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November 3, 2009 — Older cancer patients with depression showed significantly more improvement when they were treated with a collaborative program than when they were treated with usual care for their depression. They also reported having fewer thoughts of death.
The findings are reported in a supplement to the Journal of General Internal Medicine. This is the first study of collaborative care for depressed older adults with cancer conducted in a primary care setting, as opposed to cancer centers, the researchers note.
"It is important for oncologists to work collaboratively with cancer survivors and their primary care providers to detect and manage depression," lead author Jesse Fann, MD, MPH, associate professor of psychiatry and behavioral sciences at the University of Washington in Seattle, told Medscape Oncology.
"Obtaining effective treatment for depression is vital," Dr. Fann said. Depression in cancer patients can lead to loss of motivation to comply with treatment plans, he explained, and some depressed patients might start to question whether cancer treatment is "worth it."
Better Responses to Treatment
This study of older cancer patients (n = 215) was part of a much larger study of a collaborative program for the treatment of depression. The larger study had a total of 1801 patients, 60 years or older, who were diagnosed with major depression (18%), dysthymic disorder (33%), or both (49%).
The subgroup of older cancer patients had a variety of malignancies and a mean of 3 comorbid conditions.
All of the patients were treated for their depression in a primary care setting; half were randomized to usual care and the other half to collaborative care under the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) program.
Usual care comprised routinely available depression treatment, including antidepressants and referrals to specialty mental health services as deemed necessary by the attending physician or the patient.
The IMPACT program involved a depression care manager (DCM) who worked collaboratively with the patient and the primary care physician, and lasted up to a year. Treatment involved antidepressants and a structured psychotherapy program (6 to 8 sessions) delivered by the DCM. The DCM also provided education and behavioral activation, which emphasized the scheduling of pleasant events and overcoming avoidance behaviors. Patients were monitored every 2 weeks during the acute phase of treatment, and monthly thereafter.
A year later, patients in the collaborative-care group were twice as likely to have responded to the depression treatment as those in the usual-care group (39% vs 20%; P = .029). They also reported significantly more days free from depression (185.8 vs 135 days; P < .001).
In addition, there was a decrease in suicidal thoughts in the collaborative-care group, and an increase in the usual-care group, the researchers report.
Cancer patients have twice the rate of suicide as the general population, with older age at diagnosis conferring additional risk, the researchers note. They suggest that "thoughts of death and suicide may warrant particular attention in cancer patients."
Patients in the collaborative-care group also reported significantly less health-related functional impairment, a higher quality of life, and higher energy levels than those in the usual-care group.
Significant differences in depression treatment response rates persisted at 18 months, half a year after the intervention ended (38% in the collaborative-care group vs 16% in the usual-care group, P = .012). In addition, suicidal thoughts remained slightly lower, the researchers note.
"The IMPACT model of depression care was more effective than usual care in treating depression in older primary care patients with cancer and a mean of 3 comorbid conditions," the researchers conclude.
Two other studies have demonstrated the effectiveness of collaborative depression care in cancer settings, Dr. Fann noted. This collaborative approach to the treatment of care is now being incorporated into routine clinical practice, and many healthcare systems are starting to integrate DCMs into their practice, because this intervention has been found to be cost-effective, he added.
Details on how to implement the IMPACT program are available on the IMPACT Web site.
Depression After Cancer Is Treated
"Depression may persist after the cancer is successfully treated or in remission," coauthor Jürgen Unützer, MD, MA, MPH, professor of psychiatry at Washington University, commented in a statement. These patients might "have survived the disease, but still can't re-enage in life. . . [and] may feel unable to enjoy or make use of the time that has been added to their life."
These feelings of depression after cancer were articulated recently in the New York Times by reporter Dana Jennings, who has been documenting his experience of being diagnosed and treated for an aggressive prostate cancer in regular columns in the newspaper.
On September 29, he reported that he had been "ambushed by depression."
"After more than a year of diagnosis, treatment, and waiting, it's almost as if, finally and unexpectedly, my psyche heaved a sigh and gave itself permission to implode," he writes.
"This isn't about sadness or melancholy. It's more profound than that. Broadly, I have a keen sense of being oppressed, as if I were trapped, wrapped up in some thick fog coming in off the North Atlantic," he continues, and complains or "bone-smoldering fatigue."
"Partly, I think, I'm grieving for the person I was before I learned I had cancer," he writes. "Mortality is no longer abstract, and a certain innocence has been lost."
Mr. Jennings writes that he is now seeing a psychiatrist who specializes in cancer patients, and has started a course of medication. "My doctor assures me that depression isn't unusual among those who are on the far side of treatment," he says, adding that the American Cancer Society estimates that around 25% of cancer patients have depression, compared with 7% of the general population.
Writing About Depression Harder Than Cancer
The reporter reveals that he finds it difficult to write about depression. "During my dark waltz with cancer, I've depended on my natural optimism and my sense of humor to help see me through," he writes. "But depression blunts those traits."
"It's harder to write about the weight of depression than it is to write about prostate cancer and its physical indignities," he continues. "Cancer is clear biological bad luck. But depression, no matter how much we know about it, makes part of me feel as if it's somehow my fault, that I'm guilty of something that I can't quite articulate."
Several cancer survivors who have also battled with depression have posted comments to the article, identifying with many of the feelings that Mr. Jennings described.
"It is so true. You get through treatment on some kind of adrenaline and then it hits. And sadly, you will never get back that person who felt invincible," writes one woman 2 years after her treatment for breast cancer.
Another breast cancer survivor notes that Mr. Jennings "nailed it" when he wrote about "grieving for the person you were before cancer. It's stunning how impactful that knowledge is, the awareness of the fragility of life."
"No one who hasn't been through a severe illness can really comprehend the profound nature of this realization," she writes. "And that sense of desperation and anxiety about that character, Cancer, stalking you, well, it takes some years before that feeling begins to ebb."
"Each year, facing that mammogram, it's just really, really hard," she continues. "Yet one part of me knows that even should cancer return, these years after disease are the most precious to me of my life. It's when I've lived with the knowledge that each and every day needs to be honored."
The researchers have disclosed no relevant financial relationships.
J Gen Intern Med. 2009:24(Suppl 2):417-424. |
Natasha Frechette, diagnosed with multiple sclerosis two years ago, has continued her job at Navigo Research in Brooklyn Park, Minn., with the help of an understanding boss and supportive colleagues.