Effective treatment for depression in patients with cancer

The studies by Michael Sharpe and colleagues1Sharpe M Walker J Holm Hansen C et al.for the SmaRT (Symptom Management Research Trials) Oncology-2 TeamIntegrated collaborative care for comorbid major depression in patients with cancer (SMaRT Oncology-2): a multicentre randomised controlled effectiveness trial.Lancet. 2014; (published online Aug 28.)http://dx.doi.org/10.1016/S0140-6736(14)61231-9Google Scholar in The Lancet and by Jane Walker and colleagues2Walker J Holm Hansen C Martin P et al.Integrated collaborative care for major depression comorbid with a poor prognosis cancer (SMaRT Oncology-3): a multicentre randomised controlled trial in patients with lung cancer.Lancet Oncol. 2014; (published online Aug 28.)http://dx.doi.org/10.1016/S1470-2045(14)70343-2PubMed Google Scholar in The Lancet Oncology show a rigorous approach to the implementation and assessment of a complex intervention to alleviate depression in people with cancer. This research is timely, since the risk of depression has been shown to be two-to-three-times higher in patients with cancer than in the general population,3Walker J Holm Hansen C Martin P et al.Prevalence, associations, and adequacy of treatment of major depression in patients with cancer: a cross-sectional analysis of routinely collected clinical data.Lancet Psychiatry. 2014; (published online Aug 28.)http://dx.doi.org/10.1016/S2215-0366(14)70313-XGoogle Scholar and could contribute to the poorer quality of life4Brown LF Kroenke K Theobald DE Wu J Tu W The association of depression and anxiety with health-related quality of life in cancer patients with depression and/or pain.Psychooncology. 2010; 19: 734-741Crossref PubMed Scopus (182) Google Scholar and increased risk of suicide in such individuals.5Miller M Mogun H Azrael D Hempstead K Solomon DH Cancer and the risk of suicide in older Americans.J Clin Oncol. 2008; 26: 4720-4724Crossref PubMed Scopus (97) Google Scholar Neurobiological factors might play a part in the link between cancer and depression,6Roxburgh CSD McMillan DC Cancer and systemic inflammation: treat the tumour and treat the host.Br J Cancer. 2014; 110: 1409-1412Crossref PubMed Scopus (214) Google Scholar but much evidence suggests that depression in this population represents a final common pathway of distress that results from the interaction of several diverse risk and vulnerability factors.7Lo C Zimmermann C Rydall A et al.Longitudinal study of depressive symptoms in patients with metastatic gastrointestinal and lung cancer.J Clin Oncol. 2010; 28: 3084-3089Crossref PubMed Scopus (160) Google Scholar Substantial advances in the treatment of cancer have been made during the past few decades, but attention to the physical and psychological symptoms of this disease and its treatment has been given lower priority in clinical settings. To address this imbalance, professional bodies have mandated that routine distress screening be a standard of practice in cancer treatment settings.8Holland JC Distress screening and the integration of psychosocial care into routine oncologic care.J Natl Compr Canc Netw. 2013; 11: 687-689PubMed Google Scholar Such screening needs to be linked to an effective intervention programme for it to be clinically effective, although only sparse evidence has shown the benefit of such interventions in patients with cancer.9Walker J Sawhney A Holm Hansen C et al.Treatment of depression in adults with cancer: a systematic review of randomized controlled trials.Psychol Med. 2014; 44: 897-907Crossref PubMed Scopus (45) Google Scholar In other medical populations, positive outcomes in the treatment of depression have been shown to be achievable by a collaborative care approach that links care managers or nurses with primary care physicians and psychiatrists to provide and adjust psychological or pharmacological treatment, to monitor outcomes, and to ensure treatment compliance.10Gilbody S Whitty P Grimshaw J Thomas R Educational and organizational interventions to improve the management of depression in primary care: a systematic review.JAMA. 2003; 289: 3145-3151Crossref PubMed Scopus (623) Google Scholar Sharpe and colleagues have developed a collaborative care intervention for depression, which is referred to as depression care for people with cancer. This is a complex intervention involving both antidepressant medication and psychological treatment that makes available for each patient contact with, or input from, a nursing case manager trained in problem-solving therapy and behavioural activation, a primary care physician, a psychiatrist, and liaison with the patient's oncologist. The SMaRT Oncology-2 multicentre phase 3 trial of depression care for people with cancer is a major study in which 500 patients from three cancer centres in Scotland, UK, all with an expected survival of at least 12 months and a diagnosis of major depression, were randomly assigned to depression care for people with cancer or to usual care. 90% of the study population were women, and a participation rate of 47% was achieved among eligible patients. The primary outcome was treatment response at 24 weeks, defined by a 50% or greater reduction in depression severity on a self-reported measure (the Symptom Checklist Depression Scale [SCL-20]), although patients were followed for up to 48 weeks. Several other secondary and tertiary outcomes were also assessed, including depression, anxiety, physical distress, functional capacity, and quality of life. The treatment effect in SMaRT Oncology-2 is impressive, with 62% (143 of 231) of the depression care for people with cancer group having a response at 24 weeks, compared with only 17% (40 of 231) of those in the usual care group (adjusted odds ratio 8·5 [95% CI 5·5–13·4]). Statistically significant differences were also recorded between the two groups on all the secondary and tertiary outcomes. These benefits, which persisted throughout the trial, are greater than those reported by this group in their 2008 efficacy trial of this intervention.11Strong V Waters R Hibberd C et al.Management of depression for people with cancer (SMaRT oncology 1): a randomised trial.Lancet. 2008; 372: 40-48Summary Full Text Full Text PDF PubMed Scopus (258) Google Scholar In the present study, patients in the depression care treatment group received up to ten sessions with a nurse and were more likely to receive an effective dose of antidepressant medication than were those in the usual care group. Very few patients in the usual care group received counselling or a formal psychological intervention. The depression care intervention in this study was estimated to cost an additional £613 per patient, based on the cost of the treatment sessions, telephone contacts, and treatment supervision, although implementation in other cancer settings would incur further setup costs. How such a system of care could be implemented or modified to be feasible in lower resource settings that do not have ready access to primary care physicians, nurses, psychiatrists, and oncologists is a challenge that is yet to be addressed. The depression care for people with cancer research group has simultaneously published a randomised controlled efficacy trial comparing this intervention to usual care for patients with lung cancer with an expected survival of at least 3 months. In this SMaRT Oncology-3 trial,2Walker J Holm Hansen C Martin P et al.Integrated collaborative care for major depression comorbid with a poor prognosis cancer (SMaRT Oncology-3): a multicentre randomised controlled trial in patients with lung cancer.Lancet Oncol. 2014; (published online Aug 28.)http://dx.doi.org/10.1016/S1470-2045(14)70343-2PubMed Google Scholar Walker and colleagues recruited 142 participants (43% of those eligible), all of whom had major depression. The primary outcome for this trial was depression severity (measured on the SCL-20) averaged over the time in the trial, which was chosen in part because of the potential for missing data caused by the anticipated physical decline and death of these patients. In fact, 30% (43 of 142) of the participants died during the course of the trial. Those in the depression care for people with lung cancer group received a median of eight treatment sessions with the nurse, were more likely than were those in the usual care group to receive an effective dose of an antidepressant medication, and half of them had contact with a psychiatrist. No patient in either the treatment or control group received formal psychological treatment from non-depression care for people with lung cancer providers. Although not as dramatic as the results of SMaRT Oncology-2, a statistically significant improvement in depression severity was recorded in the depression care for people with lung cancer group (mean score on the SCL-20 1·24 [SD 0·64]) compared with the usual care group (mean score 1·61 [SD 0·58]; difference −0·38 (95% CI −0·58 to −0·18). Improvements in some of the secondary outcomes were also recorded in the depression care for people with lung cancer group compared with the usual care group. These two well-designed studies show that a multicomponent intervention can achieve a sustained improvement in the symptoms of depression in patients with cancer. This finding is a testament to the rigour of the studies and the nature of the treatment framework in which they took place. The individual components of the intervention are not themselves novel, but the benefit of their delivery in an integrated system of this type has not previously been shown in patients with cancer. The treatment received by the control group in both studies shows that these interventions are not routinely and consistently applied in the usual care of patients with cancer, even when they are available. What cannot be established from the SMaRT Oncology studies is which components of this complex intervention are its most active ingredients.12Campbell M Fitzpatrick R Haines A et al.Framework for design and evaluation of complex interventions to improve health.BMJ. 2000; 321: 694-696Crossref PubMed Scopus (2294) Google Scholar It is not possible in these studies to disentangle the effects of the antidepressant medication, the non-specific support and close follow-up, the problem-solving and behavioural activation delivered by the nurses, or their supervisory support. Phased research12Campbell M Fitzpatrick R Haines A et al.Framework for design and evaluation of complex interventions to improve health.BMJ. 2000; 321: 694-696Crossref PubMed Scopus (2294) Google Scholar is needed to establish the effect of specific components, and further studies are indicated to ascertain the benefit of minimal interventions or those tailored to address problems related to the cancer type or to the stage of disease.13Lo C Hales S Jung J et al.Managing Cancer And Living Meaningfully (CALM): phase 2 trial of a brief individual psychotherapy for patients with advanced cancer.Palliat Med. 2014; 28: 234-242Crossref PubMed Scopus (91) Google Scholar However, these two new research studies of a collaborative care intervention for depression in cancer patients represent a significant advance in knowledge and suggest that treatments for depression delivered within such a framework might be most likely to achieve a positive outcome. I declare no competing interests. Integrated collaborative care for comorbid major depression in patients with cancer (SMaRT Oncology-2): a multicentre randomised controlled effectiveness trialOur findings suggest that depression care for people with cancer is an effective treatment for major depression in patients with cancer. It offers a model for the treatment of depression comorbid with other medical conditions. Full-Text PDF Integrated collaborative care for major depression comorbid with a poor prognosis cancer (SMaRT Oncology-3): a multicentre randomised controlled trial in patients with lung cancerOur findings suggest that major depression can be treated effectively in patients with a poor prognosis cancer; integrated depression care for people with lung cancer was substantially more efficacious than was usual care. Larger trials are now needed to estimate the effectiveness and cost-effectiveness of this care programme in this patient population, and further adaptation of the treatment will be necessary to address the unmet needs of patients with major depression and even shorter life expectancy. Full-Text PDF Prevalence, associations, and adequacy of treatment of major depression in patients with cancer: a cross-sectional analysis of routinely collected clinical dataMajor depression is common in patients attending cancer clinics and most goes untreated. A pressing need exists to improve the management of major depression for patients attending specialist cancer services. Full-Text PDF Open Access

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