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