February
2008, Volume 12, Number 1
Article
Putting Evidence Into
Practice®: Interventions for Depression
Caryl D. Fulcher, MSN, APRN, BC, Terry Badger, PhD, APRN, BC, FAAN,
Ashley K. Gunter, BSN, RN, OCN®, Joyce A. Marrs, MS, APRN, BC, AOCNP®,
and Jill M. Reese, BSN, RN, OCN®
Depression and depressive symptoms are prevalent in
people with cancer, yet interventions for depression are a low priority for
most oncology care providers. Barriers to diagnosis and treatment include
beliefs by patients and providers that depression is an expected correlate of
cancer diagnosis, the reluctance of patients to share psychological concerns,
and the reticence of some professionals to assess patients with cancer for
depressive symptoms in the midst of busy oncology settings. Intervening to
diminish depressive symptoms in people with cancer is important because
depression has been associated with poorer quality of life, recovery, and
possibly survival. This article reviews and summarizes the evidence for
pharmacologic and nonpharmacologic interventions for
people with cancer and depression and identifies opportunities for future
research and practice change.
At a Glance
·
Depression is a prevalent, comorbid
condition for people with cancer, but barriers often prevent appropriate
assessment and intervention.
·
Evidence shows that psychoeducational
and psychosocial interventions, particularly cognitive behavioral therapy, are
beneficial in managing depressive symptoms in patients with various types of
cancer.
·
Complementary therapies are gaining popularity, but
currently no sufficient, high-quality studies support the use of such therapies
in people with cancer.
The Oncology Nursing Society (ONS) has led efforts
to identify patient
outcomes that are influenced by nursing interventions. Nursing interventions
must be within the scope of nursing practice, integral to the processes of
nursing care (Given & Sherwood, 2005), and selected based on research
examining intervention effectiveness. The 2006 ONS Putting Evidence Into Practice®
(PEP) Depression Intervention Project Team reviewed, critiqued, and summarized
the research evidence for nursing interventions related to depression in people
with cancer. This article is an evidence-based review of pharmacologic and
non-pharmacologic nursing interventions used to treat adult patients with
cancer and depression.
Oncology care providers long have recognized that
patients and their families experience emotional distress associated with
cancer and its treatment. Emotional distress is an important problem in cancer
survivorship because it significantly influences cancer recovery (Alferi, Carver, Antoni, Weiss,
& Duran, 2001; Helgeson, Snyder, & Seltman, 2004; Manne et al.,
2003; Osborne, Elsworth, & Hopper, 2003; Owen, Klapow, Roth, Nabell, &
Tucker, 2004), quality of life (QOL) (Heiney et al.,
2003; Vega et al., 2002; Vos, Garssen,
Visser, Duivenvoorden,
& de Haes, 2004), and possibly even long-term
survival (Maunsell, Brisson,
& Deschenes, 1995; Weihs,
Enright, Simmens, &
Reiss, 2000). Depression, the most common emotional distress experienced, is
estimated to have prevalence from 1.5%–50% in breast cancer survivors (Massie,
2004; Trask, 2004; Zabora, BrintzenhofeSzoc, Curbow, Hooker,
& Piantadosi, 2001), depending on how depression
is defined.
Much has been written about depression, although the
term’s many definitions may contribute to the lack of understanding of the
seriousness of depressive symptoms and can provide barriers to its treatment.
Styron (1990) wrote in Darkness Visible: A Memoir of Madness that it was
“a noun with a bland tonality and lacking any magisterial presence, used
indifferently to describe an economic decline or a rut in the ground, a true
wimp of a word for such a major illness” (p. 37). Depression is defined for this
review as the entire range of feelings and emotions expressed by individuals
with cancer as they manage personal and illness-related problems; it includes
normal sadness in response to loss as well as chronic, depressed emotional
affect and clinical depression that meets specific criteria for a psychiatric
disorder (Barsevick, Sweeney, Haney, & Chung
2002). Patients suffering with depressive symptoms that fail to meet the
criteria for diagnosis or with sufficient symptoms to meet a diagnosis are at
risk for poor health outcomes (Zabora et al., 2001).
One barrier to effective assessment and intervention
for depression is the belief of many providers and patients that depression is
a natural reaction to the diagnosis of cancer rather than a comorbid
and serious condition (Passik et al., 1998). This
myth limits identification of depression as a condition that can be treated.
Another barrier is the reluctance of many patients to share their emotional
symptoms with busy healthcare professionals; conversely, providers often are
uncomfortable probing into patients’ psychological distress.
To overcome these barriers, standards and guidelines
such as the National Comprehensive Cancer Network (NCCN) Standards of Care for
Distress Management (NCCN, 2008) call for screening, evaluating, and treating
depression in all patients with cancer (see Figure
1). Oncology nurses can play a significant role in (a) recognizing visual
and verbal cues of anxiety and depression, (b) screening for depressive
symptoms with the many valid screening tools available, and (c) integrating
evidence-based interventions into their practice.
Descriptions of screening tools for depression can
be found on the ONS Outcomes Resource Area (www.ons.org/outcomes/measures/summaries.shtml#dep).
Oncology nurses can advocate for patients and their families to improve
recognition and treatment of depressive symptoms and depression and collaborate
with mental health professionals to ensure comprehensive care. Figure 2 provides signs and symptoms of depression.
The ONS PEP Depression Intervention Project Team
explored the evidence on interventions to answer the question, “What can
oncology nurses do to assist people with cancer who also have depressive
symptoms or major depressive disorder?”
Methods
The workgroup searched MEDLINE®, CINAHL®,
PubMed®, and PsycINFO
using the search terms interventions, psychosocial interventions, psychoeducational interventions, supportive counseling,
and cancer and depressive symptoms or depression or major
depressive disorder. Years searched were 2001–2006, and the search
ended September 30, 2006. In some cases, earlier articles were reviewed in an
attempt to comprehensively cover appropriate literature.
Articles were eliminated if they did not involve an
intervention targeted for depressive symptoms or major depressive disorder, or
if they were exclusively about caregivers or pediatric patients. A health
services librarian was consulted to assist in the search.
Highlights of Reviewed Literature
Nine systematic reviews or meta-analyses from the
identified time period found the highest evidence in support of psychosocial
and psychoeducational interventions and pharmacologic
interventions. The detailed ONS PEP card can be found in the Appendix. Each study and review was rated on
strength of evidence as identified by the ONS Weight-of-Evidence Classification
Schema (see Table 1). The system critically
appraises evidence sources from strongest (multiple, well-designed, randomized,
controlled trials with samples more than 100 subjects) to weakest (e.g.,
qualitative designs, case studies, opinions). From there, interventions were
classified using a weight-of-evidence schema (Mitchell & Friese, n.d.), which ranged from
Recommended for Practice for those with strong supportive evidence to Likely to
be Effective, Benefits Balanced With Harms, Effectiveness not Established,
Effectiveness Unlikely, or Not Recommended for Practice. Interventions reviewed
are psychosocial and psychoeducational,
pharmacologic, and complementary.
Psychoeducational and Psychosocial Interventions
Evidence at the highest level (Barsevick
et al., 2002; Bennett & Badger, 2005; Given et al., 2004; Newell, Sanson-Fisher, & Savolainen,
2002; Osborne et al., 2003; Pirl, 2004; Uitter-
hoeve et al., 2004; Williams & Dale, 2006)
supports the benefit of psychoeducational and
psychosocial interventions in the management of depressive symptoms during and
following cancer treatment in patients with different types of cancer. Psychoeducational and psychosocial interventions include
cognitive-behavioral therapy, patient education and information, counseling and
psychotherapy, behavioral therapy, and supportive interventions.
Cognitive-behavioral therapy is defined as any specific psychological or
psychosocial intervention that is relatively brief, goal oriented, based on
learning principles of behavior change, and directed at effecting change in a
specific clinical outcome (Osborn, Democada, &
Feuerstein, 2006). It teaches problem-solving skills and challenges “black and
white” thinking to help reframe attitudes. Counseling and psychotherapy refer
to interactive verbal interventions, including nondirective, psychodynamic,
existential, supportive, and crisis interventions; nurses who provide such
interventions have advanced education and training. Of the interventions
studied, the most evidence is for cognitive-behavioral therapy. Patient
education, therapeutic social support, and information take many forms but
clearly are important and essential actions for oncology nurses.
Barsevick et al. (2002) examined scientific studies, qualitative or quantitative
systematic reviews, and practice guidelines published
from 1980–2000, and concluded that psychoeducational
interventions reduced depressive symptoms in patients with cancer. Behavior
therapy or counseling alone or in combinations with cancer education was found
to be beneficial. The same recommendations were made in a meta-analysis by
Williams and Dale (2006), which also included pharmacologic interventions.
Although considerable variability exists in frequency, duration, and type of
psychosocial intervention, most studies support that the interventions are
effective for reducing depressive symptoms; thus, they are recommended for
practice. Although less evidence shows that psychosocial interventions are
effective for treating those with depression, the ONS PEP Weight-of-Evidence
Classification Schema
indicates that enough evidence exists to recommend such
interventions for practice.
Pharmacologic Interventions
Antidepressant
Medications
Although much has been written about antidepressant
use in patients with depression and cancer, few randomized, controlled trials
have examined the effectiveness of antidepressants. Treatment studies of
patients with cancer and depression support use of tricyclic
antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), mianserin (atypical antidepressant not available in the
United States), and others (Goodnick & Hernandez,
2000; Lan Ly, Chidgey, Addington-Hall, & Hotopf,
2002; Pirl, 2004; Schwartz, Lander, & Chochinov, 2002). Four reviews were identified that
supported the benefits of antidepressant medication in patients with cancer (Pirl; Schwartz et al.), other comorbid
medical illness (Goodnick & Hernandez), and
palliative care (Lan Ly et al.). Studies measuring
depression at less than five weeks showed less benefit, likely because the time
to reach therapeutic effect may be four to eight weeks. No differences were
found in effectiveness between TCAs and SSRIs; however, the lower incidence of
side effects with SSRIs makes them preferable in patients with cancer. Although
no studies have specifically examined the newer serotonin-norepinephrine
reuptake inhibitor duloxetine in patients with
depression and cancer, its similarity to venlafaxine
makes it likely to be similarly effective.
Patients with malignant melanoma, traditionally
treated with interferon alfa, are known to experience
depression as a side effect of treatment. Musselman
et al. (2001) prescribed paroxetine two weeks prior
to the initiation of interferon alfa and continued it
for the first 12 weeks of therapy in a double-blind study of 40 patients.
Dosage ranged from 10–40 mg daily. Major depression developed in only 2 of the
18 patients in the paroxetine group compared to 9 of
the 20 on placebo. Paroxetine treatment also
significantly decreased the likelihood that interferon would have to be
discontinued because of severe depression.
Clinical practice guidelines, another comprehensive,
evidence-based tool to assist healthcare professionals in providing optimal
care, support the benefit of medication interventions. The National Health and
Medical Research Council, Australia (2003), which published Clinical
Practice Guidelines for the Psychosocial Care of Adults With
Cancer, concluded that the treatment of depression should incorporate
psychotherapeutic and medication interventions. Although clear evidence
supports the efficacy of antidepressant medication in treating depression in
patients with cancer, no evidence exists that any particular antidepressant is
superior to another. Antidepressant selection should be based on side-effect
profiles and patient needs. For example, the sedating properties of the TCAs
may be beneficial for some patients, and TCAs may potentiate opioid analgesia in those with pain. The long half-life of fluoxetine makes it less desirable in patients with hepatic
or renal dysfunction; in such cases, another antidepressant is preferable
(Health and Medical Research Council, Australia; National Cancer Institute,
2007). Other guidelines for the treatment of depression also provide useful
information about medication management in the treatment of depression in
adults (American Psychiatric Association, 2000; Ministry of Health, Singapore,
2004). Those guidelines contain information about selecting antidepressants,
adjusting doses, assessing response, switching
medications, managing the continuation and maintenance phases of antidepressant
treatment, and discontinuing treatment. The guidelines are not specific to
depression in patients with cancer. Although the guidelines document that
depression can coexist with medical conditions, they are not specific for the
physical impairments of many patients with cancer. In contrast, the National
Comprehensive Cancer Network (2008) has published guidelines detailing
algorithms describing care of patients with cancer and mood disorders or
adjustment disorders with depressed mood. Pharmacology with antidepressants is
an effective intervention and is recommended for practice.
Methylphenidate
One phase II study (Homsi
et al., 2001) and one systematic review (Rozans, Dreisbach, Lertora, & Kahn,
2002) explored methylphenidate (Ritalin®, Novartis) in patients with
depression in advanced cancer (cancer sites studied included breast, esophagus,
pancreas, colorectal, and other). The advantage of the central nervous system
stimulant is its reported safety and rapid onset of action. It is used most
often in advanced cancer and palliative situations, when doses typically are prescribed
twice a day starting at 5 mg and titrated until a response is obtained or side
effects dictate discontinuance. Giving the dose early in the day with food is
recommended to increase absorption and decrease insomnia. Homsi
et al. found that the maximum daily dose needed for resolution of depression
was 20 mg. In the Rozans et al. systematic review of
nine studies, methylphenidate was useful in treating depression in a variety of
malignancies, with more than 80% of patients responding favorably and less than
20% reporting side effects. Methylphenidate also is used to address opioid-induced somnolence, augment opioid
effects, improve cognitive functioning in patients with cancer, and decrease
pain scores. Those benefits may contribute to mood improvement. Using the ONS
PEP Weight-of-Evidence Classification Schema, the team concluded that
methylphenidate is likely to be effective.
Complementary Interventions
Complementary and alternative therapies used to
treat depression in patients with cancer are gaining popularity and prevalence.
Unfortunately, few randomized, controlled studies of complementary
interventions have been conducted in people with cancer and depression.
Included in this category are massage therapy, relaxation therapy,
hypnotherapy, and many others.
Massage
Therapy
Massage is the manipulation of soft-tissue areas of
the body, offered to assist in relaxation, aid in sleep, and relieve muscle
tension and pain (Cassileth & Vickers, 2004).
Studies examining the effect of massage therapy on depression are beginning to
emerge, but effectiveness has not been established. The most consistent effect
on symptom relief in patients with cancer was reduction in anxiety (Fellowes,
Barnes, & Wilkinson, 2004). Some short-term reduction in depression has
been demonstrated; self-report symptom scores of depression reduced by about
50% 2–48 hours after massage (Cassileth &
Vickers), but more and better-quality studies are needed to recommend this
intervention.
Relaxation
Therapy
Relaxation therapy refers to techniques that focus
on inducing a relaxed physical and mental state, such as progressive muscle
relaxation with or without guided imagery, hypnosis, and autogenic training (Leubbert, Dahme, & Hasenbring, 2001; Sloman, 2002). Leubbert et al.’s meta-analysis evaluated 15 randomized,
controlled studies conducted from 1980–1995. Relaxation training was found to
have a significant impact on reducing cancer treatment–related side effects,
including emotional adjustment variables (e.g., depression, anxiety, hostility). In a study of 56 people with advanced cancer,
progressive muscle relaxation and guided imagery were taught to patients; a
reduction in depression was found in all three treatment groups (Sloman). Findings from the review included a small but significant
benefit on treatment-related side effects, including depression. According to
the ONS PEP Weight-of-Evidence Classification Schema, relaxation as a method is
likely to be effective in managing depressive symptoms.
Hypnotherapy
Hypnotherapy is a behavior therapy to induce
heightened concentration, receptivity, and relaxation (Sadock
& Sadock, 2003). Rajasekaran,
Edmonds, and Higginson’s (2005) systematic review reported results of 27
studies prior to 2003. Terminally ill adult patients with cancer obtained
relief from depression, anxiety, and pain, but only 1 of the 27 was a
randomized, controlled study. Although few adverse effects were reported
overall, reports were made of patients who were unable to enter a deep trance
or who were frightened by the treatment (Rajasekaran
et al.). Most studies were considered of poor quality with very small sample
sizes. Therefore, according to the ONS PEP Weight-of-Evidence Classification
Schema, effectiveness is not established for hypnotherapy in managing depression;
further research is needed.
Other
Complementary Interventions
St. John’s wort, an herb
known to treat mild to moderate depression, should be avoided during
chemotherapy or radiation or when surgery is planned because it can adversely
impact the efficacy of some chemotherapeutic agents and prescription
medications (Deng & Cassileth, 2005). Other
complementary interventions such as nutritional and herbal supplements, yoga,
acupuncture, aromatherapy, Healing Touch, exercise, and meditation have not been
studied specifically in people with cancer, or insufficient studies have
demonstrated effectiveness to recommend for practice (Pirl,
2004). Although some studies (Post-White et al., 2003; Sloman,
2002) show promising results and benefits of such methods to reduce mood
disturbance, stress, pain, and other symptoms, effectiveness in decreasing
depressive symptoms in patients with cancer has not been established;
therefore, the method cannot be recommended.
Implications
The evidence documenting the ill effects of
depression as a comorbid symptom or diagnosis
supports the need for improved recognition and intervention. Oncology nurses
are well positioned to assess for depression during the cancer treatment
trajectory. A routine including questions about patient concerns, difficulties,
hopes, and expectations with supportive responses and information leads to
further education or referral. Nurses must educate themselves about depression
as a symptom and an illness and can select one of many,
well-established depression assessment tools to incorporate into their
practices (see Table 2). In addition, each practice
setting must develop methods to provide or make referrals for psychosocial, psychoeducational, and pharmacologic interventions.
Oncology nurses with additional expertise may do so or can collaborate with
other professionals to improve cancer care.
Conclusions
Depression, whether classified as depressive
symptoms or diagnosis, is prevalent and distressing for many patients with
cancer and their families. Depression can contribute to negative health
outcomes, including increased morbidity and mortality (Manne
et al., 2003; Osborne et al., 2003; Owen et al., 2004; Vega et al., 2002; Vos et al., 2004; Weihs et al.,
2000). Although many of the interventions used to treat depression may be
effective in patients with cancer and depression, patients with cancer are not
offered the interventions routinely. Depression remains underdiagnosed
and undertreated.
The strongest evidence exists for psychosocial and psychoeducational interventions. Further research is needed
to examine intervention dosage (frequency and duration) and combinations of
psychosocial interventions and medications with diverse cancer populations.
Pharmacologic interventions also have been found to be effective, and clinical
practice guidelines recommend the combination of psychosocial interventions and
medication. Finally, initial studies of some types of complementary and
alternative interventions have shown promise. Lack of evidence does not equate
lack of efficacy, but more studies are needed in patients with cancer and
diverse diagnoses before practice recommendations can be made.
Oncology nurses are ideally situated not only to
assess for depressive symptoms in their patients, but also to provide education
about depression and its effects, offer support, and make appropriate referrals
when needed. Such actions will augment a holistic approach to high-quality care
for patients with cancer.
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Caryl D. Fulcher, MSN, APRN, BC, is a clinical nurse specialist in the
Department of Advanced Clinical Practice at Duke University Health System in
Durham, NC; Terry Badger, PhD, APRN, BC, FAAN, is a professor and division
director in the College of Nursing at the University of Arizona in Tucson;
Ashley K. Gunter, BSN, RN, OCN®, is a clinical nurse III in the
Department of Adult Stem Cell Transplants at Duke University Health System; and
Joyce A. Marrs, MS, APRN, BC, AOCNP®, is a nurse practitioner and
Jill M. Reese, BSN, RN, OCN®, is a clinical nurse educator, both at
Hematology and Oncology of Dayton in Ohio. No financial relationships to
disclose. (Submitted April 2007. Accepted
for publication October 26, 2007.)
Author
Contact: Caryl D. Fulcher, MSN, APRN, BC, can be reached at caryl.fulcher@duke.edu, with copy to
editor at CJONEditor@ons.org.
Digital Object Identifier:10.1188/08.CJON.131-140