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Implementing collaborative care for major depression in a cancer center: An observational study using mixed-methods. Gen Hosp Psychiatry 2022; 76:3-15. [PMID: 35305403 DOI: 10.1016/j.genhosppsych.2022.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 02/16/2022] [Accepted: 03/03/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To describe the implementation of a collaborative care (CC) screening and treatment program for major depression in people with cancer, found to be effective in clinical trials, into routine outpatient care of a cancer center. METHOD A mixed-methods observational study guided by the RE-AIM implementation framework using quantitative and qualitative data collected over five years. RESULTS Program set-up took three years and required more involvement of CC experts than anticipated. Barriers to implementation were uncertainty about whether oncology or psychiatry owned the program and the hospital's organizational complexity. Selecting and training CC team members was a major task. 90% (14,412/16,074) of patients participated in depression screening and 61% (136/224) of those offered treatment attended at least one session. Depression outcomes were similar to trial benchmarks (61%; 78/127 patients had a treatment response). After two years the program obtained long-term funding. Facilitators of implementation were strong trial evidence, effective integration into cancer care and ongoing clinical and managerial support. CONCLUSION A CC program for major depression, designed for the cancer setting, can be successfully implemented into routine care, but requires time, persistence and involvement of CC experts. Once operating it can be an effective and valued component of medical care.
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Walker J, Magill N, Rosenstein DL, Frost C, Sharpe M. Suicidal Thoughts in Patients With Cancer and Comorbid Major Depression: Findings From a Depression Screening Program. J Acad Consult Liaison Psychiatry 2021; 63:251-259. [PMID: 34562640 DOI: 10.1016/j.jaclp.2021.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/10/2021] [Accepted: 09/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Major depression is found in around ten percent of patients attending cancer clinics. One of the symptoms of major depression, defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), is "thoughts of death or suicide." To implement depression screening programs for patients with cancer, we need to know the prevalence not only of this broadly defined symptom but also of more specific suicidal thoughts, as only the latter clearly indicates the need for specialist psychiatric assessment and management of suicide risk. METHODS We analyzed data from a routine 2-stage depression screening program that operated in 3 UK cancer centers, linked with demographic and clinical data obtained from a national cancer registry. We included data on 2217 patients with common cancers and comorbid, interview-diagnosed, major depression. We determined the percentage of patients with (a) the DSM-IV symptom "thoughts of death or suicide" and (b) suicidal thoughts, defined as an affirmative response to the question "have you had thoughts of ending your life?" We investigated the associations of patients' demographic and clinical characteristics with each of these using logistic regression models. RESULTS We found that 641 of 2217 (29%) of patients had the DSM symptom "thoughts of death or suicide" and 207 of 2217 (9%) had suicidal thoughts. Of the demographic and clinical characteristics that we studied, none had statistically significant associations with having the DSM symptom. Only younger age and primary cancer were associated with having suicidal thoughts. CONCLUSIONS We found that almost one-third of patients with cancer and comorbid major depression have the DSM symptom "thoughts of death or suicide." However, only a third of the patients with this symptom report suicidal thoughts. These findings suggest that around one in ten patients found by a screening program to have major depression will have suicidal thoughts requiring a psychiatric assessment. The staffing of depression screening programs should be designed with these data in mind.
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Affiliation(s)
- Jane Walker
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK.
| | - Nicholas Magill
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Donald L Rosenstein
- Departments of Psychiatry and Medicine, University of North Carolina at Chapel Hill, NC
| | - Chris Frost
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Michael Sharpe
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
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Walker J, Mulick A, Magill N, Symeonides S, Gourley C, Burke K, Belot A, Quartagno M, van Niekerk M, Toynbee M, Frost C, Sharpe M. Major Depression and Survival in People With Cancer. Psychosom Med 2021; 83:410-416. [PMID: 33938501 PMCID: PMC7614901 DOI: 10.1097/psy.0000000000000942] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The question of whether depression is associated with worse survival in people with cancer remains unanswered because of methodological criticism of the published research on the topic. We aimed to study the association in a large methodologically robust study. METHODS We analyzed data on 20,582 patients with breast, colorectal, gynecological, lung, and prostate cancers who had attended cancer outpatient clinics in Scotland, United Kingdom. Patients had completed two-stage screening for major depression as part of their cancer care. These data on depression status were linked to demographic, cancer, and subsequent mortality data from national databases. We estimated the association of major depression with survival for each cancer using Cox regression. We adjusted for potential confounders and interactions between potentially time-varying confounders and the interval between cancer diagnosis and depression screening, and used multiple imputation for missing depression and confounder data. We pooled the cancer-specific results using fixed-effects meta-analysis. RESULTS Major depression was associated with worse survival for all cancers, with similar adjusted hazard ratios (HRs): breast cancer (HR = 1.42, 95% confidence interval [CI] = 1.15-1.75), colorectal cancer (HR = 1.47, 95% CI = 1.11-1.94), gynecological cancer (HR = 1.36, 95% CI = 1.08-1.71), lung cancer (HR = 1.39, 95% CI = 1.24-1.56), and prostate cancer (HR = 1.76, 95% CI = 1.08-2.85). The pooled HR was 1.41 (95% CI = 1.29-1.54, p < .001, I2 = 0%). These findings were not materially different when we only considered the deaths (90%) that were attributed to cancer. CONCLUSIONS Major depression is associated with worse survival in patients with common cancers. The mechanisms of this association and the clinical implications require further study.
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Affiliation(s)
- Jane Walker
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Amy Mulick
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas Magill
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Stefan Symeonides
- Cancer Research UK Edinburgh Centre, University of Edinburgh, Edinburgh, UK
| | - Charlie Gourley
- Cancer Research UK Edinburgh Centre, University of Edinburgh, Edinburgh, UK
| | - Katy Burke
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Aurelien Belot
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Matteo Quartagno
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Maike van Niekerk
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Mark Toynbee
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Chris Frost
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Michael Sharpe
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
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Graham LA, Wagner TH, Richman JS, Morris MS, Copeland LA, Harris AH, Itani KM, Hawn MT. Exploring Trajectories of Health Care Utilization Before and After Surgery. J Am Coll Surg 2018; 228:116-128. [PMID: 30359825 DOI: 10.1016/j.jamcollsurg.2018.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 10/16/2018] [Accepted: 10/16/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Long-term trajectories of health care utilization in the context of surgery have not been well characterized. The objective of this study was to examine health care utilization trajectories among surgical patients and identify factors associated with high utilization that could possibly be mitigated after surgical admissions. STUDY DESIGN Hospital medical and surgical admissions within 2 years of an index inpatient surgery in the Veterans Health Administration (October 1, 2007 to September 30, 2014) were identified. Group-based trajectory analysis identified 5 distinct trajectories of inpatient admissions around surgery. Characteristics of trajectories of utilization were compared across groups using bivariate statistics and multivariate logistic regression. RESULTS Of 280,681 surgery inpatients, most underwent orthopaedic (29.2%), general (28.4%), or peripheral vascular procedures (12.2%). Five trajectories of health care utilization were identified, with 5.2% of patients among consistently high inpatient users accounting for 34.0% of inpatient days. Male (95.4% vs 93.5%, p < 0.01), African-American (21.6% vs 17.3%, p < 0.01), or unmarried patients (61.6% vs 52.5%, p < 0.01) were more likely to be high health care users as compared with other trajectories. High users also had a higher comorbidity burden and a strikingly higher burden of mental health diagnoses (depression: 30.3% vs 16.3%; bipolar disorder: 5.3% vs 2.1%, p < 0.01), social/behavioral risk factors (smoker: 41.1% vs 33.6%, p < 0.01; alcohol use disorder: 28.9% vs 12.9%, p < 0.01), and chronic pain (6.4% vs 2.8%, p < 0.01). CONCLUSIONS Mental health, social/behavioral, and pain-related factors are independently associated with high pre- and postoperative health care utilization in surgical patients. Connecting patients to social workers and mental health care coordinators around the time of surgery may mitigate the risk of postoperative readmissions related to these factors.
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Affiliation(s)
- Laura A Graham
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA; Birmingham Health Services Research & Development Unit, Birmingham VA Medical Center, Birmingham, AL
| | - Todd H Wagner
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA; Department of Surgery, Stanford University, Stanford, CA
| | - Joshua S Richman
- Birmingham Health Services Research & Development Unit, Birmingham VA Medical Center, Birmingham, AL; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Melanie S Morris
- Birmingham Health Services Research & Development Unit, Birmingham VA Medical Center, Birmingham, AL; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Laurel A Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, MA; University of Massachusetts Medical School, Worcester, MA
| | - Alex Hs Harris
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA; Department of Surgery, Stanford University, Stanford, CA
| | - Kamal Mf Itani
- VA Boston Health Care System, Boston University and Harvard Medical School, Boston, MA
| | - Mary T Hawn
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA; Department of Surgery, Stanford University, Stanford, CA.
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Klügel S, Lücke C, Meta A, Schild-Suhren M, Malik E, Philipsen A, Müller HH. Concomitant psychiatric symptoms and impaired quality of life in women with cervical cancer: a critical review. Int J Womens Health 2017; 9:795-805. [PMID: 29133983 PMCID: PMC5669786 DOI: 10.2147/ijwh.s143368] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Our aim was to summarize the current relevant literature on concomitant psychiatric symptoms with a focus on anxiety/depression in a population with gynecologic cancer; to identify the predictors, associated factors, and prevention strategies of psychiatric disorders; to examine psychiatric disorders in a population with recurrent gynecologic cancer; and to describe the limitations of the literature and future research areas. Little is known about attending psychiatric disorders in patients with gynecologic and other malignant diseases like cervical or breast cancer. However, patients suffering from other types of gynecologic cancer (eg, genital/cervical cancer) may also have an increased risk of psychiatric symptoms. In this review, we identify the potential information deficits in this field. A two-rater independent literature search was conducted using the PubMed/Google Scholar search engines to systematically evaluate the literature on the research objectives, followed by a critical reflection on the results. Of the 77 screened studies, 15 met the criteria for inclusion in this review. Patients with gynecologic malignancies, especially cervical cancer, had a very high prevalence of psychiatric symptoms including depression (33%-52%). Additionally, the risk groups facing higher rates of concomitant reduced quality of life and increased psychiatric symptoms such as depression were identified. Specifically, low socioeconomic status, sexual inactivity, absence of a partner, and physical symptoms were correlated with an increased risk. Patients suffering from recurrent gynecologic cancer should receive particular attention because of their significantly increased risk of depressive symptoms. Screening programs are needed to detect psychiatric symptoms in cervical cancer patients and the associated high-risk groups. Regular screening should be implemented, and psychosocial care should be provided during follow-up.
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Affiliation(s)
- Stephanie Klügel
- Department of Psychiatry and Psychotherapy, Carl von Ossietzky University Oldenburg, Bad Zwischenahn
| | - Caroline Lücke
- Department of Psychiatry and Psychotherapy, Carl von Ossietzky University Oldenburg, Bad Zwischenahn
| | - Aurora Meta
- Department of Psychiatry and Psychotherapy, Carl von Ossietzky University Oldenburg, Bad Zwischenahn
| | - Meike Schild-Suhren
- Department of Gynecology and Obstetrics, Carl von Ossietzky University Oldenburg, Oldenburg
| | - Eduard Malik
- Department of Gynecology and Obstetrics, Carl von Ossietzky University Oldenburg, Oldenburg
| | - Alexandra Philipsen
- Department of Psychiatry and Psychotherapy, Carl von Ossietzky University Oldenburg, Bad Zwischenahn
| | - Helge Ho Müller
- Department of Psychiatry and Psychotherapy, Carl von Ossietzky University Oldenburg, Bad Zwischenahn.,Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
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Wanat M, Walker J, Burke K, Sevdalis N, Richardson A, Mulick A, Frost C, Sharpe M. Linked symptom monitoring and depression treatment programmes for specialist cancer services: protocol for a mixed-methods implementation study. BMJ Open 2017; 7:e016186. [PMID: 28674143 PMCID: PMC5734371 DOI: 10.1136/bmjopen-2017-016186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION There is growing awareness that cancer services need to address patients' well-being as well as treating their cancer. We developed systematic approaches to (1) monitoring patients' symptoms including depression using a 'Symptom Monitoring Service' and (2) providing treatment for those with major depression using a programme called 'Depression Care for People with Cancer'. Used together, these two programmes were found to be highly effective and cost-effective in clinical trials. The overall aims of this project are to: (1) study the process of introducing these programmes into routine clinical care in a large cancer service, (2) identify the challenges associated with implementation and how these are overcome, (3) determine their effectiveness in a routine non-research setting and (4) describe patients' and clinicians' experience of the programmes. METHODS AND ANALYSIS This is a mixed-methods longitudinal implementation study. We will study the process of implementation in three phases (April 2016-December 2018): 'Pre-implementation' (setting up of the new programmes), 'Early Implementation' (implementation of the programmes in a small number of clinics) and 'Implementation and Maintenance' (implementation in the majority of clinics). We will use the following methods of data collection: (1) contemporaneous logs of the implementation process, (2) interviews with healthcare professionals and managers, (3) interviews with patients and (4) routinely collected clinical data. ETHICS AND DISSEMINATION The study has been reviewed by a joint committee of Oxford University Hospitals National Health Service Foundation Trust Research and Development Department and the University of Oxford's Clinical Trials and Research Governance Department and judged to be service evaluation, not requiring ethics committee approval. The findings of this study will guide the scaling up implementation of the programmes across the UK and will enable us to construct an implementation toolkit. We will disseminate our findings in publications and at relevant national and international conferences.
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Affiliation(s)
- Marta Wanat
- Department of Psychiatry, Psychological Medicine Research, University of Oxford, Warneford Hospital, Oxford, UK
| | - Jane Walker
- Department of Psychiatry, Psychological Medicine Research, University of Oxford, Warneford Hospital, Oxford, UK
| | - Katy Burke
- Department of Psychiatry, Psychological Medicine Research, University of Oxford, Warneford Hospital, Oxford, UK
| | - Nick Sevdalis
- Centre for Implementation Science, King’s College London, London, UK
| | - Alison Richardson
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Amy Mulick
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Chris Frost
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Michael Sharpe
- Department of Psychiatry, Psychological Medicine Research, University of Oxford, Warneford Hospital, Oxford, UK
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