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Psychosomatics 46:224-232, June 2005
© 2005 The Academy of Psychosomatic Medicine

Can Collaborative Care Address the Needs of Low-Income Latinas With Comorbid Depression and Cancer? Results From a Randomized Pilot Study

Megan Dwight-Johnson, M.D., M.P.H., Kathleen Ell, D.S.W., and Pey-Jiuan Lee, M.S.

Received Jan. 7, 2004; revision received July 28, 2004; accepted Aug. 12, 2004. From the Department of Psychiatry and Behavioral Sciences, University of Washington; and the School of Social Work, University of Southern California, Los Angeles. Address correspondence and reprint requests to Dr. Dwight-Johnson, Department of Psychiatry and Behavioral Sciences, University of Washington, Box 356560, Seattle, WA 98195-6560; mdjohnso{at}u.washington.edu (e-mail).


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
In a pilot study, 55 low-income Latina patients with breast or cervical cancer and comorbid depression were randomly assigned to receive collaborative care as part of the Multifaceted Oncology Depression Program or usual care. Relative to patients in the usual care condition, patients receiving collaborative care were more likely to show ≥50% improvement in depressive symptoms as measured by the Personal Health Questionnaire (OR=4.51, 95% CI=1.07–18.93). Patients in the collaborative care program were also more likely to show improvement in emotional well-being (increase of 2.15) as measured by the Functional Assessment of Cancer Therapy Scale than were those receiving usual care (decrease of 0.50) (group difference=2.65, 95% CI: 0.18 – 5.12). Despite health system, provider, and patient barriers to care, these initial results suggest that patients in public sector oncology clinics can benefit from onsite depression treatment.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Depression is common in cancer patients,1 worsens over the course of cancer treatment, persists long after cancer therapy,2 reoccurs with the recurrence of cancer,3 and significantly impacts functioning and medical outcomes.4 Antidepressant medication and psychosocial treatments not only improve depression in patients with cancer5–12 but also positively impact response to chemotherapy, treatment adherence, and quality of life.13–15 Unfortunately, depression is often underrecognized16–18 and undertreated in oncology settings.19,20

Latinos, the largest ethnic minority group in the United States (12.5% of the general population21) have incidence and mortality rates from cervical cancer that are twice as high as those among non-Latinos.22–25 Furthermore, incidence of breast cancer among Latinas is increasing at a higher rate than among non-Latina whites.22 Low-income Latino cancer patients who are at high risk for depression have especially poor access to mental health services26 and are particularly unlikely to receive mental health treatment.27

Collaborative care interventions that integrate mental health professionals into primary care have been effective for increasing rates of appropriate depression care,20,28–30 especially among low-income and minority patients.20,31–33 These successful collaborative care interventions address the six essential elements of the Chronic Care Model34,35: 1) the community, 2) the health system, 3) self-management support, 4) delivery system design, 5) decision support, and 6) clinical information systems (see Figure 1). Intervening at the level of these components fosters productive interactions between patients who take an active part in their care and providers backed by resources and expertise. In turn, these interactions promote improved health status, higher satisfaction for patients and providers, and lowered costs.



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FIGURE 1.  The Chronic Care Model (adapted from Improving Chronic Illness Care34)


We sought to determine whether collaborative depression care programs shown to be effective in primary care20,28–30 could be successfully adapted and implemented in public sector oncology clinics serving low-income Latino patients. We hypothesized that the Multifaceted Oncology Depression Program would result in greater reduction of depressive symptoms than would usual care and that the Multifaceted Oncology Depression Program would result in significant improvement in functional status, quality of life, and depression and cancer treatment adherence relative to usual care. We then used the Chronic Care Model to guide our implementation evaluation in preparation for a full-scale trial of the Multifaceted Oncology Depression Program.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
This study was approved by the human subjects committee at the Los Angeles County/University of Southern California (LAC/USC) Medical Center.

Setting
Women enter the LAC/USC oncology program from community-based clinics, local cancer screening programs, and inpatient and outpatient services within the medical center. The majority do not have a usual source of primary care. Staff physicians, fellows, and residents provide oncology care. Prior to study implementation, oncologists were provided with two 1-hour education sessions by the study psychiatrist (M.D.-J.) on the diagnosis and treatment of depression in cancer patients and were given pocket reference guides summarizing the sessions.

Subjects
Women at least 3 months past initial diagnosis (to avoid recruiting women with adjustment disorder) with carcinoma of the cervix (FIGO IA–IVb) or breast cancer (stage I–IV) receiving care in the LAC/USC outpatient breast and gynecology clinics were study eligible. Potentially eligible patients were identified from daily clinic records by bilingual study recruiters. Following verbal informed consent, patients were screened using the Personal Health Questionnaire (PHQ), a self-report version of the PRIME-MD.36 The PHQ-9 is a subset of questions that assesses the presence of major depressive disorder37,38 using modified DSM-IVcriteria.39 The instrument is valid and reliable37,38,40 and has been used with both English- and Spanish-speaking low-income primary care and gynecology patients.27,38,40,41 Three additional questions from the PRIME-MD were used to assess dysthymia.39

Patients were eligible if they met study criteria for major depression or dysthymia or had persistent depressive symptoms at both baseline and 1 month later. Patients were excluded if they were in palliative care, were suicidal (as determined by the PHQ-9), had a history of bipolar or psychotic disorder (as determined by screening questions from Project IMPACT20, had evidence of gross cognitive impairment, were currently abusing drugs or alcohol, were currently receiving psychotherapy, or were unable to speak Spanish or English. Following written informed consent, the study recruiter opened a sealed envelope containing a computer-generated random assignment to the treatment condition (Multifaceted Oncology Depression Program or usual care) and informed the patient of her group assignment.

The Multifaceted Oncology Depression Program Intervention
All patients assigned to the collaborative care intervention were invited to attend an initial clinical assessment and education session with the Cancer/Depression Clinical Specialist, a master’s-level social worker trained to provide manualized psychotherapy (problem-solving therapy42,43), support antidepressant medication adherence, and assist with systems navigation. In the educational session, the Cancer/Depression Clinical Specialist linked the importance of depression treatment to cancer treatment adherence, overall health, and well-being. Patients were educated about antidepressants and problem-solving therapy and allowed to choose either as their first-line depression treatment. Patients could include family members in their treatment if they preferred.

For those choosing problem-solving therapy, the Cancer/Depression Clinical Specialist scheduled a follow-up session and then attempted to meet with the patient weekly for 8 weeks. Based on cognitive behavior theory, problem-solving therapy is highly structured and manualized and has been found to reduce depressive symptoms among cancer patients.42–45 For those choosing medication, a meeting of the patient, the oncologist, and the Cancer/Depression Clinical Specialist was arranged to initiate antidepressant treatment (according to modified primary care depression treatment guidelines20,28,46). The study psychiatrist was available for same-day telephone consultation with the oncologist or Cancer/Depression Clinical Specialist, if necessary. The treatment plan was recorded by the Cancer/Depression Clinical Specialist in the patient’s medical record. Oncologists provided medication follow-up for patients during regularly scheduled clinic visits, which the Cancer/Depression Clinical Specialist attended when possible. Medication and problem-solving therapy costs were covered by the study.

The Cancer/Depression Clinical Specialist contacted patients in person or by phone at least every 2 weeks and used preprinted forms to assess side effects, medication adherence, and depressive symptom severity; she then provided feedback to the oncologist and the study psychiatrist. During biweekly supervisory sessions with the study psychiatrist, the Cancer/Depression Clinical Specialist reviewed her entire caseload, focusing on new patients and those who were not making sufficient progress in treatment. Patients who did not experience at least 50% reduction in depressive symptoms after 8 sessions of problem-solving therapy or 8 weeks of medication treatment were scheduled for an in-person evaluation by the study psychiatrist to identify potential causes for persistent depressive symptoms and make treatment adjustments. Results of this consultation were fed back to the oncologist and Cancer/Depression Clinical Specialist. Medication follow-up after the consultation was provided by the study psychiatrist or oncologist as clinically indicated.

Usual Care
Patients randomly assigned to receive usual care were informed of their depression diagnosis and the usual mental health resources available to them at LAC/USC. The study recruiters suggested that they talk with their doctor or the clinic social worker and placed a note in the patient’s medical record indicating the presence of depressive symptoms.

Measures
The screener assessed age, ethnicity/race, marital status, education, employment, number of medications for comorbid medical illness, primary language, and years in the United States. Depression symptoms were assessed at screening and after 4 and 8 months with the PHQ-9.37,38 The baseline, 4-, and 8-month assessments were conducted by telephone in English and Spanish by bilingual interviewers blind to intervention status. The baseline assessment included the anxiety module of the PHQ36 for assessing panic and generalized anxiety symptoms. Also administered at baseline was the Karnofsky Performance Status Scale,47 the most widely used method of quantifying functional status of cancer patients, which uses an 11-point rating scale (from 0 [death] to 10 [normal functioning]). Functional status and quality of life were assessed at baseline and follow-up assessments with the Functional Assessment of Cancer Therapy Scale,48 a valid and reliable 28-item questionnaire with subscale scores for physical, functional, social, and emotional well-being as well as satisfaction with the treatment relationship. It is sensitive to stage of illness and change in clinical status over time49 and is available in Spanish.50 Knowledge about depression and barriers to care were measured at baseline using self-report items adapted from Partners in Care.28 The Hispanic Stress Inventory51 was used to measure psychosocial stress at baseline. Baseline cancer stage and site, mortality data, and oncology treatment received at baseline and at 4 and 8 months were obtained from medical records. Patients were considered treatment adherent if they had completed or were in the process of completing all doctor-recommended treatment or follow-up visits. Patients were considered nonadherent if treatment was recommended but not received. The Cancer/Depression Clinical Specialist used patient logs to record intervention services received by each patient and barriers to depression treatment.

Data Analysis
Analyses were performed using the intent-to-treat approach, with last observation carried forward, and included 28 subjects assigned to the Multifaceted Oncology Depression Program and 27 subjects who received usual care. The two groups were compared at baseline on demographic and clinical characteristics using t tests, Wilcoxon rank tests, Fisher’s exact tests, and chi-square tests as appropriate. The number of patients in the collaborative intervention program and usual care groups who had any improvement in depressive symptoms (per the PHQ-9), the number who had ≥50% improvement in depression score, the number who died, and the number adherent to cancer treatment were compared at 8 months by using chi-square tests. Quality of life (measured by the Functional Assessment of Cancer Therapy) was compared at 8 months by using analysis of covariance with the baseline measurement as the covariate.


  RESULTS

 
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 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Of the 401 eligible patients, 269 (67%) agreed to undergo screening. Of those screened, 68 (25%) met study criteria for major depressive disorder or dysthymia. An additional 33 (12%) had depressive symptoms at baseline, and when rescreened 1 month later 10 had persistent depressive symptoms, and three had major depressive disorder. Of these 81 eligible patients, 55 (68%) agreed to participate (28 were assigned to the Multifaceted Oncology Depression Program and 27 to usual care), and 53 completed baseline assessments. Enrolled and not enrolled patients did not significantly differ in terms of cancer site, cancer stage, depression diagnosis, or demographic characteristics (age, race, marital status, education, or employment). Thirty-six patients completed either one or both of the follow-up assessments at 4 months (collaborative intervention: N=15, usual care: N=15) and 8 months (N=17 and 12, respectively). No significant differences were found between completers and dropouts in cancer site, cancer stage, depression diagnosis, demographic characteristics, or baseline Functional Assessment of Cancer Therapy scores. However, dropouts were four times as likely as completers to report having important personal or family problems at baseline (OR=4.3, 95% CI=1.1–16.8; p=0.03). Dropout rates did not significantly differ between the collaborative intervention and usual care groups.

Characteristics of the study group are shown in Table 1. Mean baseline PHQ-9 scores for both the collaborative intervention and usual care groups were in the mild but clinically significant range, although approximately half in each group scored in the severe range (usual care: 52%, N=14; collaborative intervention: 46%, N=13). Very few patients in usual care (4%, N=1) or the collaborative intervention (7%, N=2) were receiving depression treatment at baseline ({chi}2=0.31, df=1, p=0.57). Collaborative intervention patients had significantly higher self-rated physical well-being and worse social/family well-being on the Functional Assessment of Cancer Therapy than did patients receiving usual care, otherwise there were no significant differences between the collaborative intervention and usual care groups in baseline demographics, clinical characteristics, stressful life events, self-reported barriers to care, or knowledge about depression.


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TABLE 1. Demographic and Clinical Characteristics of Low-Income Latina Cancer Patients With Comorbid Depression Randomly Assigned to a Treatment Program Involving Either a Collaborative Intervention or Usual Care



Patients in the collaborative intervention program were significantly more likely to have any and ≥50% improvement in depressive symptoms relative to those receiving usual care (Table 2). Usual care patients were more likely to have died during the intervention period. Although there was a tendency toward improved cancer treatment adherence among patients in the collaborative intervention program than among those receiving usual care, this difference did not reach statistical significance. At 8 months, patients in the collaborative intervention program were more likely to have improved emotional well-being than were those receiving usual care (Table 3).


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TABLE 2. Clinical Outcome in Low-Income Latina Cancer Patients With Comorbid Depression Randomly Assigned to a Treatment Program Involving Either a Collaborative Intervention or Usual Care




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TABLE 3. Change in Patient Quality of Life at 8 Months in Low-Income Latina Cancer Patients With Comorbid Depression Randomly Assigned to a Treatment Program Involving Either a Collaborative Intervention or Usual Care



Among patients in the collaborative intervention program, 18% (N=5) received no intervention services. Twelve patients (43%) received four or more problem-solving therapy sessions. Three (11%) chose medication as their first-line treatment, and the study psychiatrist recommended four additional patients begin medication after inadequate response to problem-solving therapy. Of the seven patients receiving medication, only three received it for 5 or more months.

The most common patient-level barriers to depression care (as recorded by the Cancer/Depression Clinical Specialist) were feeling too medically ill to come to appointments (21%, N=6), forgetting appointments (21%, N=6), child care or other family responsibilities (21%, N=6), transportation problems (18%, N=5), personal or family problems (14%, N=4), financial problems (14%, N=4), leaving the area (14%, N=4), and stigma (11%, N=3). At the clinic level, appointments were often spaced months apart, making it difficult for the oncologist to initiate or adjust antidepressant medications. The frequent rotation of residents in clinic made it difficult to train oncologists in depression treatment.


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
Our pilot results suggest that implementation of a collaborative care depression intervention in a public sector oncology setting serving low-income Latino patients may be associated with improvements in depression and emotional well-being in this highly vulnerable population. Our findings are consistent with previous studies showing that 1) low-income minority women52 and cancer patients benefit from both manualized psychotherapy and antidepressants for the treatment of depression5–12; 2) case management can promote adherence to psychotherapy in low-income Spanish-speaking medical patients with many competing stressors53; and 3) providing depression care in medical settings is an effective means of improving access to depression care, especially among minorities.20,31–33 Intervention patients had greater survival over the study period, and while not statistically significant, the intervention also appeared to improve adherence to cancer treatment.

Even though the intervention was associated with improved depression outcomes, there were significant barriers to implementing depression care in this setting. As a result, many patients in the collaborative intervention condition did not receive an adequate course of depression treatment. To determine opportunities to enhance implementation, we used the Chronic Care Model34,35 (see Figure 1) to guide our implementation evaluation. We examined the extent to which the intervention addressed the six essential elements of the Chronic Care Model, and this evaluation suggested project adaptations for a full-scale trial.

Patient self-management support promotes the role of patients in managing their health using effective self-management and education strategies. Patient education was a central component of the Multifaceted Oncology Depression Program, and whether or not patients received problem-solving therapy, the Cancer/Depression Clinical Specialist taught key techniques (problem assessment, goal setting, action planning, problem solving) to promote self-management for both depression and cancer. Despite a preference for psychotherapy over medication,54 low-income patients may be more likely to adhere to medication,52 thus revised educational materials, including a video for patients with limited literacy, will address barriers to antidepressant use. Because family members acted as "gatekeepers" for some patients, family members were encouraged to participate in education sessions and treatment if the patient preferred, and additional educational materials targeted specifically for family members have been developed.

Delivery system design includes using planned interactions to support evidence-based care. The Multifaceted Oncology Depression Program provided clinical case management for complex patients and used a treatment algorithm to guide clinician care and prompt timely follow-up assessments. Our pilot study also helped us to define roles and distribute tasks among appropriate team members. For example, oncologists were to provide first-line antidepressants. However, overcrowded clinics with patients scheduled for brief and infrequent visits made it difficult for the oncologists to do so. In our revised intervention, an on-site psychiatrist will provide antidepressants, with the Cancer/Depression Clinical Specialist assessing adherence and side effects, providing feedback to the psychiatrist, and reminding patients about appointments. A bachelor’s-level case manager will assist with practical barriers to cancer and depression care.

Decision support includes delivering care consistent with the scientific evidence and using proven methods to educate providers. We adapted primary care depression treatment guidelines using results of efficacy trials in cancer patients. We will modify our approach to oncologist education on the basis of previous primary care depression interventions20,55 that have suggested that depression care skills are more effectively learned through case-based interactions with the study psychiatrist and Cancer/Depression Clinical Specialist than in formal didactic training. A final element of decision support is to integrate specialist expertise into the treatment setting, which we will accomplish with the onsite study psychiatrist.

Clinical information systems provide timely reminders for providers and patients to prompt appropriate care. Our revised intervention will include a password-protected web-based patient tracking system,20 which will prompt the Cancer/Depression Clinical Specialist to carry out timely intervention treatments; provide convenient access to study treatment records; and allow the study director to monitor the performance of the practice team and address any problems in treatment adherence in "real time."

In order to increase support for the intervention in the health system, we have established a sustainability committee of clinical, administrative, and community representatives. A key task of this committee will be to develop provider incentives and reduce system disincentives for delivering and supporting quality depression care. On-site supervision and consultations by the study psychiatrist will improve care coordination.

At the community level, effective interventions should form community partnerships to fill gaps in services. A strength of our intervention was the Cancer/Depression Clinical Specialist’s use of community cancer resources, such as the American Cancer Society, to obtain for patients assistance with transportation, social support, and education.

Several limitations must be considered in interpreting our results. Despite no significant differences in cancer stage, site, Karnofsky rating, or number of comorbid medical illnesses, subjects assigned to usual care had poorer self-rated physical well-being and better social/family well-being at baseline than did those assigned to the Multifaceted Oncology Depression Program, possibly contributing to differences in outcomes. Given the lack of depression care resources usually available in these clinics, disappointment among some subjects assigned to usual care over not having access to the Multifaceted Oncology Depression Program services may have also contributed to between-group differences in outcomes. Our small sample size limits study generalizability and necessitates validation in a larger sample.

Our experience with a pilot depression care intervention in a public sector oncology setting serving low-income Latinas is important because it counters the common "therapeutic nihilism" that depression is an inevitable and untreatable consequence of cancer and poverty. We gained an in-depth understanding of system, provider, and patient barriers to depression care in this setting, which has guided the development of a socioculturally appropriate intervention manual and educational materials that are linguistically and idiomatically appropriate for Latino cancer patients. A full-scale randomized trial of our adapted intervention is underway.


  ACKNOWLEDGMENTS

 
The authors thank Diana Pineda and Maria Moreno for their hard work and devotion to patient care. This study was supported by NCI grant R21 CA93390-01 (Dr. Ell, principal investigator) and the UCLA/NIMH Faculty Scholars Program (NIMH grant K-12-MH00990-01–01; Kenneth B. Wells, M.D., M.P.H., principal investigator).


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 DISCUSSION
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