The most important implication of this study is that paying the same systematic attention to the management of comorbid major depression as we presently do to the associated medical condition achieves much better outcomes for patients.
—Michael Sharpe, MD, Jane Walker, PhD, and colleagues
In the Scottish SMaRT Oncology-2 study reported in The Lancet, Michael Sharpe, MD, and Jane Walker, PhD, of University of Oxford, United Kingdom, and colleagues found that an integrated collaborative treatment program for depression (“depression care for people with cancer”) was associated with significantly higher depression response and remission rates compared with usual care in cancer patients with major depression, and also resulted in significant improvements in health, functioning, and quality of life.1
In the trial, 500 cancer outpatients with major depression from three cancer centers and associated clinics in Scotland were randomly assigned between May 2008 and May 2011 to the depression care for people with cancer intervention (n = 253) or usual care (n = 247), with stratification by trial center and minimization by age, primary cancer, and sex. The primary outcome measure was treatment response defined as a ≥ 50% reduction in Symptom Checklist Depression Scale [SCL-20] score (range, 0–4) at 24 weeks in the intention-to-treat population. This degree of improvement is considered comparable to no longer meeting diagnostic criteria for major depression.
Outcome data were collected up until 48 weeks. Analysis was adjusted for stratification and minimization variables and baseline scores.
Depression care for people with cancer is a manualized, multicomponent collaborative care treatment that is delivered systematically by a team of cancer nurses and psychiatrists in collaboration with patients’ oncology teams and primary care physicians.
The nurses established a therapeutic relationship with the patient, provided information about depression and treatment, delivered brief psychological interventions (problem-solving therapy and behavioral activation), and monitored patient progress using the Patient Health Questionnaire (PHQ)-9 depression severity scale. Psychiatrists supervised treatment with the aim of achieving a treatment target of PHQ-9 score < 10 and ≥ 50% below baseline score, advised primary care physicians on prescribing antidepressants, and provided direct consultations with patients not exhibiting improvement.
The initial treatment phase consisted of a maximum of 10 sessions with the nurse over 4 months, after which PHQ-9 scores were monitored monthly by telephone for 8 months, with additional nurse sessions being provided for patients not meeting treatment targets. Usual care was provided by patients’ oncologists and primary care physicians.
Treatment Group Characteristics
Patients in the intervention and control groups were generally balanced for age and age range (mean age, 57 and 56 years; range, 23–85 and 26–84 years; 31% and 32% aged > 60 years), sex (90% women in both), marital status (62% and 61% with spouse/partner), and employment status (54% and 51% not working).
The groups were also well balanced for duration of current depressive episode (1–6 months in 52% and 50%, ≥ 1 year in 27% and 19%), number of previous depressive episodes (0 in 31% and 35%, > 1 in 33% and 22%), antidepressant use (at any dose in 40% and 38%, at ≥ minimum effective dose in 28% and 26%), primary cancer (breast in 55% and 53%, gynecologic in 23% and 26%, genitourinary in 5% and 6%, other in 17% and 15%), cancer treatment within previous 2 months (none in 38% and 35%, surgery in 6% and 4%, hormone therapy in 38% in both, radiotherapy in 9% and 7%, chemotherapy in 19% and 22%), cancer status (nonactive disease in 79% in both, active disease with radical treatment in 8% and 5%, active disease with palliative treatment in 13% and 16%), and perceived quality of depression care (poor in 32% and 25%, fair in 33% and 36%, good in 21% and 27%, very good in 8% and 10%, excellent in 6% and 2%).
Patients had similar baseline scores on the SCL-20 and anxiety scores on the SCL-10 anxiety scale and similar scores for pain, fatigue, physical functioning, social functioning, role functioning, overall health, and quality of life on the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30).
Response was observed in 62% of patients in the intervention group vs 17% of those in the usual-care group (absolute difference = 45%, 95% confidence interval = 37%–53%, adjusted odds ratio [OR] = 8.5, P < .0001). The intervention group also had a significantly greater frequency of depression remission, defined as SCL-20 score < 0.75 at weeks 24, 36, and 48 (33% vs 4%, adjusted OR = 13.1, P < .0001) and significantly lower average depression severity (score of 0.94 vs 1.71,
P < .0001).
Self-rated assessment of depression at 24 weeks was “better/much better” for 79% vs 49%, “has not changed” for 17% and 33%, and “worse/much worse” for 4% and 17% (P < .0001).
Anxiety assessed by SCL-10 anxiety score and pain, fatigue, physical functioning, social functioning, role functioning, overall health, and quality of life on the EORTC-QLQ-C30 were all consistently better in the intervention group at 12, 24, 36, and 48 weeks (all P < .05). Ratings of quality of depression care at 12 weeks were “excellent/very good” by 72% of the intervention group vs 25% of the usual-care group (P < .0001), with this difference persisting through 48 weeks.
Cancer-related death occurred in 19 patients in the intervention group and 15 in the usual-care group. One intervention group patient was admitted to a psychiatric ward, and one attempted suicide during the trial, with neither of these events considered to be related to trial procedures.
The mean additional cost per patient for providing the depression care for people with cancer intervention was £613 (roughly equivalent to US$1,020 at current exchange rates).
The investigators concluded: “Our 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.”
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. Furthermore, the additional cost of delivering depression care for people with cancer was quite modest, especially in the context of cancer treatment. The most important implication of this study is that paying the same systematic attention to the management of comorbid major depression as we presently do to the associated medical condition achieves much better outcomes for patients. ■
Disclosure: The study was funded by Cancer Research UK and the Chief Scientist Office of the Scottish Government. The study authors reported no potential conflicts of interest.
1. Sharpe M, Walker J, Hansen CH, et al: Lancet. August 27, 2014 (early release online).
Drs. Sharpe and Walker are the joint first authors of the Lancet article.
Clinical depression is highly prevalent, associated with significant morbidity, often underrecognized, and inadequately treated in cancer patients. Professor Michael Sharpe and Jane Walker, PhD, and their colleagues’ seminal work on enhancing treatment of depression in cancer patients using a...