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Depression care for people with cancer: a collaborative care intervention ,☆☆ Jane Walker, M.B., Ch.B. , Michael Sharpe, M.D. Psychological Medicine Research, School of Molecular & Clinical Medicine, University of Edinburgh, EH4 2XR Edinburgh, UK Received 2 April 2009; accepted 18 May 2009 Abstract Depression management for patients with chronic medical illnesses, including cancer, is often inadequate. Depression Care for People with Cancer(DCPC) has been designed to be integrated into specialist cancer services and is being evaluated in the Symptom Management Research Trials (SMaRT) Oncology series of randomized controlled trials. The intervention is an extended form of the collaborative care model and is delivered by a care manager, who receives regular supervision from a psychiatrist. The care manager coordinates the patient's depression management, by liaising with both their primary care physician and their cancer team, and provides a brief talking treatment. This article describes the design and delivery of DCPC as given in the SMaRT Oncology trials. © 2009 Elsevier Inc. All rights reserved. Keywords: Depression; Cancer; Collaborative; Nurse 1. Introduction Depression Care for People with Cancer(DCPC) is a collaborative care intervention for major depression, which has been designed to be integrated into specialist cancer services. DCPC is currently being evaluated in the Symptom Management Research Trials (SMaRT) Oncology series of randomized controlled trials. These trials aim to determine the effects of adding DCPC to usual care, in cancer outpatients. This article describes the design and delivery of DCPC as given in the SMaRT Oncology trials. 2. Background Cancer survival rates have improved to the extent that cancer is now a chronic illness for many people; the 5-year survival rate for people diagnosed with cancer is approxi- mately 60% (including all types of cancer) and an estimated 9.6 million people living in the United States have had a diagnosis of cancer at some time in their lives [1]. When depression is comorbid with a chronic medical illness, it is associated with especially large decrements in subjective health [2]. In addition, patients who have both a medical disorder and depression suffer from worse physical symp- toms and poorer quality of life and are less likely to adhere to medical treatments [35]. Despite the importance of comorbid depression, its management in patients with chronic medical conditions, including cancer, has been found to be inadequate [6,7]. This failure of care has been attributed to a number of factors: failure to diagnose depression, to provide evidence-based treatment and failure to actively monitor patients' response to treatment and modify it as needed [810]. Improving the management of depression in patients with cancer therefore requires a system of care that addresses all these failings. Available online at www.sciencedirect.com General Hospital Psychiatry 31 (2009) 436 441 Work performed at Psychological Medicine Research, The Cancer Research Centre, School of Molecular and Clinical Medicine, University of Edinburgh, Scotland, UK. ☆☆ Funding: Cancer Research UK. Corresponding author. Psychological Medicine Research, The Uni- versity of Edinburgh Cancer Research Centre, Western General Hospital Edinburgh, EH4 2XR, UK. Tel.: +44 131 777 3541. E-mail address: [email protected] (J. Walker). 0163-8343/$ see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2009.05.010

Depression care for people with cancer: a collaborative care intervention

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Page 1: Depression care for people with cancer: a collaborative care intervention

Available online at www.sciencedirect.com

General Hospital Psychiatr

y 31 (2009) 436–441

Depression care for people with cancer: a collaborativecare intervention☆,☆☆

Jane Walker, M.B., Ch.B.⁎, Michael Sharpe, M.D.Psychological Medicine Research, School of Molecular & Clinical Medicine, University of Edinburgh, EH4 2XR Edinburgh, UK

Received 2 April 2009; accepted 18 May 2009

Abstract

Depression management for patients with chronic medical illnesses, including cancer, is often inadequate. “Depression Care for Peoplewith Cancer” (DCPC) has been designed to be integrated into specialist cancer services and is being evaluated in the Symptom ManagementResearch Trials (SMaRT) Oncology series of randomized controlled trials. The intervention is an extended form of the collaborative caremodel and is delivered by a care manager, who receives regular supervision from a psychiatrist. The care manager coordinates the patient'sdepression management, by liaising with both their primary care physician and their cancer team, and provides a brief talking treatment. Thisarticle describes the design and delivery of DCPC as given in the SMaRT Oncology trials.© 2009 Elsevier Inc. All rights reserved.

Keywords: Depression; Cancer; Collaborative; Nurse

1. Introduction

“Depression Care for People with Cancer” (DCPC) is acollaborative care intervention for major depression, whichhas been designed to be integrated into specialist cancerservices. DCPC is currently being evaluated in the SymptomManagement Research Trials (SMaRT) Oncology series ofrandomized controlled trials. These trials aim to determinethe effects of adding DCPC to usual care, in canceroutpatients. This article describes the design and deliveryof DCPC as given in the SMaRT Oncology trials.

☆ Work performed at Psychological Medicine Research, The CancerResearch Centre, School of Molecular and Clinical Medicine, University ofEdinburgh, Scotland, UK.

☆☆ Funding: Cancer Research UK.⁎ Corresponding author. Psychological Medicine Research, The Uni-

versity of Edinburgh Cancer Research Centre, Western General HospitalEdinburgh, EH4 2XR, UK. Tel.: +44 131 777 3541.

E-mail address: [email protected] (J. Walker).

0163-8343/$ – see front matter © 2009 Elsevier Inc. All rights reserved.doi:10.1016/j.genhosppsych.2009.05.010

2. Background

Cancer survival rates have improved to the extent thatcancer is now a chronic illness for many people; the 5-yearsurvival rate for people diagnosed with cancer is approxi-mately 60% (including all types of cancer) and an estimated9.6 million people living in the United States have had adiagnosis of cancer at some time in their lives [1]. Whendepression is comorbid with a chronic medical illness, it isassociated with especially large decrements in subjectivehealth [2]. In addition, patients who have both a medicaldisorder and depression suffer from worse physical symp-toms and poorer quality of life and are less likely to adhere tomedical treatments [3–5]. Despite the importance ofcomorbid depression, its management in patients withchronic medical conditions, including cancer, has beenfound to be inadequate [6,7]. This failure of care has beenattributed to a number of factors: failure to diagnosedepression, to provide evidence-based treatment and failureto actively monitor patients' response to treatment andmodify it as needed [8–10]. Improving the management ofdepression in patients with cancer therefore requires a systemof care that addresses all these failings.

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A number of organizational strategies have beenproposed to improve depression management in nonspe-cialist settings. Reviews have identified the collaborativecare model, originally developed by Katon et al. [11], asthe most effective of these [12]. Collaborative careinterventions can be defined as multifaceted organizationalinterventions, which include the introduction of a caremanager to assist in the management of patients withdepression through structured and systematic delivery ofinterventions [13]. A recent meta-analysis sought todetermine the “active ingredients” of collaborative careinterventions and found that systematic identification ofpatients, antidepressant use, care managers with a specificmental health background and regular specialist supervisionof care managers were all associated with better patientoutcomes in published trials [14].

3. The design of DCPC

DCPC is an extended form of the collaborative caremodel (see Fig. 1). The intervention is delivered by a caremanager, who receives regular supervision from a psychia-trist. The care manager coordinates the patient's depressionmanagement by liaising with both their primary carephysician and their cancer team. This differs from othercollaborative care interventions for comorbid depression, inwhich liaison has been between the care manager and eitherthe primary care physician [15–18] or the medical specialist[19,20]. Patients for whom the intervention may be suitableare identified through a systematic screening process; thisaddresses the problem of missed depression diagnosis.

As well as coordinating the patient's depression care, thecare manager provides a brief talking treatment according toa treatment manual. This treatment manual includes educa-tion about depression and information about antidepressant

Fig. 1. The collaborative care model in DCPC. Red arrows represent patientcontact with health professionals about depression care. Blue arrowsrepresent liaison between health professionals about depression care. N.B.The thickness of the arrows represents the estimated intensity of the contact.

medication [21]. The care manager also teaches the patienthow to be more active and how to cope more effectively withtheir problems, using Problem-Solving Treatment, a briefand simple treatment based on cognitive-behavioral princi-ples that has previously been included in collaborative careinterventions for depression [17–20,22,23].

The care manager in DCPC is a specially trained cancernurse. Cancer nurses were chosen to deliver the interventionin order to integrate the patient's depression treatment withtheir cancer care and to avoid the stigma associated with“psychiatric” treatment. Because they are familiar with cancerand its treatment, DCPC care managers are comfortablediscussing cancer-related problems with patients and are ableto liaise effectively with the cancer team. Care managers alsoreceive intensive training, full time over a period of threemonths, in basic psychiatry and depression management aswell as Problem-Solving Treatment. Training is deliveredaccording to a bespoke manual, which also includes practicein delivering the intervention; supervised practice haspreviously been found to be necessary to achieve compe-tency in delivering Problem-Solving Treatment [24]. Com-petency is assessed formally and must be achieved before acaseload is assigned. Caremanagers are supervised by a teamof board certified psychiatrists, with experience in consulta-tion-liaison psychiatry.

4. Delivery of DCPC

4.1. Identification of patients

Patients with major depression are identified throughsystematic screening services that have been established aspart of routine clinical care in participating cancer centers.Patients are screened for depression in two stages:

Stage 1: Outpatients complete questionnaires, usingtouch-screen computers, when they attend the cancercenter. These questionnaires include the Hospital Anxietyand Depression Scale (HADS) [24]. A screening assistantguides patients and conveys the results of screening to thepatient's oncologist before their consultation.Stage 2: Patients who have a total HADS score of 15 ormore are contacted by trained staff (psychology graduatesand nurses) for a brief telephone interview; this cutoff haspreviously been found to offer optimal sensitivity andspecificity as an initial screen for major depression [25].The telephone interview includes the major depressioncomponent of the Structured Clinical Interview for DSM-IV [26] to identify those with major depression.

Patients with major depression are referred to the SMaRTOncology team and, following informed consent procedures,undergo a structured assessment to determine their suitabilityto participate. DCPC has been designed to supplement theusual care of depression, rather than to replace existingpsychiatric services. Patients are therefore excluded from thetrials if they require intensive psychiatric or psychological

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care, for example, for high suicide risk, or if they havepsychiatric comorbidity such as substance misuse, psychoticillness or bipolar affective disorder.

4.2. Site of delivery

DCPC sessions are delivered at the cancer clinic. If thepatient is unable to attend the clinic the session may bedelivered by telephone or, in exceptional circumstances, intheir home.

4.3. Phases of treatment

Treatment is delivered in two phases. In the initial“treatment phase” patients are offered a maximum of 10face-to-face sessions over 4 months. The content of thesessions is described below and in Table 1. Patients thenenter the “maintenance phase” and receive a follow-uptelephone call every month for a specified period, to monitortheir symptoms of depression. Patients whose depressive

Table 1DCPC session structure

Session Content

Session 1 Patient completes PHQ-9Information gathered about cancerAssessment of depressive symptomsInformation gathered about previous treatmentsand depressive episodesExplanation of depression and its treatments(includes information leaflet and DVD)Advantages and disadvantages of takingantidepressant medicationPlan for “being active”Explanation of Problem-Solving Treatment

Session 2 Patient completes PHQ-9Review of moodReview of changes in cancer and its treatmentReminder of treatments for depressionProblem listProblem-Solving TreatmentPlan for ‘things to do’ before next session

Further sessions Patient completes PHQ-9Review of moodReview of changes in cancer and its treatmentProblem-Solving TreatmentPlan for “things to do” before next session

Penultimate session Patient completes PHQ-9Review of moodReview of changes in cancer and its treatmentDepression awareness planPlan for ‘things to do’ before next session

Final session Patient completes PHQ-9Review of moodReview of changes in cancer and its treatmentFollow-up plan

Follow-up sessions Patient completes PHQ-9Booster sessions Patient completes PHQ-9

Review of moodReview of changes in cancer and its treatmentReview and improve depression awareness plan

symptoms relapse during the maintenance phase may beoffered “booster sessions.” Patients whose symptoms do notrespond to treatment during either phase are reviewed by asupervising psychiatrist, who makes an appropriate manage-ment plan.

4.4. Coordination of care

In the UK National Health Service all patients areregistered with a primary care physician [general practitioner(GP)]. Patients who have cancer may therefore receivetreatment for their depression from their GP or from theircancer team. In order to ensure a coordinated approach todepression care the care manager liaises with each patient'sGP, cancer team and any other relevant health professionals(e.g., palliative care physician). Regular reports are sent tothe GP (with copies to other relevant professionals) whichdetail the patient's current antidepressant medication,depression score and progress in treatment. The reports arechecked by a supervising psychiatrist before being sent andany recommendations are added regarding changes toantidepressant medication.

4.5. Education about depression

During the first session of DCPC the care manager elicitsthe patient's understanding of their depressive symptomsand provides them with education about depressivedisorder. This is achieved through verbal explanation, awritten information leaflet and a DVD that the patientwatches at home. Emphasis is placed on the fact thatdepression is an illness, not merely a reaction to havingcancer, and that it is treatable. The care manager alsoprovides education about the ways of treating depression,focusing on antidepressant medication, being active andlearning to cope with problems better.

4.6. Antidepressant medication

The patient is encouraged to consider taking antidepres-sant medication by listing the possible advantages anddisadvantages of this strategy. The care manager asks thepatient about their worries regarding antidepressant medica-tion, such as addiction or side effects, and providesappropriate factual information to allow the patient tomake an informed decision. If the patient chooses to trymedication, the care manager liaises with their GP regardinga prescription. The supervising psychiatrist may make arecommendation to the GP regarding the choice ofmedication, based on the profile of the patients' depressivesymptoms, potential side effects and possible interactionswith other drugs.

4.7. Being active

At the end of each session the patient makes a list of“things to do” with their care manager. This list includes aplan for “being active.” Being active ideally involvesphysical exercise but if the patient is unable or unwilling

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Fig. 3. An example of monitoring progress using the PHQ-9 in DCPC.

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to exercise a plan is made to do something that will providethem with a feeling of satisfaction.

4.8. Problem-Solving Treatment

The care manager assists the patient in making a list ofproblems during the second session. In subsequent sessionsone problem is chosen at a time by the patient and the caremanager guides the patient in defining the problem, settinga realistic goal and brainstorming possible solutions (seeFig. 2). The patient then chooses a solution and tries it out.As the sessions progress, the patient is encouraged to domore of the session work himself, thus increasing his senseof control over his problems.

4.9. Monitoring of progress

Patients are asked to complete a depression measure [thePatient Health Questionnaire-9 (PHQ-9)] [27] at each face toface and follow-up session (see Fig. 3). The care manageruses this in the first session as an aid to discussing thepatient's symptoms. The score is used in subsequent sessionsto monitor the patient's progress and can be viewed ingraphical form by the care manager and psychiatrist during

Fig. 2. An example of problem solving in DCPC.

supervision. Response to treatment is defined as a 50% dropon the PHQ-9 as well as a PHQ-9 score of less than 10 [28].

4.10. Depression awareness plan

In his penultimate treatment phase session the patientis guided in making a depression awareness plan, the aimof which is for the patient to manage his own symptomsof depression. The plan includes a checklist of symptomsthe patient experienced during their depressive episodeand a time each week when the patient chooses tomonitor himself for these. The patient also identifies

Fig. 4. An example of a depression awareness plan in DCPC.

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things that helped his depression and lists these as well asa plan to follow, should his symptoms worsen or recur(see Fig. 4).

4.11. Supervision

Care managers receive weekly group supervision from apsychiatrist. Each care manager presents his current cases,beginning with new patients, according to a structuredformat. All DCPC sessions are audio or video-recorded —these form the basis for the remainder of the supervisionsession, when specific sections are selected for review.

5. Evaluation of DCPC

DCPC is currently being evaluated in the SMaRTOncology series of trials. SMaRT Oncology-1, a one-centre,proof-of-concept randomized controlled trial, found thatadding DCPC improved patients' symptoms of depressionmore than usual care alone and that this effect was sustainedbeyond the 6-month duration of the intervention [29].SMaRT Oncology-2 is a larger multicenter effectivenessand cost-effectiveness trial, which will test whether DCPC iseffective in a more “real world” setting [30].

DCPC has also been adapted and piloted in patients withlung cancer, who are more likely to have a limited lifeexpectancy. SMaRT Oncology-3 will test the efficacy of theadaptation (DCPC) in a multicenter proof-of-conceptrandomized controlled trial [31].

DCPC is a new development of the collaborative caremodel which has the potential to improve the care providedby specialist cancer centers. The SMaRTOncology trials willprovide cancer services with robust data on the effectivenessand cost-effectiveness of this intervention, to allow them todecide whether it should be implemented in their routineclinical care.

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