Written by: Keith Wilson, PhD, CPsych, Department of Psychology, The Ottawa Hospital Rehabilitation Centre
Psychosocial oncology has done a good job of documenting the 10% – 20% prevalence of major depression (MD) among people with cancer, as well as the fact that MD accounts for a disproportionate amount of suffering. Where we have lagged is in demonstrating that we can treat MD with a sensible, evidence-based, practical and efficient intervention suitable for integration into oncology settings. With this study by Sharpe et al., we may finally have caught up.
“Depression Care for People with Cancer” consists, in part, of a brief (up to 10 sessions), manualised psychotherapy that draws on the cognitive-behavioural strategies of behavioural activation and problem-solving. In this trial, the therapy was administered by nurses who received rigorous training in these therapeutic techniques. The nurse-therapists were supervised by psychiatrists, who also consulted on medications and worked with patients who were not improving.
Sharpe et al. randomized 500 patients diagnosed with MD at three Scottish cancer centres to receive either the Depression Care for People with Cancer program or usual care (which could include referral to existing psychosocial oncology services). The trial endpoint was depression status at 24 weeks, but patients were followed for almost a year.
The authors describe the results as “striking”. Among patients who received the Depression Care for People with Cancer program, 62% reached the pre-specified primary outcome of a 50% reduction in depression symptoms. In contrast, only 17% of those receiving usual care achieved this degree of improvement. Moreover, a third of patients receiving the Depression Care for People with Cancer program met criteria for full remission of MD, compared to only 4% of those receiving usual care. In addition to these statistically robust differences in depression itself, secondary outcomes of anxiety, pain, fatigue, social participation, and quality of life were all reliably better for those receiving the Depression Care for People with Cancer program, and sustained over the duration of follow-up. Interestingly, the researchers also kept careful records of the time spent administering the intervention. They calculated the cost as £613 – about $1,100 Canadian.
Why I like this article: It is rare in psychosocial research to read individual studies that have the potential to be game-changers for an entire field, but this work comes close. Methodologically, this is a textbook example of how to design a rigorous clinical trial of a complex intervention. The findings should be appreciated widely by everyone involved in cancer care. If this treatment was available in a pill form that could reduce the suffering of that many people, for that duration of time, in multiple dimensions of distress, at such a low cost, we can speculate that it would quickly become a routine standard of care. Our challenge now is to translate this compelling research knowledge into genuine and widely available integrated care in cancer treatment programs.
Article: Sharpe, M., Walker, J., Hansen, C.H., Martin, P., Symeonides, S., Gourley, C., Wall, L., Weller, D., Murray, G., for the SMaRT (Symptom Management Research Trials) Oncology-2 Team. (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.
Journal Website: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61231-9/abstractAuthor Website: http://www.psych.ox.ac.uk/team/PIs/michael-sharpe