All too often, depression in cancer patients is regarded as an expected reaction by health care providers – and even by the patients themselves. This can lead to depression among cancer patients being accepted instead of treated.

The trend is greatly exacerbated among economically disadvantaged patients, who are less likely to receive effective depression treatment. One contributing factor is that low-income minority patients are less likely to participate in clinical trials that would address gaps in knowledge about strategies to increase their participation and about socio-cultural adaptations that enhance knowledge about culturally competent treatment.

Kathleen Ell, the Ernest P. Larson Professor of Poverty, Ethnicity and Health at the USC School of Social Work, recently reported on the design of a groundbreaking randomized clinical trial that is addressing these problems and how to combat them. The cultural adaptations to recruitment and depression treatments and baseline and recruitment findings of the project recently were reported in General Hospital Psychiatry.

In collaboration with USC Social Work Research Assistant Professor Bin Xie, Research Data Manager Pey-Jiuan Lee and PhD candidate Anjanette Wells – as well as researchers from the Keck School of Medicine of USC – Ell set out to recruit a large sample of participants in the trial designed to test if socio-culturally tailored collaborative care can be effective in treating depression and improving quality of life among lower-income, minority patients suffering from cancer and major depression. The study, funded by the National Cancer Institute, built upon the team's previous research on cancer patients and depression.

The result was the Alleviating Depression Among Patients with Cancer (ADAPt-C) randomized clinical trial conducted at Los Angeles County + USC Medical Center. In view of known barriers to participation in cancer trials and to depression treatment retention in low-income minority populations, efforts were made to facilitate recruitment and acceptance of the intervention and to minimize study attrition, including: 1) recruitment from a public-sector system of care; 2) Spanish-speaking research staff, and study and intervention materials in Spanish that are adapted for literacy and idiomatic content; 3) telephone data collection and intervention telephone option; 4) flexible outcome interview and intervention hours, including evening and weekend telephone visits and scheduling depression treatment visits to coincide with cancer treatment or follow-up appointments; 5) supportive patient navigation/case management intervention to address barriers to both cancer treatment and depression treatment; 6) family education materials and attention to family-member roles; and 7) a maintenance, open-ended support group in both English and Spanish.

The investigators used what is known as the Patient Health Questionnaire depression scale to identify cancer patients meeting DSM-IV criteria for major depression. Eligible patients had been diagnosed with cancer within the previous 90 days and were receiving acute cancer treatment or follow-up care in oncology clinics. Of 2,547 potentially eligible patients, 2,330 (91.5 percent) were screened – 1,682 (72.2 percent) females and 648 (27.8 percent) males. Of patients screened, 541 met criteria for major depression, and 375 women and 71 men were enrolled (86.4 percent vs. 66.4 percent, p<.0001, respectively) and randomized to intervention or EUC.

Most of the participating patients were Hispanic, had lived in the United States for more than 10 years, were currently unemployed, and more than half had medical conditions in addition to cancer. Of 446 enrolled patients, 48 percent also reported having symptoms consistent with dysthymia and 8 percent had clinical anxiety scores of 14/24 or more. Baseline data underscored low levels of care for depression: Only 10 percent of patients reported receiving antidepressant and/or anti-anxiety medication, 6.5 percent having received counseling from a social worker, psychologist or doctor about their depression or anxiety, and 4 percent having attended a cancer support group.

In previous work with cancer patients, the research team had identified what they call "competing stressors" that can become serious barriers keeping patients from getting and sticking with the depression treatment they need. These include communication breakdown between health care system and patient, cancer-treatment side effects and the stresses of family caregiving.

"What may be a mundane stressor to the healthy – paying bills or keeping medical appointments – becomes magnified to those suffering from cancer," says Ell. "This can be especially true in lower-income, minority populations."

To address these issues, the team made sure supportive patient navigation and case-management services were integrated within a stepped depression-treatment algorithm that included offering patients depression education and a choice of psychotherapy and/or antidepressant medication treatment; patient navigation services to address vital needs of cancer patients in public-sector care systems; helping patients overcome barriers to treatment; and maintenance/relapse prevention follow-up over 12 months.

Ell and her team are currently analyzing depression symptom improvement and overall quality of life between patients receiving intervention care versus modestly enhanced usual oncology care.