Depression in older cancer patients is very common, and has debilitating effects on their quality of life both during and after treatment. University of Washington researchers are showing that there are ways to better this situation.
"Little is known about the optimal approach to treating depression in this population, and older cancer patients are less likely to be treated for their depression than are younger cancer patients," said Dr Jesse Fann, UW associate professor of psychiatry and behavioural sciences. Fann is the director of psychiatric services at the Seattle Cancer Care Alliance, and an investigator in the Clinical Research Division at the Fred Hutchinson Cancer Research Center in Seattle.
Fann and his colleagues evaluated the effectiveness in older, depressed cancer patients of an intervention called Improving Mood-Promoting Access to Collaborative Treatment (IMPACT), in comparison to a similar set of patients receiving usual care. All participants had either major depression or a type of chronic depression called dysthymia, or a combination of both.
IMPACT participants worked with a depression care manager in their primary-care clinic for up to a year. Under the supervision of the patient’s primary-care provider and a psychiatrist, the care manager offered the patient support in taking anti-depressants if prescribed by the primary-care provider, education about depression, care coordination and structured counselling sessions that helped the patient engage in pleasant activities and that taught problem-solving skills.
The intervention was tested in 18 primary-care clinics in 5 states. The clinics served a variety of different socio-economic, geographic, and ethnic populations.
At the end of six months, 55 percent of the patients in the IMPACT group and 34 percent of the usual care participants showed a 50 percent or greater reduction in their depression symptoms. The IMPACT participants also had higher remission rates from depression, more depression-free days, less fatigue, a better quality of life, less functional impairment and fewer thoughts of death. Many of these benefits persisted during the one-year follow up period after the intervention was completed.
"Among the functional impairments older cancer patients can experience with depression are fatigue and thinking problems, such as forgetfulness, feeling mentally slowed down, and having difficulty concentrating or solving problems. Decisions that used to be straightforward or easy for them have become challenging," Fann explained.
Based on their findings, the researchers concluded that the IMPACT collaborative care program is feasible and more effective than standard care in managing depression among older cancer patients in primary-care, and is widely applicable.
"The IMPACT intervention can be successfully provided in diverse types of primary-care settings in various locations, and not just at specialised cancer centres. It can literally double the likelihood that the patient’s depression will improve over time," said Dr Jurgen Unutzer, UW professor of psychiatry and behavioural sciences and a co-investigator on the study with Fann and Dr Ming-Yu Fan, UW research assistant professor of psychiatry and behavioural sciences.
The results were published 20 October in a supplement of the Journal of General Internal Medicine on cancer survivorship care in primary-care.
Obtaining effective treatment for depression is vital, explained Fann, because of the serious, troubling effects depression has on many cancer patients: A depressed person may feel less motivated to exercise or eat well, to carry out treatment plans or be an active participant in their care. The risk of suicide is twice as high among older cancer patients compared to the general population, and the risk is even higher with older age. Some depressed patients question if cancer treatment is worth it, even if they don’t plan to end their lives. Patients may rebuff family and friends, and feel incapable of making arrangements for the future.
"Depression may persist after the cancer is successfully treated or in remission. They have survived the disease, but still can’t re-engage in life." Unutzer added. "Patients may feel unable to enjoy or make use of the time that has been added to their life."
The elderly are the largest segment of our population with cancer, and older cancer patients are becoming a significant segment of primary care practice, Fann and Unutzer said. By supporting depression care in primary-care settings, they added, health-care providers can help older cancer patients truly benefit from advances in cancer treatment by improving their quality of life.
Their suggestion to older cancer patients: "If you have depression, you don’t have to ‘just live with it’. Treatment may increase the odds that you will feel less tired and feel more like getting on with life. You dealt with cancer, and you can do something about depression."
The "Improving Primary Care for Older Adults with Cancer and Depression" study was supported by grants from the John A. Hartford Foundation, the California Health Care Foundation, the Hogg Foundation, and the Robert Wood Johnson Foundation.
(Source: University of Washington: General Internal Medicine: October 2009)