotherapy and antidepressant agents simultaneously. The study of the benefit of paroxetine in an interferon trial for melanoma illustrates how an antidepressant can be incorporated into a standard chemotherapy regimen. Fluoxetine as a supportive treatment was also prescribed and adjusted by oncologists in a Cancer and Leukemia Group B lung cancer chemotherapy protocol.
Improving Access to Care for Survivors
As patients recover from acute illness, they carry the legacy of the cancer but are not as tightly bound to the locus of specialty care. Programs that continue to screen survivors of specific tumors for depression and to ease the path to mental health referral may make distinct contributions to the patient with both cancer and depression. The timing of psychological screening, locus of treatment, and duration of treatment remain questions to study. Telephone monitoring may be particularly helpful to improve diagnosis and treatment of depressive disorder in survivors of distinct tumor groups. How access and treatment can be improved for patients who are known to have poor access to mental health care, like rural, elderly, African American, or Latino cancer patients, is another important area of study.
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TopAbstractIntroductionMajor Depressive DisorderBarriers to Quality of...Special CategoriesStrategies To Improve Depression...Further ResearchLeadershipReferences |
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The outcome depends on leaders who believe that effective treatment of depression is one element in state-of-the-art quality care for cancer patients. Von Korff et al. (29) noted the lack of individual and organizational incentives for improving care of depression. A leader who supports the best functional outcome for cancer patients corrects that conflict. Systems change is always difficult, and even more so in the current turmoil of finance for health care services. Although physician education and guidelines are important, no lasting effect is likely unless the cancer physician appreciates that he or she can alleviate the emotional pain of depressive disorder by appropriate referral. A high standard of care should be expected. A path should be available for diagnosis and treatment of depression by personnel who will follow through, monitoring the patient's clinical response and adherence to prescribed medication regimens (81). The leadership must be armed with research that documents the improvement in outcome for patients treated both for cancer and for clinical depression. Stepped care strategies could be developed such that patient outcomes are monitored and care plans modified with more intensive management reserved for patients who have not had a good outcome (39).
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