Elsevier

General Hospital Psychiatry

Volume 29, Issue 3, May–June 2007, Pages 223-231
General Hospital Psychiatry

Psychiatric–Medical Comorbidity
Improving treatment of depression among low-income patients with cancer: the design of the ADAPt-C study

https://doi.org/10.1016/j.genhosppsych.2007.01.005Get rights and content

Abstract

Objective

This article describes the randomized clinical trial methodology for a population-based study of oncology patients receiving cancer care in a public sector medical center. The primary goal is to test the effectiveness of socioculturally tailored collaborative care intervention in improving depression and quality of life outcomes among low-income ethnic minority patients with major depression and cancer.

Methods

The Patient Health Questionnaire (PHQ-9) depression scale was used to identify patients meeting criteria for major depression (one cardinal depression symptom plus a PHQ-9 score of ≥10). Study-eligible patients were ≥90 days from cancer diagnosis who were receiving acute cancer treatment or follow-up care in oncology clinics. Patients with advanced disease limiting life expectancy to <6 months, acutely suicidal or on antipsychotic medication were excluded. Allowing for attrition due to death or loss to follow-up, the study was powered at the 80% level to detect a 20% difference between study arms in the proportion of patients with ≥50% reduction in PHQ-9 symptoms at 12 months.

Results

Of 2330 patients screened, 23.2% met criteria. An 82.4% enrollment rate resulted in 446 primarily women being recruited and randomized to intervention or usual care.

Conclusion

The study applies methods used in primary care depression trials with adaptations for oncology care clinics and for low-income minority patients.

Introduction

Depressive disorders and symptoms are common in cancer patients (up to 38% having major depression) [1], [2], [3], worsen over the course of cancer treatment, persist long after cancer therapy [4], reoccur with the recurrence of cancer [5], and significantly impact quality of life [6], [7], [8], [9]. Unfortunately, clinicians and patients often perceive depression as an expected and reasonable reaction to cancer; thus, depression is frequently underrecognized and undertreated in oncology practice [10], [11], [12], [13], [14], [15], [16]. Low-income patients are particularly unlikely to receive mental health treatment [17], [18].

Patient, provider and health system barriers to care contribute to the failure to effectively manage depression symptoms. Patients may be reluctant to report symptoms or to see a mental health professional, and if prescribed treatment may not adhere to prescribed treatment, citing concerns about side effects and/or preoccupation with active cancer treatment. Providers may be reluctant to raise the issue and may be less aware of effective treatments, while organizational barriers reduce timely and integrated access to mental health professionals. Culturally based preferences for depression care can become a barrier to care if the preferred mode of care is not available [19], while culturally based explanations for depression symptoms may influence symptom expression and patient–provider communication [20], [21], [22], [23]. Perceived stigma, family perceptions, and practical barriers such as cost and transportation to therapy may also impede receipt of care among low-income populations [24], [25].

Depression care quality-improvement strategies are effective in reducing barriers to depression care — including among racial/ethnic minorities [26]. Organizational strategies [27] generally include multifaceted, quality improvement disease-management interventions that change the way depression care is delivered, such as the implementation of routine depression screening, systematic application of evidence-based practice guidelines, clinical decision-making protocols and algorithms (cancer-specific available on the National Cancer Institute and National Comprehensive Cancer Network Web sites), follow-up through remission and maintenance, enhanced roles of nurses or social workers as depression care managers as well as integration between primary care and mental health specialists or service systems.

Depression care models that use collaboration between primary care physicians and mental health professionals, where expertise in psychopharmacology in treating depression is provided by a psychiatrist and psychotherapy and supportive care management is provided by depression specialist nurses or social workers, have been found to be effective in primary care [28]. An adapted model for oncology was found to be effective in a randomized pilot study of 55 low-income, predominantly Latina patients with breast or cervical cancer who met criteria for major depression [29], suggesting that cancer patients in public sector oncology clinics can benefit from depression treatment. What was learned from this preliminary study led to further adaptations for low-income minority patients and the public sector that serves them. We present here the design of the Alleviating Depression Among Patients with Cancer (ADAPt-C) randomized clinical trial, sociocultural adaptations in the care management model and the baseline characteristics of the sample (Fig. 1).

Section snippets

Study site, sample recruitment and randomization

Los Angeles County + University of Southern California (USC) Medical Center is a large public sector center that provides oncology care to a predominantly Hispanic population. The study was approved by the USC Health Sciences Institutional Review Board. Trained bilingual study recruiters identified potentially eligible patients by reviewing daily oncology clinic charts. Patients were then assessed for language preference and asked to provide brief verbal consent to be screened for depressive

Discussion

The ADAPt-C study has demonstrated the feasibility of recruiting a low-income, ethnic minority population-based oncology care sample of primarily female patients with depression and cancer in a randomized controlled trial. We believe that the use of bilingual, bicultural recruitment staff, approaching patients in the clinics and offering patients a choice of treatment facilitated recruitment among women, but was less effective in overcoming reluctance to participate among men (a finding that

Acknowledgments

The study is supported by R01CA105269 from the National Cancer Institute, Office of Cancer Survivorship, Division of Cancer Control & Population Sciences, Bethesda, MD (PI, Dr. Ell). Dr. Jurgen Unützer and Dr. Wayne Katon provided consultation on the study design.

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