Integrated or Collaborative Behavioral Health Care Model

STUDY PURPOSE: To provide an evidence-based review to update treatment guidelines for depression in patients with cancer. Conducted analysis of pharmacologic and collaborative care interventions

TYPE OF STUDY: Meta-analysis and systematic review

• FINAL NUMBER STUDIES INCLUDED = 25 RCTs, 2 pharmacologic, 9 psychologic, 7 collaborative care
• TOTAL PATIENTS INCLUDED IN REVIEW = 3,502
• SAMPLE RANGE ACROSS STUDIES: 38–472
• KEY SAMPLE CHARACTERISTICS: Varied tumor types and multiple phases of care from active treatment to palliative care

PHASE OF CARE: Multiple phases of care
 
APPLICATIONS: Palliative care

All interventions examined had at least a short-term benefit for the treatment of depression. Pharmacologic interventions can be associated with adverse events, and psychological interventions had short-term efficacy but no long-term efficacy. Collaborative care interventions showed persistent benefit.

• Limited search
• Limited number of studies included
• High heterogeneity
• Relatively few studies for each type of intervention analyzed

Pharmacologic, psychological, and collaborative care interventions demonstrated at least a short-term benefit for the treatment of depression among patients with cancer at various treatment phases. Collaborative care interventions showed strong and sustained effectiveness, suggesting that the integration of depression treatment into oncology settings can improve patient outcomes.

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.

To evaluate feasibility and effectiveness of a brief psychosocial intervention delivered by front-line health professionals as part of a planned stepped integrated care model

Clinical sites were randomized to the intervention or control condition. Those randomized to the intervention received a training manual and had a one-day skill development program focusing on supportive-expressive, CNT, and dignity-conserving strategies. At intervention sites, the level of intervention was determined based on distress thermometer (DT) scores and assigned to trained healthcare providers. Patients with HADS scores of 8-21 received the health provider intervention described, and those with HADS scores of 22 or higher were referred for specialist treatment. Patients were contacted and offered up to four individual sessions by telephone or face to face. Weekly supervision was provided by a psychiatrist in a group setting. Patients completed baseline measurements in clinic visits and follow-up measures were provided via reply paid envelope. A phone reminder was done to encourage completion of follow-up measures. Health professionals who delivered the intervention included oncology nurses, physiotherapists, cancer care coordinators, radiation therapists, and an occupational therapist.

• N = 358   
• AGE: Mean = 58.9 years
• MALES: 29.9%  
• FEMALES: 69.1%
• KEY DISEASE CHARACTERISTICS: Varied tumor types–breast and gynecologic were most prevalent. Seventy-six percent had disease progression.  
• OTHER KEY SAMPLE CHARACTERISTICS: Most were married and not working. Formal education level ranged from less than high school to university education. Patients taking antidepressants were excluded.

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: Australia

Cluster, randomized, crossover, multi-site design

• Hospital Anxiety and Depression Scale (HADS)
• FACT-General for quality of life
• EQ 5D-5L
• Demoralization scale
• Unmet needs

There were no significant differences in outcome measures between those patients in the intervention or control conditions. In the intervention condition, 112 were allocated to written resources, 115 to the brief intervention, and 18 were allocated to specialist treatment. There were no differences in outcomes in any of these groups. Providers involved in delivering the intervention reported that it was difficult to provide this along with the other demands in daily practice.

The brief intervention delivered by various front-line healthcare professionals was insufficient to effectively manage depression or anxiety. The amount of skill development provided to the mix of providers involved may have been insufficient.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Key sample group differences that could influence results
• Measurement/methods not well described
• Intervention expensive, impractical, or training needs
• Subject withdrawals ≥ 10%
• Other limitations/explanation: The timing of follow-up measurement is unclear. The differences in effectiveness according to the provider used for the intervention may be a question. Some of these disciplines have no basic education in psychosocial intervention as part of professional education. Significant education and training for skill development and ongoing clinical supervision are required.

This study did not demonstrate effectiveness of this stepped program and brief intervention by varied healthcare professionals. Other research has shown that nurse-delivered programs can be effective. Many other disciplines do not have the depth of initial education in psychosocial care and may require much more education and training to develop sufficient skill to provide an effective intervention for anxiety and depression.

To assess the efficacy of an integrated treatment program for major depression in patients with lung cancer compared to usual care

Nurses were specially trained to deliver psychological interventions to patients who were physically deteriorating. The training emphasized the achievement of competency and included tutorials and role-play among other methods. The trained nurses provided 10 structured sessions with patients, usually in their homes, immediately following the diagnosis of depression. Additional treatment was provided by phone and, for those patients who did not meet targets, additional treatment was provided.

• N = 142  
• AVERAGE AGE = 63.8 years (range = 40.7–82.2 years)
• MALES: 35%, FEMALES: 65%
• KEY DISEASE CHARACTERISTICS: The majority of patients were diagnosed with lung cancer, and most of those diagnoses were non-small cell lung cancer.
• OTHER KEY SAMPLE CHARACTERISTICS: The majority of patients were retired and had a spouse or partner.

• 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

• Hopkins Symptom Checklist (SCL-20) depression scale version B (20 items rated 0–4)

Average depression severity was significantly lower in patients allocated to the intervention group. Care was given by a nurse who usually visited patients in their homes. Depression improvement was self-rated. Improvement was seen in anxiety, quality of life, role functioning, perceived quality of care, and the proportion of patients achieving a 12-week treatment response.

In this study, the intervention proved to be more effective than usual care in reducing depression severity. Participants also saw improvements in anxiety, quality of life, and role functioning.

• Risk of bias (sample characteristics)
• Unintended interventions or applicable interventions not described that would influence results 
• Measurement/methods not well described
• Intervention expensive, impractical, or training needs
• Other limitations/explanation: Psychiatrists also prescribed medications. I was difficult to determine which parts of the intervention were effective.