Alleviating Depression Among Patients With Cancer (ADAPt-C)

According to the American Cancer Society, symptoms of depression are common among cancer patients and their family members. In fact, one in four cancer patients develop clinical depression at some point during their treatment or recovery. In the general population, the incidence of clinical depression is higher among women; among African Americans, Hispanics, and other non-Hispanic minorities; and among adults aged 45-64 years. Depression can adversely affect the course and outcome of common chronic conditions such as cancer, arthritis, asthma, cardiovascular disease, diabetes, and obesity, according to a 2012 report by the Centers for Disease Control and Prevention. Among patients coping with cancer, depression can make it harder to function and follow treatment plans, which underscores the importance of developing depression interventions designed specifically for this population.

Alleviating Depression Among Patients With Cancer (ADAPt-C) is a socio-culturally adapted collaborative care program for low-income, minority, adult cancer patients who have symptoms of major depression or dysthymia (by DSM-IV criteria) and are receiving acute or follow-up oncology care. Implemented within a freestanding or hospital-based oncology clinic, ADAPt-C provides personalized, stepped care depression treatment delivered by master's-level social workers in collaboration with a psychiatrist. The social workers provide supportive assistance in the form of problem-solving therapy (PST) to address psychosocial and practical problems in patients' daily life and patient navigation and case management services to address barriers to engaging in depression care (while simultaneously managing their cancer treatment). The social workers carry out the majority of treatment, communicate with the oncologist and nursing staff as needed, and provide case management and patient support. For Spanish-speaking patients, bilingual social workers are assigned to provide care in Spanish and to act as translators during psychiatric evaluations. 

ADAPt-C social workers are required to have training in the psychiatric evaluation of cancer patients and an understanding of antidepressant medication use with this group. In addition, they should have an understanding of cultural issues affecting cancer care among minority patients. ADAPt-C social workers receive 2 weeks of formal training in PST. The training consists of self-study of the PST and ADAPt-C manuals; video and in-person didactic sessions; observation of a skilled ADAPt-C social worker conducting an initial evaluation and two PST sessions with a cancer patient; and treatment of three to five patients under close supervision. The social workers and psychiatrists also receive training in cultural competency via a self-administered training manual. Once trained, one social worker should be able to effectively manage 35-40 patients in active treatment.

In the ADAPt-C stepped care algorithm, the goals of treatment are to achieve symptomatic remission from depression; to achieve maximum full return of psychosocial functioning; and to prevent relapse and recurrence of depression. The initial visit with the social worker includes extensive patient education around depression, a semi-structured psychiatric and psychosocial history and assessment, and development of a personalized treatment plan that reflects the patient's preference for first-line treatment using either antidepressant medication or psychotherapy.

If the patient chooses antidepressant medication as the first-line treatment, he or she is evaluated for eligibility by the psychiatrist and then started on an appropriate antidepressant. Additional psychotropics, such as an antianxiety agent or sedative-hypnotic, may be prescribed if clinically indicated. The psychiatrist evaluates the patient at regular intervals, and the social worker meets with or calls the patient every other week to assess treatment responsiveness and discuss questions or problems the patient may be having with the medication. If the patient's depression does not respond to the initial medication, the treatment plan is modified by adding another medication; switching to another antidepressant medication; trying a combination of antidepressant medication and PST; or stopping the antidepressant medication and starting PST. If the patient's depression continues to be unresponsive after these modifications, and/or additional psychiatric disorders are uncovered, the social worker and psychiatrist team may refer the patient to a mental health clinic for treatment or suggest other types of psychotherapy with or without the addition of antidepressant medication regimens not yet tried.

If the patient chooses psychotherapy as the first-line treatment, he or she begins a series of 8-12 highly structured, one-on-one counseling sessions. Sessions are approximately 45 minutes long and delivered weekly by phone or at the oncology clinic. In Session 1, the social worker introduces and explains the treatment approach. The next few sessions focus on creating a positive and constructive problem-solving orientation to improve physical and psychological functioning (Session 2) and defining a problem, collecting all available information, and setting realistic goals for eliminating the problem (Sessions 3 and 4). Patients are trained to generate alternative solutions using brainstorming techniques in Session 5 and learn strategies for effective decision making in Session 6. In Session 7, patients are encouraged to carry out a solution plan using program-prepared worksheets, rehearsal, and role-play exercises. They learn self-reinforcement for problems that are resolved satisfactorily, as well as troubleshooting strategies for problems that remain unresolved. In Session 8, problem-solving coping skills are reviewed and practiced, along with discussion of potential problem-and-solution scenarios that may come up in the future. Session 9 is a therapy closure meeting; problem-solving skills are reviewed and practiced, the initial goals from the very first introductory session are discussed and how they were met, and recommendations are provided on how to maintain treatment gains and monitor self-improvement. The patient is encouraged to continue to use the coping skills and problem-solving strategies learned during the course of psychotherapy and to process feelings and thoughts about therapy termination and the dissolution of the therapeutic relationship.

ADAPt-C is structured as a 12-month intervention, but the duration of treatment may vary depending on treatment response, defined as follows:

- Full Treatment Response (depression in remission): fewer than three of nine DSM-IV depressive symptoms and at least a 50% reduction in the Physical Health Questionnaire (PHQ-9) Depression scale score

- Partial Treatment Response: at least a 30% reduction in DSM-IV symptoms and a 30% reduction in the PHQ-9 Depression scale score

- No Treatment Response: five or more DSM-IV depression symptoms or a PHQ-9 Depression scale score greater than 15

Patients who continue to report depression symptoms (partial or no treatment response) may receive continued weekly psychotherapy for up to 12 months with or without concurrent antidepressant medication.

Patients with full treatment response enter a 6- to 9-month maintenance/relapse prevention phase. The social worker calls the patient monthly to provide support in engaging in pleasant activities, using problem-solving skills learned during treatment, and adhering to a medication regimen, as applicable. Telephone contacts include PHQ-9 monitoring of depression symptoms and education about the importance of continuing treatment. Patients treated with antidepressants are encouraged to continue their antidepressant regimen during the maintenance phase, with prescriptions handled by the patient's oncologist in consultation with the ADAPt-C psychiatrist. Those at high risk for relapse (defined by a history of dysthymia prior to cancer, more than two prior episodes of major depression in their lifetime, or persistent depressive symptoms even before cancer) are encouraged to continue maintenance antidepressant medication with or without psychotherapy for at least 2 years. Decisions about maintenance therapy for a patient with two uncomplicated episodes of depression are made based on judgment and patient preference. If a relapse occurs in the maintenance phase, the social worker schedules an in-person follow-up session and/or an office visit with the psychiatrist. Additional psychotherapy sessions and/or medication adjustments are made as clinically indicated. 

- About 2 hours for social workers and psychiatrists to complete a self-administered training in cultural competency

- 2 weeks of training for social workers to develop skills in delivering problem-solving therapy, which includes self-study of the PST and ADAPt-C manuals, videotaped and in-person didactic sessions, becoming familiar with patient educational handout materials, and observation of a skilled therapist conducting an initial evaluation and two PST sessions with a cancer patient

- 8-12 one-on-one counseling sessions, about 45 minutes each, delivered weekly per patient, either by phone or at the oncology clinic during the active treatment period

- An initial face-to-face, 45-minute evaluation and medication treatment session with the ADAPt-C psychiatrist for each patient who chooses antidepressant medication treatment

- 7-11 additional, weekly medication sessions, 15-20 minutes each, with the psychiatrist during the active treatment period for patients who choose antidepressant medication treatment

- 8-12 one-hour weekly telephone conference calls or in-person meetings between the social worker and psychiatrist to discuss the status of patients

- 9 additional monthly counseling sessions, 45 minutes each, delivered by the social worker in the maintenance phase

ADAPt-C targets low-income, adult cancer patients who have major depression or dysthymia symptoms (according to DSM-IV criteria) and are undergoing acute or follow-up care in oncology clinics.

ADAPt-C is implemented within freestanding or hospital-based oncology clinics. 

Materials required for implementation include:

- ADAPt-C Implementation Guide

- Provider - Therapist Training Materials

- ADAPt-C Intervention Assessment and Tracking Materials

- ADAPt-C Intervention Patient Materials

For costs associated with this program, please contact: Kathleen Ell. (See products page on the EBCCP website for contact information).

A randomized controlled trial evaluated the effects of ADAPt-C on depression symptoms and health-related quality of life among low-income, primarily Hispanic women with cancer and depression or dysthymia. Patients were randomly assigned to receive 12 months of ADAPt-C or enhanced usual care (control group). Enhanced usual care consisted of standard oncology care from treating oncologists who were informed of the patient's depression status. Patients in the control group received educational pamphlets on depression and cancer and a list of financial, psychosocial, transportation, and child care services provided by the clinic or in the community. Treating oncologists attended a didactic session on depression treatment given by the study psychiatrist and were free to prescribe antidepressants or refer patients to mental health care; control patients could also seek care in the community.

Study participants were patients 18 years or older who had been diagnosed with cancer at least 90 days before study entry and were receiving acute or follow-up care in public safety net oncology clinics for low-income patients. Eligibility criteria required that participants had experienced one of two cardinal depression symptoms daily or for more than half of the days in the prior 2 weeks, and had a score of 10 or greater on the Patient Health Questionnaire (PHQ-9) 9-item Depression scale or positive responses to two questions from DSM-IV that indicate dysthymia. 

Four hundred seventy-two eligible patients provided written informed consent and completed a baseline interview before computer-driven randomization to the intervention or enhanced usual care groups. The mean age of the randomized sample was 48.7 years. The majority of participants were women (85%) and Hispanic (88%); 75% had been in the United States for at least 10 years, and 64% had not completed high school. Sixty-four percent had gynecologic or breast cancer, 28% had stage 3 or 4 cancer or recurrent cancer, and 29% had moderate to severe depression at baseline, defined by a PHQ-9 score of 15 or greater.

After the baseline assessment, participants were assessed at 6-month intervals through 24 months post-baseline. Patients completed the PHQ-9 Depression scale and the Functional Assessment of Cancer Therapy Scale (FACT-G) in English or Spanish. The FACT-G is a 27-item questionnaire with four subscales that measure health-related quality of life: physical well-being, social/family well-being, emotional well-being, and functional well-being. Clinically meaningful improvement of depression symptoms was defined as a greater than 50% decrease or greater than 5-point reduction in the PHQ-9 Depression scale score at each follow-up assessment compared with baseline. Remission of depression symptoms was defined as a PHQ-9 Depression scale score of less than 5.

•  A larger percentage of intervention than enhanced usual care control patients showed a 50% decrease in PHQ-9 Depression scale score at 12-month (p=.01) and 24-month (p=.02) follow-up relative to baseline, after adjustment for gender, race/ethnicity, years in the United States (<10 versus >10 years), dysthymia, baseline depression severity (PHQ-9 score >15 versus <15), anxiety, cancer stage, cancer type, and cancer treatment status (before treatment, in acute treatment, or in follow-up care).

• A larger percentage of intervention than enhanced usual care control patients showed a 5-point decrease from baseline in PHQ-9 Depression scale score at 12-month (p=.01), 18-month (p=.03), and 24-month (p=.02) follow-up, after adjustment for gender, race/ethnicity, years in the United States (<10 versus >10 years), dysthymia, baseline depression severity (PHQ-9 score >15 versus <15), anxiety, cancer stage, cancer type, and cancer treatment status (before treatment, in acute treatment, or in follow-up care).

• A larger percentage of intervention than enhanced usual care control patients showed remission of their depression symptoms as defined by a PHQ-9 Depression scale score of less than 5 at 18-month follow-up (p=.03), after adjustment for gender, race/ethnicity, years in the United States (<10 versus >10 years), dysthymia, baseline depression severity (PHQ-9 score >15 versus <15), anxiety, cancer stage, cancer type, and cancer treatment status (before treatment, in acute treatment, or in follow-up care).

• Compared with enhanced usual care control patients, intervention patients had higher physical well-being subscale scores on the FACT-G at 6-month (p=.01) and 18-month (p=.02) follow-up, after adjustment for gender, race/ethnicity, years in the United States (<10 versus >10 years), dysthymia, baseline depression severity (PHQ-9 score >15 versus <15), anxiety, cancer stage, cancer type, and cancer treatment status (before treatment, in acute treatment, or in follow-up care).

• Compared with enhanced usual care control patients, intervention patients had higher functional well-being subscale scores on the FACT-G at 6-month (p=.02), 12-month (p=.02), 18-month (p=.01), and 24-month (p=.01) follow-up, after adjustment for gender, race/ethnicity, years in the United States (<10 versus >10 years), dysthymia, baseline depression severity (PHQ-9 score >15 versus <15), anxiety, cancer stage, cancer type, and cancer treatment status (before treatment, in acute treatment, or in follow-up care).

• Compared with enhanced usual care control patients, intervention patients had higher social/family well-being subscale scores on the FACT-G from baseline through 24-month follow-up (p<.001), as well as at two individual follow-up assessment points - 12-month (p<.001) and 24-month (p=.03) - after adjustment for gender, race/ethnicity, years in the United States (<10 versus >10 years), dysthymia, baseline depression severity (PHQ-9 score >15 versus <15), anxiety, cancer stage, cancer type, and cancer treatment status (before treatment, in acute treatment, or in follow-up care).

• Compared with enhanced usual care control patients, intervention patients had higher emotional well-being subscale scores on the FACT-G from baseline through 24-month follow-up (p<.001), after adjustment for gender, race/ethnicity, years in the United States (<10 versus >10 years), dysthymia, baseline depression severity (PHQ-9 score >15 versus <15), anxiety, cancer stage, cancer type, and cancer treatment status (before treatment, in acute treatment, or in follow-up care). However, the two groups of patients did not differ significantly at any of the individual follow-up assessment points.