Abstract CN03-04: Patient, provider, and organizational barriers to receipt of depression care among low-income minority patients with cancer

Depression care management: Depressive disorders and symptoms are common in cancer patients, worsen over the course of cancer treatment, persist long after cancer therapy, recur with the recurrence of cancer, and significantly impact quality of life and co-occur with pain and fatigue. While there is strong evidence of effective depression treatment for patients with comorbid illness, however, low-income minority cancer patients are less likely to receive care attributable to patient, provider, organizational system and cost/staffing barriers. This disparity provides a compelling need to develop and test solutions that are sustainable in community-based practice and acceptable to patients and providers in safety net community care.

Patient barriers: For underserved populations these can include patient socio-economic and cultural barriers and skill in navigating fragmented health care systems, communication with providers, and community resource access. Whether depression treatments are effective and widely accepted by cancer patients will depend, in part, on whether they are socio-culturally compatible with patient preferences and practical needs and can be implemented within community care practice systems serving these populations. Patients may be reluctant to report symptoms or to see a mental health professional and if treatment is prescribed they may be non-adherent, citing concerns about stigma, side effects and/or preoccupation with active cancer treatment. Post-treatment, survivors may experience increased vulnerability as a result of decreased contact with the oncology team and less access to emotional support from personal networks. The impact of having had cancer and coping with late effects may precipitate significant affective distress or reduce the likelihood of sustained remission among patients who experienced major depression during acute treatment. Fear of cancer recurrence or the need for further treatment may contribute to avoiding or delaying seeking surveillance, follow-up or symptom management care. Low-income and medically uninsured patients with cancer have less access to mental health services and to cancer support groups. In addition, culturally based preferences for depression care can become a barrier to care if the preferred mode of care is not available. Personal culturally based explanations for depression symptoms may influence symptom expression and patient-provider communication. Finally, patient perceptions of bias and cultural competence in health care, family perceptions, and practical barriers such as lost work time and transportation to therapy may impede receipt of care. In our experience, many of our Hispanic patients attribute the etiology of depression to socio-economic as well as illness and treatment related stress and they prefer psychotherapy that addresses stressor coping skill management and a supportive relationship with a therapist over antidepressant medication. Many of their stresses are social, economic or logistic which call for patient navigation services.

Socio-cultural frameworks. Socio-cultural Explanatory Theories illustrate that how low-income minority populations use health care and make decisions about whether to follow medical advice is influenced by individual cognitive, affective, and cultural resources and barriers in combination with environmental supports and barriers. While culturally patterned beliefs, perceptions, and attitudes (e.g., culturally-determined and culturally-distinct normative patterns of physical and psychological symptom definition, response, and help-seeking) are believed to be critical antecedents of health behaviors, behavior is not independent of powerful environmental factors. Interventions can be guided by adapting care models in key areas.

Provider barriers: Physicians may miss depression because they assume it a “natural consequence of cancer” or have significant time constraints that impede depression assessment and management. Depressive symptom prevalence varies by cancer site, stage, and treatment as well as by the methods and criteria used in assessing depression. Unfortunately, clinicians and patients often perceive depression as an expected and reasonable reaction to cancer; as a result, major depression is frequently under-recognized and under-treated in oncology practice and simply informing oncologists of patients need does not result in treatment.

Assessing depression. Routine depression screening guidelines have grown, although widespread implementation has lagged. Few oncologists use routine screening tools, frequently attributable to workload. Establishing a diagnosis of clinical depressive disorder among cancer patients can be confounded by biologic and physical symptoms that can mask a depression or contribute to its development and persistence. Difficulty in differentiating medical and depressive symptoms challenges the identification and treatment of cancer patients with depressive disorder, while failure to assess and treat can deprive patients of care that is shown to improve quality of life, cancer treatment adherence and possibly mortality.

Treating depression in patients with cancer. Treating depression may be indicated at any stage in the illness trajectory from diagnosis, to treatment, to chronic illness management or “cancer survivorship”, while treatment is most effective for patients with assessed indication. NCCN Guidelines for Distress Management recommend the use of psychotherapy in combination with antidepressants for mood disorders; however, few studies have compared their effectiveness across minority populations.

Organizational barriers: Organizational system barriers include financing, staffing resources, communication across fragmented clinics and providers, and compatibility with organizational incentives and system culture. Providers may be reluctant to raise the issue, be less aware of effective treatment, and/or lack access to mental health professionals.

Quality improvement strategies in primary care have been effective in reducing organizational barriers to depression care. Organizational strategies generally adapt depression care delivery, such as the implementing routine brief depression screening, systematic application of evidence-based practice guidelines, clinical decision-making protocols and algorithms, follow-up through remission and maintenance, enhanced roles of nurses or social workers as depression care managers, as well as integration between primary care and mental health specialists or service systems. Depression care models that use collaboration between primary care physicians and mental health professionals have been found to be effective in primary care and found to improve patient adherence and prevent relapse.

Pathways between oncology and primary care. Recent evidence finds that patients with cancer and their caregivers believe that there is an important and unique role for primary care in offering continuity of care and information that is patient-centered and holistic, throughout the cancer trajectory through the use of protocols for primary care. Primary care physicians are felt to be important allies, especially in managing the psychosocial concerns of patients, thus, it is suggested that a “transition of care” or “shared care” protocols be developed between oncology and primary care, with the latter to provide ongoing surveillance and psychosocial support and clinical management.

Quality of care improvement strategies highlight potential cost barriers. Investigators have reported that patient navigation improves patient depression treatment adherence and cost effectiveness among minority patients, a need for post-cancer treatment monitoring, and provider/organizational need for mental health and coordinating staff. However, quality of care improvement calls attention to cost issues. In some cases costs may increase and financial stakeholders may question whether improved clinical outcomes can translate into daily and affordable practice.

The Chronic Care Model is a comprehensive model to guide organizational considerations.

Health system organization: Patient self-management support promotes patients' role in managing their health using effective self-management and education strategies. To promote self-management for both depression and cancer, linguistically and culturally adapted educational materials, including a video for patients with limited literacy and a CD in relaxation techniques, to address adherence to antidepressant use and self management support can be helpful. Because family members act as “gatekeepers” for some patients, family members can be invited to participate in education and treatment sessions if the patient prefers and additional educational materials targeted specifically for family members can be distributed. Delivery system redesign generally includes the addition of mental health provider collaboration. Decision support includes the use of the stepped care algorithms and supporting written information for medical and organizational providers as well as methods to facilitate communication of information across key providers and organizational systems, e.g., oncology and primary care. Clinical information systems can provide timely reminders for providers and patients to prompt appropriate care. Health system design can be designed to include patient navigation and mental health providers within or outside of the organized care system and be provided in concordance with a written guideline protocol. At the Community Level, effective interventions should form community partnerships to fill gaps in services.