Systematic review and meta-analysis of collaborative care interventions for depression in patients with cancer.

BACKGROUND: Previous systematic reviews have found limited evidence for the effectiveness of pharmacological and psychological interventions for the management of depression in patients with cancer. This paper provides the first meta-analysis of newer collaborative care interventions, which may include both types of treatment, as well as integrated delivery and follow-up. Meta-analyses of pharmacological and psychological interventions are included as a comparison. METHODS: A search of MEDLINE, EMBASE, PsycINFO, and the Cochrane Library from July 2005 to January 2015 for randomized controlled trials of depression treatments for cancer patients diagnosed with a major depressive disorder, or who met a threshold on a validated depression rating scale was conducted. Meta-analyses were conducted using summary data. RESULTS: Key findings included eight reports of four collaborative care interventions, eight pharmacological, and nine psychological trials. A meta-analysis demonstrated that collaborative care interventions were significantly more effective than usual care (standardized mean difference = -0.49, p = 0.003), and depression reduction was maintained at 12 months. By comparison, short-term (up to 12 weeks), but not longer-term effectiveness was demonstrated for both pharmacological and psychological interventions. CONCLUSIONS: Collaborative care interventions have newly emerged as multidisciplinary care delivery models, which may result in more long-term depression remission. This review also updates previous findings of modest evidence for the effectiveness of both pharmacological and psychological interventions for threshold depression in cancer patients. Research designs focusing on combined treatments and delivery systems may best further the limited evidence-base for the management of depression in cancer.

Management of Depression in Patients With Cancer: A Clinical Practice Guideline.

PURPOSE: This report updates the Cancer Care Ontario Program in Evidence-Based Care guideline for the management of depression in adult patients with cancer. This guideline covers pharmacologic, psychological, and collaborative care interventions, with a focus on integrating practical management tools to assist clinicians in delivering appropriate treatments for depression in patients with cancer. METHODS: Recommendations were developed by synthesizing information from extant guidelines and reviews and searching for randomized controlled trials from the date of database inception (1964 for MEDLINE and 1974 for EMBASE) to January 2015. Quality assessment of guidelines and systematic reviews were conducted by using the Appraisal of Guidelines for Research and Evaluation II (AGREE II), Assessment of Multiple Systematic Reviews (AMSTAR), and Cochrane Risk of Bias tools. Final recommendations were developed through a standardized Program in Evidence-Based Care multidisciplinary expert and knowledge user review process. RESULTS: Two high-quality relevant clinical practice guidelines, eight pharmacologic trials, nine psychological trials, and eight collaborative care intervention trials composed the evidence base upon which the recommendations were developed. Eight specific recommendations were made to establish a standard of care for the management of depression in patients with cancer. The recommendations and practical management tools were reviewed as being well organized and helpful, although systemic barriers to implementation were identified. CONCLUSION: This updated guideline supports the previous general recommendation that patients with cancer who have depression may benefit from psychological and/or pharmacologic interventions, without evidence for the superiority of any specific treatment over another. New recommendations for a collaborative care model that incorporates a stepped care approach suggest that multidisciplinary mental health care restructuring may be required for optimal management of depression.

A randomized, controlled, pilot study of dialectical behavior therapy skills in a psychoeducational group for individuals with bipolar disorder.

BACKGROUND: Bipolar disorder (BD) is a chronic and disabling psychiatric disorder characterized by recurrent episodes of mania/hypomania and depression. Dialectical behavior therapy (DBT) techniques have been shown to effectively treat borderline personality disorder, a condition also marked by prominent affective disturbances. The utility of DBT techniques in treating BD has been largely unexplored. The purpose of this research was to conduct a pilot study of a DBT-based psychoeducational group (BDG) in treating euthymic, depressed, or hypomanic Bipolar I or II patients. METHODS: In this experiment, 26 adults with bipolar I or II were randomized to intervention or wait-list control groups and completed the Beck depression inventory II, mindfulness-based self-efficacy scale, and affective control scale at baseline and 12 weeks. The BDG intervention consisted of 12 weekly 90-min sessions which taught DBT skills, mindfulness techniques, and general BD psychoeducation. RESULTS: Using RM-ANOVA, subjects in BDG demonstrated a trend toward reduced depressive symptoms, and significant improvement in several MSES subscales indicating greater mindful awareness, and less fear toward and more control of emotional states (ACS). These findings were supported with a larger sample of patients who completed the BDG. Furthermore, group attendees had reduced emergency room visits and mental health related admissions in the six months following BDG. LIMITATIONS: The small sample size in RCT affects power to detect between group differences. How well improvements after the12-week BDG were maintained is unknown. CONCLUSIONS: There is preliminary evidence that DBT skills reduce depressive symptoms, improve affective control, and improve mindfulness self-efficacy in BD. Its application warrants further evaluation in larger studies.

Quality of life analysis in patients with anterior skull base neoplasms.

BACKGROUND: Significant morbidity is associated with management of anterior skull base neoplasms. The aim of this study was to evaluate the posttreatment patient's quality of life (QOL). METHODS: A retrospective chart review identified 27 patients. QOL tools included the Functional Assessment of Cancer Therapy-Head & Neck, Centre for Epidemiologic Studies Depression Scale (CES-D), Atkinson Life Happiness Rating (ALHR), and Midface Dysfunction Scale (MDS). RESULTS: Postoperative radiotherapy and chemotherapy was required in 16 and 2 patients, respectively. The median FACT, ALHR, and CES-D scores were 118 +/- 21, 9 +/- 2, and 17 +/- 8, respectively. Smell and nasal crusting disturbance was reported by 69% and 61%, respectively. CES-D > 16 and patients with recurrent disease correlated with a lower Total-FACT score. Adjuvant radiotherapy correlated with a lower FACT-H&N score. Patient sex, marital-status, pathology, surgical technique, or complication rate did not correlate with worse QOL. CONCLUSION: Anterior skull base neoplasms survivors have an overall acceptable QOL. Most complaints relate to MDS. Recurrence, adjuvant radiotherapy, and MDS had lower QOL scores.

A pilot survey of patient-initiated assaults on medical students during clinical clerkship.

OBJECTIVES: To assess the incidents of patient-initiated assault (PIA) against clinical clerks during the first six months of clinical clerkship. To characterise the assaults with respect to service, location, clerk gender, patient gender. To examine the students' perceptions of the reporting process for PIA. METHODS: A brief email survey was sent to all third year medical students after six months of clinical clerkship experience. Students were asked to describe assault experiences including: location, service, patient gender and injuries sustained. RESULTS: Six students reported experiencing physical assault in the first six months of clerkship. Assaults occurred on psychiatry (4) and internal medicine (2) services. Two of the assaults took place during consultations in the emergency department. All students reported having pre-clerkship training in management of violent situations. No students were aware of PIA reporting protocols for their hospital. CONCLUSIONS: Clinical clerks are at risk of PIA during their training. Students experiencing PIA feel that current levels of pre-clerkship training do not adequately inform them of the resources available after such an incident. These findings underline the need for PIA programs in the undergraduate curriculum including preclerkship training and clear, institution-wide reporting guidelines.

Development and pilot testing of a psychoeducational intervention for oral cancer patients.

OBJECTIVE: Oral cancer elicits considerable distress in both the pre and post-treatment periods. This paper details the development, validation and pilot-testing of a psychoeducational intervention for oral cancer patients. METHOD: An educational booklet covering information about oral cancer and its treatment and effective coping strategies was developed by a multi-disciplinary team. It was evaluated by patient focus groups and content/educational experts, delivered to subjects in pre and post-operative presentations by a health educator, and pilot-tested in a randomized controlled trial versus standard care. RESULTS: Pilot data from 19 subjects (10 psychoeducation, nine standard care) indicates that the intervention is feasible and highly acceptable. At follow-up the intervention group showed a gain in knowledge, less body image disturbance, lower anxiety and a trend toward higher wellbeing. CONCLUSION: This program, which is currently being evaluated in a larger RCT with extended follow-up, should prove useful in reducing the psychosocial burden of oral cancer and its treatment.

Screening for depression in head and neck cancer.

OBJECTIVES: The objectives of this study are to identify the prevalence of depression and the accuracy of depression screening instruments in ambulatory head and neck cancer patients who have received radiation. This population is at risk for depression because of the life-threatening nature of the illness, and treatment-induced oral morbidity. METHODS: Sixty subjects were evaluated for Major and Minor Depression according to Research Diagnostic Criteria using the Schedule for Affective Disorders and Schizophrenia (SADS). Screening instruments examined were the Beck Depression Inventory (BDI), the Hospital Anxiety and Depression Scale (HADS) and the Centre for Epidemiological Studies-Depression (CES-D) scale. Accuracy was assessed by calculating the sensitivities, specificities, positive predictive values (PPV) and areas under curve (AUC) from Receiver Operating Characteristic (ROC) curves. RESULTS: The prevalence of Major and Minor Depression was 20%. All of the screening instruments tested were found to be highly accurate. Statistically significant differences between the instruments were not observed but the HADS demonstrated the highest absolute levels of sensitivity, specificity and PPV. No cases of Major Depression were missed by any of the instruments tested. CONCLUSIONS: These results suggest that a significant minority of head and neck cancer patients are depressed in the post radiation period, and that accurate screening for clinically significant depression is possible using any of the three instruments evaluated here.

Psychosocial adjustment in head and neck cancer: the impact of disfigurement, gender and social support.

BACKGROUND: The purpose of this study was to examine the psychosocial impact of disfigurement, gender, and social support after surgical treatment of head and neck cancer. METHOD: Eighty-two ambulatory head and neck cancer patients, 6 months or more after treatment and free of active disease were assessed. Ratings of disfigurement were obtained using a valid and reliable 9-point scale developed for the study. Standardized measures of social support, depressive symptoms, well-being, and life happiness were used. RESULTS: The sample as a whole displayed high levels of life happiness, low levels of depression, and positive feelings of well-being. Women demonstrated higher levels of depression and lower life happiness; subjects with greater disfigurement were more depressed. Social support seemed to buffer the impact of greater levels of disfigurement on well-being for women but not for men. CONCLUSION: These results suggest that women with head and neck cancer who experience low social support and face disfiguring treatment are at greatest risk for psychosocial dysfunction.