Nurse-Delivered Psychotherapy Lifts Spirits of Depressed Cancer Patients
By John Gever
EDINBURGH, Scotland, 5 july 2008 -- Depression therapy sessions delivered by oncology nurses significantly lifted the moods of cancer patients, researchers here said.
Compared with 99 cancer patients who had physician-delivered usual care for depression, 97 patients given nurse-delivered intensive therapy along with usual care in the randomized trial gained an extra 0.34 points, on average ((95% CI 0.13 to 0.55), on the four-point Symptom Checklist-20 scale after three months.
The advantage was maintained for a full year, reported Michael Sharpe, M.D., of the University of Edinburgh, and colleagues in the July 5 issue of The Lancet.
The intensive therapy cost an extra $10,556 per quality-adjusted life-year gained, they estimated.
Dr. Sharpe and colleagues called it "a feasible, acceptable, and cost-effective way to improve patients' quality of life."
They wrote, "Supplementation of usual care with a nurse-delivered complex intervention improved the symptoms of depression more than did usual care alone."
Usual care was the standard treatment available to everyone in Great Britain, received either from a primary-care doctor or a hospital specialist. It could involve psychotherapy and/or anti-depressant drug treatment, according to individual consultations between patients and physicians.
In addition to whatever depression treatment was given under this system, the intensive therapy included 10 individual sessions over three months with an oncology nurse.
These 45-minute sessions included problem-solving therapy to help patients overcome feelings of helplessness; education about depression and the available treatments; and counseling on talking about depression with oncologists and primary-care physicians.
Most sessions were conducted in person but could be done by telephone or at patients' homes when circumstances required.
Patients also received monthly telephone calls to assess depression symptoms for three months after the individual sessions ended. Those with worsening signs of depression could receive one or two additional in-person therapy sessions.
The session content was adapted from a program first developed for use in primary care. The nurses delivering the therapy had no prior psychiatric experience. They followed a manual developed by the investigators and were supervised by a psychiatrist. All sessions were video-recorded and 10% were reviewed for adherence to the treatment manual.
At baseline, those in the usual-care group had mean depression scores of 2.25 while the mean score in the intervention group was 2.35.
After three months, these had declined to 1.55 and 1.20, respectively. Adjusting for baseline scores and confounding variables, the difference between groups amounted to 0.34 points.
At the end of six months, the advantage for the intervention group grew to 0.59 points (95% CI 0.37 to 0.81) after adjustments. The two groups began to converge again, but at one year the intervention still appeared to have been more effective (difference 0.42 points, 95% CI 0.17 to 0.67).
The intensive therapy also appeared to improve patients' quality of life by secondary measures, such as anxiety and fatigue symptom scores and in the proportion who no longer met criteria for major depression on the Structured Clinical Interview for DSM-IV.
However, there was no difference in effects on pain or physical functioning, the researchers found.
They said the effectiveness of usual care may have been artificially enhanced because the study protocol required the investigators to inform patients' primary care physicians that the patients had major depression.
In the ordinary course of cancer care, oncology clinic personnel who determine a patient is depressed might not pass that along to the primary care doctor.
Dr. Sharpe and colleagues said that antidepressant use in both groups was more common than they had previously seen in depressed cancer patients.
One limitation of the study is that it focused on patients who were relatively well. About 66% were in clinical remission from their cancers, and those with other psychiatric diagnoses or a history of depression were excluded.
In an accompanying commentary, Gary Rodin, M.D., of the University Health Network in Toronto, said the study showed "that trained nurses with no previous psychiatric experience can deliver a cost-effective collaborative psychosocial intervention for cancer patients with major depressive disorder."
He added, "Such multi-component interventions are potentially feasible in cancer treatment centers and can be perceived by patients as less stigmatizing than referral to a mental-health specialist."
He noted that the study did not evaluate the efficacy of the intervention's individual components, which could help in improving the approach.
Dr. Rodin also suggested that future studies address the inclusion of spouses in depression treatment programs.
"Spouses are most often identified as primary caregivers for cancer patients and might report depressive symptoms that are at least as severe as those of the patients themselves," he wrote.
The study was funded by Cancer Research UK. No potential conflicts of interest were reported.
Primary source: The LancetSource reference:Strong V, et al "Management of depression for people with cancer (SMaRT oncology 1): a randomised trial" Lancet 2008; 372: 40-48. Additional source: The LancetSource reference: Rodin G, "Treatment of depression in patients with cancer" Lancet 2008; 372: 8-10.
Compared with 99 cancer patients who had physician-delivered usual care for depression, 97 patients given nurse-delivered intensive therapy along with usual care in the randomized trial gained an extra 0.34 points, on average ((95% CI 0.13 to 0.55), on the four-point Symptom Checklist-20 scale after three months.
The advantage was maintained for a full year, reported Michael Sharpe, M.D., of the University of Edinburgh, and colleagues in the July 5 issue of The Lancet.
The intensive therapy cost an extra $10,556 per quality-adjusted life-year gained, they estimated.
Dr. Sharpe and colleagues called it "a feasible, acceptable, and cost-effective way to improve patients' quality of life."
They wrote, "Supplementation of usual care with a nurse-delivered complex intervention improved the symptoms of depression more than did usual care alone."
Usual care was the standard treatment available to everyone in Great Britain, received either from a primary-care doctor or a hospital specialist. It could involve psychotherapy and/or anti-depressant drug treatment, according to individual consultations between patients and physicians.
In addition to whatever depression treatment was given under this system, the intensive therapy included 10 individual sessions over three months with an oncology nurse.
These 45-minute sessions included problem-solving therapy to help patients overcome feelings of helplessness; education about depression and the available treatments; and counseling on talking about depression with oncologists and primary-care physicians.
Most sessions were conducted in person but could be done by telephone or at patients' homes when circumstances required.
Patients also received monthly telephone calls to assess depression symptoms for three months after the individual sessions ended. Those with worsening signs of depression could receive one or two additional in-person therapy sessions.
The session content was adapted from a program first developed for use in primary care. The nurses delivering the therapy had no prior psychiatric experience. They followed a manual developed by the investigators and were supervised by a psychiatrist. All sessions were video-recorded and 10% were reviewed for adherence to the treatment manual.
At baseline, those in the usual-care group had mean depression scores of 2.25 while the mean score in the intervention group was 2.35.
After three months, these had declined to 1.55 and 1.20, respectively. Adjusting for baseline scores and confounding variables, the difference between groups amounted to 0.34 points.
At the end of six months, the advantage for the intervention group grew to 0.59 points (95% CI 0.37 to 0.81) after adjustments. The two groups began to converge again, but at one year the intervention still appeared to have been more effective (difference 0.42 points, 95% CI 0.17 to 0.67).
The intensive therapy also appeared to improve patients' quality of life by secondary measures, such as anxiety and fatigue symptom scores and in the proportion who no longer met criteria for major depression on the Structured Clinical Interview for DSM-IV.
However, there was no difference in effects on pain or physical functioning, the researchers found.
They said the effectiveness of usual care may have been artificially enhanced because the study protocol required the investigators to inform patients' primary care physicians that the patients had major depression.
In the ordinary course of cancer care, oncology clinic personnel who determine a patient is depressed might not pass that along to the primary care doctor.
Dr. Sharpe and colleagues said that antidepressant use in both groups was more common than they had previously seen in depressed cancer patients.
One limitation of the study is that it focused on patients who were relatively well. About 66% were in clinical remission from their cancers, and those with other psychiatric diagnoses or a history of depression were excluded.
In an accompanying commentary, Gary Rodin, M.D., of the University Health Network in Toronto, said the study showed "that trained nurses with no previous psychiatric experience can deliver a cost-effective collaborative psychosocial intervention for cancer patients with major depressive disorder."
He added, "Such multi-component interventions are potentially feasible in cancer treatment centers and can be perceived by patients as less stigmatizing than referral to a mental-health specialist."
He noted that the study did not evaluate the efficacy of the intervention's individual components, which could help in improving the approach.
Dr. Rodin also suggested that future studies address the inclusion of spouses in depression treatment programs.
"Spouses are most often identified as primary caregivers for cancer patients and might report depressive symptoms that are at least as severe as those of the patients themselves," he wrote.
The study was funded by Cancer Research UK. No potential conflicts of interest were reported.
Primary source: The LancetSource reference:Strong V, et al "Management of depression for people with cancer (SMaRT oncology 1): a randomised trial" Lancet 2008; 372: 40-48. Additional source: The LancetSource reference: Rodin G, "Treatment of depression in patients with cancer" Lancet 2008; 372: 8-10.
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