Journal of Psychosomatic Research 67 (2009) 399–402

Short communication

Patient and general practitioner preferences for the treatment of depressionin patients with cancer: How, who, and where?

Laura Hodges⁎, Isabella Butcher, Annet Kleiboer, Gillian McHugh, Gordon Murray,Jane Walker, Rebecca Wilson, Michael Sharpe

Psychological Medicine Research, School of Molecular and Clinical Medicine, University of Edinburgh,Royal Edinburgh Hospital, Edinburgh, UK

Received 29 September 2008; received in revised form 17 March 2009; accepted 17 March 2009

Abstract

Objective: The objective of this study was to determine andcompare patient and general practitioner (GP) preferences for thetreatment of depression in patients with cancer. Methods: Atreatment preference questionnaire was completed by 100 patientswho had been diagnosed with both cancer and major depressivedisorder and by 86 GPs who had had experience of at least 1patient with cancer and depression. Participants were asked to rankoptions for how depression should be treated, who should deliverthe treatment, and where treatment should occur. Results: The topthree preferences of patients and GPs for how depression should betreated differed (Pb.001). Patients preferred talking treatmentalone, whereas GPs preferred a combination of drug and talking

⁎ Corresponding author. Psychological Medicine Research, University ofEdinburgh,Royal EdinburghHospital, KennedyTower, EH10 5HFEdinburgh,UK. Tel.: +44 0131 537 6683; fax: +44 0131 537 6641.

E-mail address: laura.hodges@ed.ac.uk (L. Hodges).

0022-3999/09/$ – see front matter © 2009 Elsevier Inc. All rights reserved.doi:10.1016/j.jpsychores.2009.03.008

treatment. Both patients and GPs preferred treatment to be given bythe GP, with older patients having a stronger preference for this.Counselors and cancer nurses were also popular preferences;mental heath professionals were unpopular. The preferred place oftreatment was primary care for both patients and GPs, althoughmany patients preferred treatment in the cancer center. Conclu-sion: Effective and acceptable services for depressed cancerpatients need to take patients and GP preferences into account. Amodel of service that allows a choice of initial treatment modalityand collaborative care between primary care and cancer centernurse would meet this requirement.© 2009 Elsevier Inc. All rights reserved.

Keywords: Cancer; Collaborative care; Depression; Preferences; Primary care; Treatment

Introduction

Depressive disorder is a relatively common problem forpatients with cancer that can affect both their quality of lifeand their adherence to medical treatment [1]. Despite theexistence of effective treatments, depression in cancerpatients is often poorly managed [2]. Consequently, weneed to consider how management might be improved.Before developing new ways of achieving this aim, it isnecessary to know what sort of services patients and theirgeneral practitioners (GPs) would prefer. Failure to do thismay lead to poor uptake of these services.

The aim of this study was, therefore, to determine thepreferences not only of patients with depression and cancerbut also of GPs for how the depression should be treated,who should treat the depression, and where the depressionshould be treated.

Method

Design

A cross-sectional questionnaire survey of patients andGPs was used.

Sample

PatientsPatients attending clinics at a regional tertiary cancer

center between October 2003 and December 2005 completed

Table 1Characteristics of the patient sample

Patients (N=100)

Sex, n (%)Female 77 (77)Male 23 (23)Age (years)Mean (S.D.) 56.4 (11.7)Range 24–86Deprivation (Scottish Index of Multiple Deprivation, 2004)Mean (S.D.) 17.88 (15.23)Range 1.1–76.9Primary cancer site, n (%)Breast 56 (56)Gynecological 14 (14)Colorectal 9 (9)Testicular 8 (8)Prostate 7 (7)Lung 3 (3)Renal 2 (2)Sarcoma 1 (1)Extent of disease, n (%)Active disease 75 (75)Disease free (posttreatment follow-up) 25 (25)Marital status, n (%)Married 64 (64)Single 11 (11)Divorced 9 (9)Widowed 9 (9)Separated 7 (7)Employment status, n (%)Retired 39 (39)Employed 45 (45)Professional 18 (18)Manual 18 (18)Clerical 9 (9)

Unemployed 15 (15)Housewife 1 (1)Previous experience with treatment for depression, n (%)Antidepressants 30 (30)Talking treatment 10 (10)Antidepressants+talking treatment combined 3 (3)No previous treatment 57 (57)

400 L. Hodges et al. / Journal of Psychosomatic Research 67 (2009) 399–402

a two-stage screening process to identify those with majordepressive disorder (MDD). Patients who scored 15 or moreon the Hospital Anxiety and Depression Scale [3] wereinterviewed using the relevant section of the StructuredClinical Interview for the DSM-IV. Patients with a diagnosisof cancer and MDD (with a duration of at least 4 weeks butless than 2 years) and with an estimated cancer prognosis ofmore than 6 months were invited to take part in a trial ofdepression management (SMaRT Oncology 1 Trial) [4].The first 100 consecutive patients recruited into the trialcompleted the treatment preference questionnaire priorto randomization.

General practitionersThe GPs of the last 101 patients who had participated in

the trial were contacted at trial completion. Therefore, allthe GPs had recent experience of a patient with both cancerand MDD. Four GPs had more than one patient participat-ing in the trial, and two patients were lost to follow-up,leaving 95 eligible GPs. Of these, 86 participated in thesurvey (91%). The main reason given for nonresponse waslack of time.

Measures

Patients and GPs were given similar preference ques-tionnaires. Both patients and GPs were instructed to rank, inthe order of their preference, prespecified options for threeaspects of the management of depression for patients withcancer: (a) how the depression should be treated (talkingtreatment, drug treatment, or talking and drug treatmentcombined; talking treatment was deliberately not furtherspecified to be as broad as possible), (b) who they thoughtshould treat the depression (GP, psychologist, psychiatrist,counselor, cancer nurse, or psychiatric nurse), and (c) wheretreatment for depression should be delivered (GP practice,psychiatric hospital, general hospital, community psychiatricteam, or cancer center). Information on age, gender, cancertype, postcode (to calculate deprivation score), and previousexperience of treatment for depression was also collectedfrom patients.

Procedure

Patients completed the preference questionnaire during aface-to-face assessment with a research nurse. GPs were sentthe preference questionnaire by post.

Analysis

For each question, the percentage of those choosing eachpossible option as first preferences were determined. Theassociation of patient first preferences with age, gender, orprevious experience of treatment was tested using one-wayanalysis of variance for age and chi-squared tests for genderand previous experience of treatment. In addition to first

treatment choices, we also compared patients and GPs ontheir three most highly ranked options and the rank order ofthese using chi-squared tests.

Results

Sample

Table 1 displays the demographic and clinical character-istics of the patient sample.

First preference

Table 2 displays the proportion of the patient and GPsamples selecting each treatment option as their firstpreference. The only statistically significant association ofpatient preference was with age (P=.012). Patients who

Table 2GPs' and patients' first preferences for management of depression in cancer outpatients

How should depression be treated? a Who should treat depression? b Where should depression be treated? c

Patients,n (%)

GPs,n (%)

Patients,n (%)

GPs,n (%)

Patients,n (%)

GPs,n (%)

Drug treatment only 3 (3) 0 (0) GP 38 (38) 41 (50) GP practice 47 (47) 46 (57)Talking treatment only 71 (71) 27 (33) Counselor 26 (26) 15 (19) Psychiatric hospital 1 (1) 0 (0)Drug and talking treatment combined 26 (26) 56 (67) Cancer nurse 30 (31) 15 (19) General hospital 3 (3) 0 (0)

Psychiatrist 0 (0) 6 (7) Community psychiatric team 9 (9) 13 (16)Psychiatric nurse 1 (1) 4 (5) Cancer center 40 (40) 22 (27)Psychologist 4 (4) 0 (0)

a Complete data for 83/86 GPs and 100/100 patients.b Complete data for 81/86 GPs and 99/100 patients.c Complete data for 81/86 GPs and 100/100 patients.

401L. Hodges et al. / Journal of Psychosomatic Research 67 (2009) 399–402

preferred treatment by their GP were older (mean=63 years)than patients who thought that depression should be treatedby a counselor (mean=53 years), a cancer nurse (mean=56years), or a mental health specialist (mean=56 years). Therewas no significant association between preference for whoshould treat depression or where depression should betreated and gender or previous treatment experience.

Three most highly ranked preferences

How should depression be treated?For patients, almost two thirds of the sample (65%)

ranked talking treatment first, the combination of drug andtalking treatment second, and drug treatment alone third. ForGPs, the most common order of preference (37%) was drugand talking treatment first, talking treatment only second,and drug treatment alone third. A chi-squared analysis foundthese rankings of GPs and patients to be significantlydifferent (Pb.001).

Who should treat depression?Both patients and GPs selected treatment given by a GP as

their favorite choice, closely followed by treatment given bya cancer nurse and counselor. Being treated by a psychiatrist,psychiatric nurse, and psychologist consistently receivedlow rankings.

Where depression should be treated?Forty-two percent of patients selected GP practice, cancer

center, and general hospital as their first three choices.Eighty-eight percent of the GPs selected GP practice, cancercenter, and community psychiatric team in various orders.

Discussion

The main findings were that, firstly, while both patientsand GPs preferred talking treatment, there was cleardisagreement on the role of antidepressant drugs; neithersaw these as first choice but GPs preferred to addantidepressant drugs to the talking treatment whereas most

patients did not. Secondly, both patients and GPs preferredtreatment to be given by the GP. This preference wasstronger in older patients. Many patients also expressed apreference for treatment by a cancer nurse or a counselor. Itwas notable that neither patients nor GPs expressed apreference for treatment given by mental health professionals[3]. The preferred place of treatment for both patients andGPs was general practice or the cancer center and not mentalhealth services.

The disagreement between patients and GPs aboutantidepressant drugs has been previously noted [5,6]. Wehave found it to be the case for patients with cancer as well,despite the fact that most of these patients have had anticancerchemotherapy. This disagreement merits further study as it islikely to lead to poor outcomes for patients [7] and unwantedprescribing by doctors [8] if it remains unaddressed.

There was general agreement that depression should betreated by GPs in primary care. However, many patientsmentioned the cancer center (40%) and cancer nurse(31%) as first preference, probably reflecting theirfamiliarity with these services. Older patients' greaterpreference for the GP may reflect a more conservativeattitude to specialist services. While there are clearadvantages to locating depression management in primarycare, the evidence suggests that depression is oftenineffectively treated in primary care [2]. In addition,while the advantage of the cancer center and cancer nurseis that treatment for depression could be more integratedwith the patients' medical care, the focus on medicaltreatment in specialist centers leads to depression beinginadequately treated there also [9]. The irony is thattreatment by those who specialize in treating depression—mental health professionals (i.e., psychiatrist or psychol-ogist)—was strikingly unpopular among both patients andGPs. Consequently, better services are required to buildon the strengths of each of these options while also beingacceptable to patients. One potentially effective andacceptable approach to management is to deliver treatmentin a collaborative care model involving primary care andcancer center nurses with specialist psychiatric supportprovided to these staff [4].

402 L. Hodges et al. / Journal of Psychosomatic Research 67 (2009) 399–402

Strengths and limitations

The entire patient sample had cancer and major depres-sion, making their stated preferences realistic. However, thesample was potentially biased by their prior agreement totake part in a trial. Patients with chronic depression (morethan 2 years) or with other serious psychiatric comorbiditywere excluded. The majority of patients in the study samplewere female, had breast cancer, and were living in areas ofrelatively low social deprivation.

The whole GP sample had experience of at least one oftheir patients having MDD and cancer. Furthermore, patientshad not been referred from primary care but were detected byscreening in the cancer center where a diagnosis of MDDwas made, making them more representative. However, theGPs were all from the Edinburgh area.

The questions asked were limited in order to maximizecompletion. However, this limited our ability to exploremore sophisticated aspects of preference such as equalranking of options or preferences for stepped-careapproaches. A qualitative study would be able to investigateattitudes towards treatments in more depth.

Conclusion

The preferences of cancer patients and GPs for themanagement of depression were similar in that both had alow preference for mental health specialists and services anda high preference for involvement of the GP and use oftalking treatments. However, they differed on the role ofantidepressant agents, with the GPs' preference being highand the patients' preference being low. Many patientspreferred that their depression be treated by a cancer nursein a cancer center. Collaborative care that includes both

psychological treatment and education about antidepres-sants, provided by GP and cancer center nurse (withspecialist psychiatric supervision), delivered in both primarycare and in the cancer center could be both effective andacceptable to patients and their GPs [4].

Acknowledgments

This research was supported by Cancer Research UK.

References

[1] Chochinov HM. Depression in cancer patients. Lancet Oncol 2001;2:499–505.

[2] Sharpe M, Strong V, Allen K, Rush R, Postma K, Tulloh A, et al. Majordepression in outpatients attending a regional cancer centre: screeningand unmet treatment needs. Br J Cancer 2004;90:314–20.

[3] Zigmond AS, RP S. The Hospital Anxiety and Depression Scale. ActaPsychiatr Scand 1983;67:361–70.

[4] Strong V, Waters R, Hibberd C, Murray G, Wall L, Walker J, et al.Management of depression for people with cancer (SMaRToncology 1):a randomised trial. Lancet 2008;372:40–8.

[5] Churchill R, Khaira M, Gretton V, Chilvers C, Dewey M, Duggan C,et al. Treating depression in general practice: factors affecting patients'treatment preferences. Br J Gen Pract 2000;50:905–6.

[6] Dwight-Johnson M, Sherbourne CD, Liao D, Wells KB. Treatmentpreferences among depressed primary care patients. J Gen Intern Med2000;15:527–34.

[7] Pyne JM, Rost KM, Farahati F, Tripathi SP, Smith J, Williams DK, et al.One size fits some: the impact of patient treatment attitudes on the cost-effectiveness of a depression primary-care intervention. Psychol Med2005;35:839–54.

[8] Dowrick C, Gask L, Perry R, Dixon C, Usherwood T. Do generalpractitioners' attitudes towards depression predict their clinical beha-viour? Psychol Med 2000;30:413–9.

[9] Fallowfield L, Ratcliffe D, Jenkins V, Saul J. Psychiatric morbidity andits recognition by doctors in patients with cancer. Br J Cancer 2001;84:1011–5.