Sharpe, M., Walker, J., Holm Hansen, C., Martin, P., Symeonides, S., Gourley, C., . . . Murray, G. (2014). Integrated collaborative care for comorbid major depression in patients with cancer (SMaRT Oncology-2): A multicentre randomised controlled effectiveness trial. Lancet, 384, 1099–1108. 

To compare the effectiveness of an integrated treatment program for major depression in patients with cancer with usual care

This study enrolled patients with major depression from three cancer centers. Patients were randomly assigned in a one-to-one ratio to either the standard care for depression or an intervention group. The intervention consisted of a multicomponent treatment program. This collaborative care model was expanded to include integration with the patients' specialist medical care. Potential participants were identified by the depression screening offered to all patients attending the selected National Health Service clinics in Scotland. A database software program randomized participants to the standard care or intervention groups. In the standard care group, the primary care physician and oncologist were informed of the diagnosis of major depression and asked to treat their patient accordingly. In the intervention group, the physicians were informed of the diagnosis and the participant saw a specially trained nurse under the supervision of a psychiatrist. This program was an intensive, collaborative care-based program specifically designed to be integrated with the patient’s cancer treatment.

• N = 500  
• AGE = Not available
• MALES: Not available  
• FEMALES: Exact numbers not available, but greater than half of patients were female
• KEY DISEASE CHARACTERISTICS: Majority were women with breast or gynecologic cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Participants were receiving adjuvant treatment or follow-up

• SITE: Multi-site    
• SETTING TYPE: Outpatient    
• LOCATION: Scotland, United Kingdom

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Elder care, palliative care 

Randomized, controlled trial comparing a standard treatment and an intervention

• Symptom Checklist Depression Scale (SCL-20) (self-reported)
• Primary outcomes were measured at 24 weeks.  
• Treatment response was defined as a reduction of at least 50% in depression severity from baseline.
• Secondary response was defined as an average depression score over 24, 36, and 48 weeks.
• Tertiary outcomes were anxiety, pain, fatigue, social, role functioning, overall health, and quality of life.

From 2008 to 2011, 253 patients were placed into the intervention group and 247 were placed in the standard of care group. Baseline characteristics did not differ between groups. Rates of antidepressant prescriptions at minimum effective doses and dose adjustments were higher in the intervention group. Very few patients from either group received formal psychological treatment from mental health professionals. The primary outcome of treatment response was achieved by 62% of patients in the intervention group compared to 17% of patients in the standard care group. The odds ratio was eight to five (95% confidence interval, p < .0001). The intervention was better than standard care for all secondary and tertiary outcomes. The mean additional cost per patient of providing depression care was in the 95% confidence interval.

A statistically significant number of patients had a clinical response in the intervention group versus the standard of care. This group also had a much greater improvement in anxiety, pain, fatigue, functional ability, quality of life, and perceived quality of care.

• Risk of bias (sample characteristics)
• Findings not generalizable
• Intervention expensive, impractical, or training needs
• Other limitations/explanation: The sample was mainly women receiving adjuvant treatment or follow-up care. The trial was completed in one particular healthcare system. The researchers were not able to determine whether one component of the intervention was more important than others. Patients were followed for only one year. Long-term outcomes are unknown.

Nurses are able to  play a major role in screening for depression and are able to provide (with training) interventions to help patients improve the symptoms of depression. Nurses also can provide longitudinal follow-up in assessing the improvement of depression. Attention to and treatment of depression in patients with cancer is effective. Nurses can advocate for sufficient attention to depression screening and management.