Intervention delivered by nurses can help combat depression in cancer patients

A team of Scottish researchers have shown that cancer patients offered a depression care intervention - delivered by specially trained oncology nurses with no previous psychiatric experience - showed improvements in symptoms of depression compared to patients offered usual care.

The beneficial effects of the “Depression Care for People with Cancer” package (DCPC) were found to be sustained at 12 months follow-up, to the surprise of the investigators. 

Major depressive disorder severely impairs the quality of life of patients with medical disorders, such as cancer. Estimates suggest that clinical depression affects 10% of patients with cancer. Few studies have, however, been undertaken to guide clinicians in the management of this type of depression.

Professor Michael Sharpe and colleagues, from the University of Edinburgh Cancer Research Centre, Western General Hospital, Edinburgh, Scotland, undertook the SMRT (Symptoms Management Research Trials) oncology 1 trial to study the use of the DCPC package, originally designed for the treatment of depression in primary care.  
In the study, funded by Cancer Research UK, 200 patients all with a cancer prognosis of more than six months, and major depression, were randomised to receive the usual care of antidepressants and mental health referrals or usual care in addition to the DCPC programme. The patients were on average 56.6 years, and 71 % were women. 

 
Patients allocated to the DCPC arm were offered an average of seven one-to-one consultations over three months with a specially-trained cancer nurse. The sessions aimed to help patients to understand depression and its treatments, including antidepressants, and provided problem-solving strategies to help patients overcome feelings of helplessness.

The nurses also communicated with each patient's oncologist and primary-care doctor about the management of their depression. Following the initial treatment, the nurse monitored the patient's progress by telephone and provided optional booster sessions if needed. Depression levels were measured using the self-reported Symptom Checklist-20 depression scale (range 0 to 4), and also by interview at three, six, and 12 months for both groups. The nurses, who had no previous experience of psychiatry, were trained to deliver the intervention using written materials, tutorials and supervised practice over a period of at least three months. The primary outcome was the difference in mean score on the self-reported Symptom Checklist-20 depression scale (range 0 to 4) at three months with the analysis undertaken according to intention to treat. Sharpe and colleagues found that patients who received DCPC had a lower depression level - by 0.34 on the scale - than those who did not receive DCPC. The treatment group also had a major depression rate that was 23% lower than in the usual care group. After 12 months, the benefits from the DCPC intervention were still evident. The DCPC intervention also improved anxiety and fatigue, but did not improve pain or physical functioning.  

DCPC treatment, claim the researchers, has the potential to be extremely cost-effective. Over the six months DCPC cost £336 (US$668) per patient, which is equivalent to £5278 per quality-adjusted life-year gained. This is well within that usually considered to be cost effective, write the authors . They concluded: “The intervention proved to be feasible to deliver, acceptable to the patients who received it and also cost effective in terms of the increase in quality-adjusted life-years achieved.”  

The limitations of the study, say the researchers, are that the physical symptoms of depression can overlap with those caused by medical disorders, a potential bias in self-rated outcome assessments. Also, patients who had cancers with poor prognosis and those with chronic depression pre dating the diagnosis, were excluded.
In future studies, the team hope to investigate whether the programme is cost effective if implemented on a larger scale, and whether the intervention might also benefit patients who have cancers with a poor prognosis, such as lung cancer. The investigators also wish to explore whether quality of life might be improved if pain were treated at the same time, and whether the approach might be effective for patients who attend specialist services for other medical disorders.

In an accompanying comment, Gary Rodin (Princess Margaret Hospital, University Health Network, Toronto, Canada), wrote: “In a well-designed study, Sharpe and colleagues have shown that trained nurses with no previous psychiatric experience can deliver a cost-effective collaborative psychosocial intervention for cancer patients with major depressive disorder. Such multi-component interventions are potentially feasible in cancer treatment centres and can be perceived by patients as less stigmatising than referral to a mental health specialist.”