It is not uncommon for patients suffering from disorders such as cancer to experience major depression - a condition that sharply reduces quality of life. The medical community, however, lacks substantial research that can assist physicians in helping patients manage depression. In order to add to this scarce body of evidence, Sharpe and colleagues conducted the SMaRT (Symptoms Management Research Trials) oncology 1 trial to study this new complex care package (DCPC) specially designed for cancer patients with depression and delivered by nurses.
Funded by Cancer Research UK, the trial consisted of 200 patients - all with a cancer prognosis of more than six months and major depression - selected from a regional cancer center in Scotland. The patients were about 56.6 years, on average, and 71% were women (141 of 200). In the randomization process, 99 patients were placed in a group that received the usual care of antidepressants and mental health referrals that depressed cancer patients receive from their general practitioner and cancer team. The other 101 patients were placed in a group that received the usual care in addition to DCPC.
The DPCP consisted of about seven one-on-one counseling sessions (over three months) with a trained cancer nurse. In these sessions, the nurses provided information about depression and ways to treat it (such as information on the various antidepressant medications). As a method of preventing feelings of helplessness among cancer patients, the nurses also offered problem-solving treatment. Not only did the nurses remain in contact with each patient's oncologist and primary-care doctor to discuss depression management, but they also monitored progress via telephone after the sessions were completed. If necessary, nurses would meet with patients for optional additional sessions. The researchers used two methods to measure depression in both groups: 1) the self-reported Symptom Checklist-20 depression scale, range 0 to 4, and 2) interviews after three, six, and 12 months.
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. Although the DCPC did not reduce pain or improve physical functioning, it did help patients who were suffering from anxiety and fatigue.
The researchers claim that DCPC is potentially cost-effective. Studying the numbers, the researchers report that the per patient cost of DCPC over six months is £336 (US$668), which can be expanded to £5278 per quality-adjusted life-year gained. This figure can be compared to the median level of cost per quality-adjusted life-year gained of about £10,000 (US$20,000) for anti-cancer treatments in general.
"The intervention - Depression Care for People with Cancer - offers a model for the management of major depressive disorder in patients with cancer and other medical disorders who are attending special medical services that is feasible, acceptable, and potentially cost effective," conclude the authors.
An accompanying Comment, written by Professor Gary Rodin (Princess Margaret Hospital, University Health Network, Toronto, ON, Canada), notes that, "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 multicomponent interventions are potentially feasible in cancer treatment centres and can be perceived by patients as less stigmatising than referral to a mental health specialist."
Management of depression for people with cancer (SMaRT oncology 1): a randomised trial
Vanessa Strong, Rachel Waters, Carina Hibberd, Gordon Murray, Lucy Wall, Jane Walker, Gillian McHugh, Andrew Walker, Michael Sharpe
The Lancet (2008). 372(9632): pp. 40-48.
Written by: Peter M Crosta