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Shaw et al. BMC Health Services 2019) 19:120RESEARCH ARTICLEOpen AccessIs care really shared? A systematic review ofcollaborative care (shared care) interventionsfor adult cancer patients with depressionJoanne Shaw1* , Suvena Sethi1, Lisa Vaccaro1, Lisa Beatty2, Laura Kirsten3, David Kissane4, Brian Kelly5,Geoff Mitchell6, Kerry Sherman7 and Jane Turner8AbstractBackground: Collaborative care involves active engagement of primary care and hospital physicians in shared careof patients beyond usual discharge summaries. This enhances community-based care and reduces dependence onspecialists and hospitals. The model, successfully implemented in chronic care management, may have utility fortreatment of depression in cancer. The aim of this systematic review was to identify components, delivery and rolesand responsibilities within collaborative interventions for depression in the context of cancer.Methods: Medline, PsycINFO, CINAHL, Embase, Cochrane Library and Central Register for Controlled Trials databaseswere searched to identify studies of randomised controlled trials comparing a treatment intervention that met thedefinition of collaborative model of depression care with usual care or other control condition. Studies of adult cancerpatients with major depression or a non-bipolar depressive disorder published in English between 2005 and January2018 were included. Cochrane checklist for risk of bias was completed (Study Prospero registration: CRD42018086515).Results: Of 8 studies identified, none adhered to the definition of ‘collaborative care’. Interventions delivered weremulti-disciplinary, with care co-ordinated by nurses (n 5) or social workers (n 2) under the direction of psychiatrists(n 7). Care was primarily delivered in cancer centres (n 5). Care co-ordinators advised primary care physicians (GPs)of medication changes (n 3) but few studies (n 2) actively involved GPs in medication prescribing andmanagement.Conclusions: This review highlighted joint participation of GPs and specialist care physicians in collaborative caredepression management is promoted but not achieved in cancer care. Current models reflect hospital-basedmulti-disciplinary models of care.Protocol registration: The protocol for this systematic review has been registered with PROSPERO. Theregistration number is CRD42018086515.Keywords: Collaborative care, Shared care, Systematic review, Depression, Cancer, Randomised controlled trialBackgroundA diagnosis of cancer impacts individuals’ psychologicaland physical wellbeing. Prevalence estimates of majordepression (16%), minor depression and dysthymia(22%) in cancer patients are higher than in the generalpopulation. [1, 2] In palliative settings, the prevalence of* Correspondence: joanne.shaw@sydney.edu.au1The University of Sydney, Psycho-oncology Co-operative Research Group,School of Psychology, Faculty of Science, Sydney, NSW 2006, AustraliaFull list of author information is available at the end of the articledepression approaches 49%. [3] Inadequate treatment ofdepression results in poorer adherence to anti-cancertreatments, decreased tolerance of cancer treatmentside-effects, higher use of health care resources includingincreased hospital re-admissions, may adversely impact oninterpersonal relationships and reduced overall survival.[3–9] Co-existing depression therefore poses a significantburden for patients, families and the health system. Cognitive behavioural therapy (CBT) is effective in treatingdepression [10] with a meta-analysis (n 198 studies, 22,238 patients) reporting medium to large effect sizes The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication o/1.0/) applies to the data made available in this article, unless otherwise stated.
Shaw et al. BMC Health Services Research(2019) 19:120sustained 6–12 months post intervention. A recentmeta-analysis also confirmed the effectiveness of antidepressant medication in the treatment of depression [11]both in combination with psychological therapy and asprimary treatment. [12] To guide evidence-based treatment, there has been a renewed effort to promote routinedistress screening as a first step to improve detection andhence treatment for depression in cancer care. [13] Suchstrategies have included the development of a clinicalpathway for identification and management of depressionin adults with cancer, an international first. [14]Despite increased evidence about effective treatments,many patients still do not seek treatment for theirdepression. For instance, a meta-analysis of 53 studies(n 12,052) found in a research context less than 60% ofdistressed cancer patients engage in psychological treatment. [15] Uptake in routine care is even lower. [16] Ata system level access to treatment is constrained by ashortfall in the psycho-oncology workforce resulting inlong waiting lists and geographical disparities in access.[17–19] Practical constraints such as transport, inconvenience and cost have also been suggested. [20, 21]Normalisation of distress and attribution of somaticdepression symptoms to cancer by clinicians also meansdepression goes untreated and patients’ attitudes tomental illness are also likely to play a role. [22] Patientfactors such as negative attitudes to mental health andstigma also reduce patient willingness to access treatment. [23]. To address perceived barriers, models of carethat encompass systematic identification of depressionin cancer patients, reduce dependence on specialistinput and enable timely access to evidence-based treatment have been proposed.The collaborative care model, based on the principlesof chronic disease management, has been successfullyimplemented to treat medical conditions including depression. [24, 25] Core components of collaborative carefor depression are: i) a multi-professional approach topatient care, ii) a structured management plan tailoredto depression symptom severity, iii) scheduled patientfollow-ups and iv) enhanced inter-professional communication. [26] The model endorses a multi-disciplinaryapproach involving joint participation of primary andspecialist care physicians in planned delivery of care overand above routine discharge and referral. [23] A keyaspect of effective collaborative care is case management[27] in which a member of the clinical team worksclosely with the main treating physician and monitorspatient progress including adherence to psychologicaland pharmacological treatments, initiating treatmentchanges as necessary. [28] A meta-analysis of collaborative care interventions (n 37 studies, 12,355 patientswith depression receiving primary care) found that interventions that included a mental health professional as aPage 2 of 18care provider within the clinical team reported the largest effect sizes. [29]The evidence base for collaborative care for depressionamong patients with cancer is rapidly developing. Arecent meta-analysis of studies (n 8) purporting to becollaborative care interventions concluded that the interventions were significantly more effective than usualcare (standardized mean difference 0.49, p 0.003),with remission rates for depression higher in the intervention groups at 12 months. While promising, the collaborative care interventions identified in that meta-analysisvaried in content, intensity, and number of components,thus making it difficult to determine the relative contribution of each component to overall effectiveness. [30] Priorto wider implementation of the model, greater understanding of the determinants essential to model success for thetreatment of depression in oncology is required. The aimof this systematic review was to determine the fidelity ofthe depression collaborative care models trialled in oncology to the recommended collaborative care criteria. Specifically, the review sought to identify reported interventioncomponents, delivery models and role responsibilities.MethodsStudy eligibilityTypes of studiesStudies presenting primary data from randomisedcontrolled trials (RCTs) of adult cancer patients with majordepression or a non-bipolar depressive disorder, whichcompared a treatment intervention designated as a collaborative (or shared) model of depression care with usual careor other control group and published in English were included. Non-randomised, single-arm, case control studies,qualitative studies and case-series reports were excluded.ParticipantsStudies were eligible if participants were over 18 years ofage with a current or prior diagnosis of cancer (excludingbasal cell carcinoma and squamous cell carcinoma) andwhere the study population met a threshold for clinicaldepression on a validated depression measure or structuredclinical interview. Studies including separate sub-groupanalyses of patients that met the criteria for clinical depression were also eligible for inclusion.InterventionsCollaborative care, defined as a treatment approach integrating primary- and tertiary-level (hospital) care in themanagement of co-morbid depression in cancer patients.ControlsTreatment as usual, wait-list control groups, and othertreatment interventions.
Shaw et al. BMC Health Services Research(2019) 19:120OutcomesStudies reporting data on the efficacy of collaborativecare interventions.Search strategyMedline, PsycINFO, CINAHL, Embase and the CochraneLibrary and Central Register for Controlled Trials databases were searched using the keywords and MeSH terms[Depression/depressive disorder/ or depressive disorder,major/or dysthymic disorder/] and [Cancer or Carcinomaor Neoplasm] and [Collaborative Care or Shared Care orIntegrative Care] and randomised controlled trials forEnglish language articles published between January 2005to January 2018 as the first collaborative care interventionfor depression in cancer was published in 2005. Primarystudies presenting data from RCTs of adult cancer patientswith major depression or a non-bipolar depressive disorderthat compared care delivered in a collaborative care modelwere identified. See Additional file 1: Table S1 for an example database search strategy. Reference lists of retrievedarticles and previous systematic reviews were also searchedfor relevant publications. Searches were conducted for outcome data for published study protocols identified.Page 3 of 18(n 3) [33, 36, 40], MDD or dysthymia (n 2) [37, 38],MDD, dysthymia or persistent depressive symptoms 1month (n 1) [35] and depressive symptoms based onself-report questionnaires only (n 2) [34, 39] Greaterthan 60% female participation was reported in six studies[33, 35–37, 39, 40] primarily due to an over-representationof breast cancer patients. Of the included studies threewere conducted by a single group in Scotland [31, 34, 35]and the remainder were conducted by separate groups inthe USA. Study Characteristics are listed in Table 1.Collaborative care interventionsStudy settingIn contrast to depression collaborative care models morebroadly, five studies delivered the intervention within thecancer centre, [34–37, 39] with a single study conductedin primary care. [38] A further study allowed patients tochoose either the cancer centre or primary care for treatment[36]and another study in advanced cancer providedan option for care to be delivered in the patient’s home.[40] For two studies conducted in cancer clinics much ofthe care was provided via telephone/ web-based as well asface to face blended models. [34, 39] See Table 1 for studysetting.Data abstractionAbstracts were identified and independently reviewed bytwo reviewers (SS and LV). Data extraction was independently conducted by three reviewers (SS, LV and JS) andcoding disagreements arising were discussed and consensuscoding applied. A coding framework was developed toextract the components of collaborative care based on thekey criteria defining collaborative care models: i) multi-professional patient care, ii) a structured stepped care management plan, iii) scheduled patient follow-ups and iv)enhanced inter-professional communication [23] Specifically, the following information was extracted for each study:study characteristics, including study aim(s), population,design and primary outcome(s); intervention description,follow up protocols and role of health professionals.Reasons for study exclusion are listed in Additional file 2:Table S2. The review methodology undertaken adhered toPRISMA guidelines for systematic reviews [31] and thesearch process is summarised in Fig. 1. Risk of bias was determined based on the Cochrane criteria (Additional file 3:Table S3). [32]ResultsStudy characteristicsEight primary studies met the review inclusion criteria.Mean sample size was 281 patients (SD 161.04; range55–500). Cancer populations included lung (n 1) [33],upper gastrointestinal/liver (n 1) [34], mixed breast andgynaecological (n 2) [34, 35] or heterogeneous (n 4)[36–39]. Participants had major depressive disorder (MDD)Model componentsClassification of studies based on collaborative care interventions found three studies [33, 40] (collectively calledthe SMART studies) utilised variations of a DepressionCare for People with Cancer (DCPC) intervention. [41]Two studies [35, 38] implemented the Improving Mood –Promoting Access to Collaborative Treatment program(IMPACT), a stepped care management program developed for treatment of depression in older primary care patients and a third study (ADAPT-C [42]) adapted theIMPACT protocol to incorporate a greater patient navigation role for Latino cancer patients. [37] A further twostudies reported study-specific blended face to face andtelephone [39] or web-based [34] collaborative care interventions. The key components of each intervention arelisted in Table 2.All interventions provided psychoeducation and themajority (n 7) included psychological therapy and/oranti-depressant medication. For the studies based on theIMPACT intervention, patient preference influenceddelivery of first line psychological or anti-depressant therapy. [35, 37, 38] The SMART studies [33, 36, 40] recommended both psychological therapy and anti-depressantmedication, if indicated. Similarly, treatment associatedwith the web-based collaborative care model was based onpatient preference for cognitive behavioural therapy (CBT),antidepressant medication or both [34] and medicationalone was considered first line treatment in the Kroenketrial. [39] In those studies where psychological treatment
Shaw et al. BMC Health Services Research(2019) 19:120Page 4 of 18Fig. 1 (PRISMA diagram): Search process for the review (as at January 2018)was a component of the intervention, treatment lengthranged from 8 weekly sessions [33] up to 10 sessions over3–4 months [31, 34, 35] with Problem Solving Treatment(PST) and Behavioural Activation the most commonpsychological interventions. [33, 35–38, 40] A single studycharacterised their therapy as CBT. [34] One study did notinclude a psychological therapy option as part of the treatment plan. [39] Six studies reported data on psychologicaltreatments received. [33, 35, 36, 39, 40] Rate of uptake forpsychological treatment in the intervention groups werehigher than control groups and ranged from 5 to98%. [33, 35–37, 40] Studies reliant on patient preferences for either psychological or pharmacological depression treatment reported lower rates of uptake (5–43%).[35, 37] Similarly, rates of antidepressant use were higherthan controls and ranged from 35 to 85% of participantsat 6 months. [33, 36, 37, 39, 40]Five studies included training in intervention deliveryfor care co-ordinators [33, 34, 36, 37, 40] and a singlestudy documented training for oncologists responsiblefor antidepressant management. [35] Care co-ordinators’fidelity to the intervention manual was formally assessedin four studies [33, 36, 37, 40] although fidelity assessment and ongoing education were not included as partof the protocol for studies where the role of prescribingwas delegated to oncologists and GPs.Inter-professional roles within the collaborative care modelWith respect to multi-professional involvement, all studiesincluded a care co-ordinator and a mental health specialistas the primary members of the care team. Across studies,delivery of the psychological/psychoeducation componentsof the intervention as well as patient liaison and assessment of treatment adherence was undertaken by an appropriately trained nurse (n 4), [33, 36, 39, 40] social worker(n 2) [35, 37] or a psychologist (n 1) [34] with onestudy including both a nurse and a psychologist. [38] Thecare co-ordinators all underwent formal study-specifictraining and had weekly [33, 34, 36–40] or bi-weekly [35]supervision to review patient progress and initiate treatment adjustments, as required. Supervision was generallyprovided by a psychiatrist (n 7), although in one study aclinical psychologist was the appointed supervisor. [32]
Multicentre RCTcomparing collaborativecare intervention withusual careRCT comparingcollaborative careintervention with usualcaremulticentre effectivenessand cost effectiveness RCTcomparing collaborativecare intervention withusual careMulticentre efficacy RCTcomparing collaborativecare intervention withusual careFann [38] (2009USA)Kroenke [39](2010)USASharpe [40](2014)ScotlandWalker [33](2014)ScotlandAssess the efficacy of anintegrated treatment programme(depression care for people withcancer) for major depressionin patients with lung cancercompared with usual care.(SMART 3)Establish whether depressioncare for people with cancer(intervention) is better thanusual care in achieving aclinically useful improvementin depression(SMART 2)472 (85%female)200 (71%female)average depressionseverity during trialparticipation:participant’s depressionseverity averagedover the time fromrandomisation up to‘treatment response’measured at 24 weeks;defined as a reductionof 50% baselinedepression score,measured via SymptomChecklist (SCL-20D)142 (65%female)500 (90%female)405 (309depression;68% female)treatment response215 (60%defined 50% reduction female)in SCL-20 score at 12monthsTo determine whetherReduction of 50% incentralized telephone-based care depression severity;management coupled with(HSCL-20) at 12 months.automated symptom monitoringcan improve depression andpain in patients with cancer.Examine the effectiveness ofcollaborative care (IMPACT) fordepression in in older primarycare patientsTreatment responseat 12 months; definedas 50% or a 5-pointreduction of PHQ-9scoreSingle centre efficacyRCT comparingcollaborative careintervention withEnhanced usual care(standard oncology careplus psycho-educationalpamphlets; list of center/community financial,social services,transportation, andchildcare resources)Ell [37] (2008;2011)USADetermine the effectivenessof the Alleviating DepressionAmong Patients With Cancer(ADAPt-C) collaborative caremanagement for majordepression or dysthymiaInvestigate whether usual careself-reportedplus depression care for peopledepressive symptomswith cancer (intervention) could (SCL-20D) at 3 monthsachieve a greater reduction indepressive symptoms at 3months compared to usual carealone, and whether this wouldbe sustained at 6 and 12 months.(SMART1)Single centre proof ofconcept RCT comparingcollaborative careintervention with usualcare55 (100%female) 50% improvementin depression score(PHQ9) at 8 monthsHeterogeneousstage mixed63.7 (8.8)Lung; ‘poorprognosis’56.3 (10.1) Breast,gynaecological,genitourinary; ‘good prognosis’5
Collaborative care, defined as a treatment approach inte-grating primary- and tertiary-level (hospital) care in the management of co-morbid depression in cancer patients. Controls Treatment as usual, wai
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