Journal of General Internal Medicine

, Volume 24, Supplement 2, pp 417–424 | Cite as

Improving Primary Care for Older Adults with Cancer and Depression

Original Article
First Online:

Abstract

Background

Depression is common among older cancer patients, but little is known about the optimal approach to caring for this population. This analysis evaluates the effectiveness of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) program, a stepped care management program for depression in primary care patients who had an ICD-9 cancer diagnosis.

Methods

Two hundred fifteen cancer patients were identified from the 1,801 participants in the parent study. Subjects were 60 years or older with major depression (18%), dysthymic disorder (33%), or both (49%), recruited from 18 primary care clinics belonging to 8 health-care organizations in 5 states. Patients were randomly assigned to the IMPACT intervention (n = 112) or usual care (n = 103). Intervention patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care provider and who offered education, care management, support of antidepressant management, and brief, structured psychosocial interventions including behavioral activation and problem-solving treatment.

Results

At 6 and 12 months, 55% and 39% of intervention patients had a 50% or greater reduction in depressive symptoms (SCL-20) from baseline compared to 34% and 20% of usual care participants (P = 0.003 and P = 0.029). Intervention patients also experienced greater remission rates (P = 0.031), more depression-free days (P < 0.001), less functional impairment (P = 0.011), and greater quality of life (P = 0.039) at 12 months than usual care participants.

Conclusions

The IMPACT collaborative care program appears to be feasible and effective for depression among older cancer patients in diverse primary care settings.

KEY WORDS

depression cancer treatment quality of life 
This is a preview of subscription content, log in to check access.

Notes

Conflict of Interest

None disclosed.

References

  1. 1.
    Institute of Medicine. Cancer in Elderly People: Work-shop Proceedings. Washington, DC: The National Academies Press; 2007.Google Scholar
  2. 2.
    American Cancer Society. Cancer Facts and Figures 2008. http://www.cancer.org/downloads/STT/2008CAFFfinalsecured.pdf.
  3. 3.
    Spoletini I, Gianni W, Repetto L, et al. Depression and cancer: an unexplored and unresolved emergent issue in elderly patients. Crit Rev Oncol Hematol. 2008;65:143–55.CrossRefPubMedGoogle Scholar
  4. 4.
    Kua J. The prevalence of psychological and psychiatric sequelae of cancer in the elderly—how much do we know? Ann Acad Med Singapore. 2005;34:250–6.PubMedGoogle Scholar
  5. 5.
    Unutzer J. Clinical practice. Late-life depression. N Engl J Med. 2007;357:2269–76.CrossRefPubMedGoogle Scholar
  6. 6.
    Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet. 2007;370:851–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Evans DL, Charney DS, Lewis L, et al. Mood disorders in the medically ill: scientific review and recommendations. Biol Psychiatry. 2005;58:175–89.CrossRefPubMedGoogle Scholar
  8. 8.
    Institute of Medicine. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press; 2007.Google Scholar
  9. 9.
    Massie MJ. Prevalence of depression in patients with cancer. J Natl Cancer Inst Monogr. 2004:57–71.Google Scholar
  10. 10.
    Patrick DL, Ferketich SL, Frame PS, et al. NIH State-of-the-Science Conference Statement: symptom management in cancer: pain, depression, and fatigue. J Natl Cancer Inst. 2003;95:1110–7.PubMedCrossRefGoogle Scholar
  11. 11.
    NCCN Clinical Practice Guidelines in Oncology Distress Management V.1 11/08/07; http://www.nccn.org/professionals/physician_gls/default.asp Accessed April 8, 2009.
  12. 12.
    Gill D, Hatcher S. Antidepressants for depression in people with physical illness. Cochrane Database Syst Rev. 2000:CD001312.Google Scholar
  13. 13.
    Williams S, Dale J. The effectiveness of treatment for depression/depressive symptoms in adults with cancer: a systematic review. Br J Cancer. 2006;94:372–90.CrossRefPubMedGoogle Scholar
  14. 14.
    Mynors-Wallis LM, Gath DH, Lloyd-Thomas AR, Tomlinson D. Randomised controlled trial comparing problem solving treatment with amitriptyline and placebo for major depression in primary care. BMJ. 1995;310:441–5.PubMedGoogle Scholar
  15. 15.
    Nezu AM, Nezu CM, Felgoise SH, McClure KS, Houts PS. Project Genesis: assessing the efficacy of problem-solving therapy for distressed adult cancer patients. J Consult Clin Psychol. 2003;71:1036–48.CrossRefPubMedGoogle Scholar
  16. 16.
    Roth AJ, Modi R. Psychiatric issues in older cancer patients. Crit Rev Oncol Hematol. 2003;48:185–97.CrossRefPubMedGoogle Scholar
  17. 17.
    Fallowfield L, Ratcliffe D, Jenkins V, Saul J. Psychiatric morbidity and its recognition by doctors in patients with cancer. Br J Cancer. 2001;84:1011–5.CrossRefPubMedGoogle Scholar
  18. 18.
    Passik SD, Dugan W, McDonald MV, Rosenfeld B, Theobald DE, Edgerton S. Oncologists' recognition of depression in their patients with cancer. J Clin Oncol. 1998;16:1594–600.PubMedGoogle Scholar
  19. 19.
    Von Korff M, Unutzer J, Katon W, Wells K. Improving care for depression in organized health care systems. J Fam Pract. 2001;50:530–1.PubMedGoogle Scholar
  20. 20.
    Merckaert I, Libert Y, Delvaux N, et al. Factors that influence physicians' detection of distress in patients with cancer: can a communication skills training program improve physicians' detection? Cancer. 2005;104:411–21.CrossRefPubMedGoogle Scholar
  21. 21.
    Kadan-Lottick NS, Vanderwerker LC, Block SD, Zhang B, Prigerson HG. Psychiatric disorders and mental health service use in patients with advanced cancer: a report from the coping with cancer study. Cancer. 2005;104:2872–81.CrossRefPubMedGoogle Scholar
  22. 22.
    Pirl WF, Muriel A, Hwang V, et al. Screening for psychosocial distress: a national survey of oncologists. J Support Oncol. 2007;5:499–504.PubMedGoogle Scholar
  23. 23.
    Greenberg DB. Barriers to the treatment of depression in cancer patients. J Natl Cancer Inst Monogr. 2004:127–35.Google Scholar
  24. 24.
    Sneed JR, Rutherford BR, Rindskopf D, Lane DT, Sackeim HA, Roose SP. Design makes a difference: a meta-analysis of antidepressant response rates in placebo-controlled versus comparator trials in late-life depression. Am J Geriatr Psychiatry. 2008;16:65–73.CrossRefPubMedGoogle Scholar
  25. 25.
    Coyne JC, Thompson R, Palmer SC, Kagee A, Maunsell E. Should we screen for depression? Caveats and potential pitfalls. Appl Preventive Psychology. 2000;9:101–21.CrossRefGoogle Scholar
  26. 26.
    Gilbody SM, House AO, Sheldon TA. Routinely administered questionnaires for depression and anxiety: systematic review. BMJ. 2001;322:406–9.CrossRefPubMedGoogle Scholar
  27. 27.
    Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;136:765–76.PubMedGoogle Scholar
  28. 28.
    Hirschfeld RM, Keller MB, Panico S, et al. The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA. 1997;277:333–40.CrossRefPubMedGoogle Scholar
  29. 29.
    Sarkisian CA, Lee-Henderson MH, Mangione CM. Do depressed older adults who attribute depression to “old age” believe it is important to seek care? J Gen Intern Med. 2003;18:1001–5.CrossRefPubMedGoogle Scholar
  30. 30.
    Klap R, Unroe KT, Unutzer J. Caring for mental illness in the United States: a focus on older adults. Am J Geriatr Psychiatry. 2003;11:517–24.PubMedGoogle Scholar
  31. 31.
    Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006;166:2314–21.CrossRefPubMedGoogle Scholar
  32. 32.
    Unutzer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288:2836–45.CrossRefPubMedGoogle Scholar
  33. 33.
    Lin EH, Katon W, Von Korff M, et al. Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial. JAMA. 2003;290:2428–34.CrossRefPubMedGoogle Scholar
  34. 34.
    Unutzer J, Katon W, Williams JW Jr., et al. Improving primary care for depression in late life: the design of a multicenter randomized trial. Med Care. 2001;39:785–99.CrossRefPubMedGoogle Scholar
  35. 35.
    First MD, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID). Clinical Version. Washington, DC: American Psychiatric Press; 1996.Google Scholar
  36. 36.
    Mayfield D, McLeod G, Hall P. The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry. 1974;131:1121–3.PubMedGoogle Scholar
  37. 37.
    Callahan CM, Unverzagt FW, Hui SL, Perkins AJ, Hendrie HC. Six-item screener to identify cognitive impairment among potential subjects for clinical research. Med Care. 2002;40:771–81.CrossRefPubMedGoogle Scholar
  38. 38.
    International Classification of Diseases, Ninth Revision, Clinical Modification. Washington, D.C.: Public Health Service. US Dept of Health and Human Services; 1988.Google Scholar
  39. 39.
    Jones LE, Doebbeling CC. Suboptimal depression screening following cancer diagnosis. Gen Hosp Psychiatry. 2007;29:547–54.CrossRefPubMedGoogle Scholar
  40. 40.
    Mynors-Wallis LM, Gath DH, Day A, Baker F. Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. BMJ. 2000;320:26–30.CrossRefPubMedGoogle Scholar
  41. 41.
    Derogatis LR, Lipman RS, Covi L. SCL-90: an outpatient psychiatric rating scale–preliminary report. Psychopharmacol Bull. 1973;9:13–28.PubMedGoogle Scholar
  42. 42.
    Lave JR, Frank RG, Schulberg HC, Kamlet MS. Cost-effectiveness of treatments for major depression in primary care practice. Arch Gen Psychiatry. 1998;55:645–51.CrossRefPubMedGoogle Scholar
  43. 43.
    Leon AC, Olfson M, Portera L, Farber L, Sheehan DV. Assessing psychiatric impairment in primary care with the Sheehan Disability Scale. Int J Psychiatry Med. 1997;27:93–105.PubMedGoogle Scholar
  44. 44.
    Rubin D. Multiple Imputation for Non-response in Surveys. New York, NY: John Wiley & Sons; 1987.CrossRefGoogle Scholar
  45. 45.
    Hunkeler EM, Katon W, Tang L, et al. Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care. BMJ. 2006;332:259–63.CrossRefPubMedGoogle Scholar
  46. 46.
    Nail LM. My get up and go got up and went: fatigue in people with cancer. J Natl Cancer Inst Monogr. 2004:72–5.Google Scholar
  47. 47.
    Misono S, Weiss NS, Fann JR, Redman M, Yueh B. Incidence of suicide in persons with cancer. J Clin Oncol. 2008;26:4731–8.CrossRefPubMedGoogle Scholar
  48. 48.
    Unutzer J, Tang L, Oishi S, et al. Reducing suicidal ideation in depressed older primary care patients. J Am Geriatr Soc. 2006;54:1550–6.CrossRefPubMedGoogle Scholar
  49. 49.
    Strong V, Waters R, Hibberd C, et al. Management of depression for people with cancer (SMaRT oncology 1): a randomised trial. Lancet. 2008;372:40–8.CrossRefPubMedGoogle Scholar
  50. 50.
    Ell K, Xie B, Quon B, Quinn DI, Dwight-Johnson M, Lee PJ. Randomized controlled trial of collaborative care management of depression among low-income patients with cancer. J Clin Oncol. 2008; 26:4488–96.CrossRefPubMedGoogle Scholar
  51. 51.
    Dwight-Johnson M, Ell K, Lee PJ. Can collaborative care address the needs of low-income Latinas with comorbid depression and cancer? Results from a randomized pilot study. Psychosomatics. 2005;46:224–32.CrossRefPubMedGoogle Scholar
  52. 52.
    McBean AM, Warren JL, Babish JD. Measuring the incidence of cancer in elderly Americans using Medicare claims data. Cancer. 1994;73:2417–25.CrossRefPubMedGoogle Scholar
  53. 53.
    McClish DK, Penberthy L, Whittemore M, et al. Ability of Medicare claims data and cancer registries to identify cancer cases and treatment. Am J Epidemiol. 1997;145:227–33.PubMedGoogle Scholar
  54. 54.
    Wang PS, Walker AM, Tsuang MT, Orav EJ, Levin R, Avorn J. Finding incident breast cancer cases through US claims data and a state cancer registry. Cancer Causes Control. 2001;12:257–65.CrossRefPubMedGoogle Scholar
  55. 55.
    Fleishman SB. Treatment of symptom clusters: pain, depression, and fatigue. J Natl Cancer Inst Monogr. 2004:119–23.Google Scholar

Copyright information

© Society of General Internal Medicine 2009

Authors and Affiliations

  • Jesse R. Fann
    • 1
    • 2
    • 3
  • Ming-Yu Fan
    • 1
  • Jürgen Unützer
    • 1
  1. 1.Department of Psychiatry and Behavioral SciencesUniversity of Washington School of MedicineSeattleUSA
  2. 2.Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleUSA
  3. 3.Psychiatry and Psychology ServiceSeattle Cancer Care AllianceSeattleUSA

Personalised recommendations