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Depression, Correlates of Depression, and Receipt of Depression Care Among Low-Income Women With Breast or Gynecologic Cancer

From the University of Southern California, School of Social Work and Keck School of Medicine, Department of Psychiatry, Los Angeles, CA; University of Maryland, School of Social Work, Baltimore, MD; and Department of Psychiatry, University of Washington, Seattle, WA

Address reprint requests to Kathleen Ell, DSW, School of Social Work-0411, University of Southern California, University Park, Los Angeles, CA 90089; e-mail: ell{at}usc.edu

	ABSTRACT

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PURPOSE: To assess the prevalence of depression among low-income, ethnic minority women with breast or gynecologic cancer, receipt of antidepressant medications or counseling services, and correlates of depression.

PATIENTS AND METHODS: Study patients were 472 women receiving cancer care in an urban public medical center. Women had a primary diagnosis of breast (stage 0 to III) or gynecologic cancer (International Federation of Gynecology and Obstetrics stage 0 to IIIB). A diagnostic depression screen and baseline questionnaire were administered before or during active treatment or during active follow-up. Self-report data were collected on receipt of depression treatment, use of supportive counseling, pain and receipt of pain medication, functional status and well-being, and perceived barriers to cancer care.

RESULTS: Twenty-four percent of women reported moderate to severe levels of depressive disorder (30% of breast cancer patients and 17% of gynecologic cancer patients). Only 12% of women meeting criteria for major depression reported currently receiving medications for depression, and only 5% of women reported seeing a counselor or participating in a cancer support group. Neither cancer stage nor treatment status was correlated with depression. Primary diagnosis of breast cancer, younger age, greater functional impairment, poorer social and family well-being, anxiety, comorbid arthritis, and fears about treatment side effects were correlated with depression.

CONCLUSION: Findings indicate that depressive disorder among ethnic minority, low-income women with breast or gynecologic cancer is prevalent and is correlated with pain, anxiety, and health-related quality of life. Because these women are unlikely to receive depression treatment or supportive counseling, there is a need for routine screening, evaluation, and treatment in this population.

	INTRODUCTION

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Major depressive disorder (MDD) and depressive symptoms are prevalent in patients with cancer,^1,2 with significant differences in prevalence by site.³ Variable and relatively high rates (up to 48%, depending on the criteria used in assessments) are found among women with breast or gynecologic cancer,^4-7 with some evidence that depression can worsen over the course of cancer treatment and persist long after cancer therapy.⁸ However, the majority of the patients in these studies have been non-Hispanic white and middle- to upper-income women. Less is known about the prevalence of depression among low-income, ethnic minority women with cancer.

Correlates of depression among cancer patients include pain, anxiety, poorer functional status, fatigue, quality of life, and survival.^9-15 Low-income, ethnic minority patients with cancer also encounter economic and other barriers to cancer care,^16-19 and an association between economic stress and depressive symptoms has been found for cancer²⁰ and noncancer patients.²¹

Oncologists and nurses are found to correctly detect mild to moderate depressive symptoms in only one third of patients with depressive symptoms, to underestimate the level of depressive symptoms among patients who are more severely depressed, and to be most influenced by overt symptoms.^22-25 Furthermore, studies find that the majority of depressed patients with cancer who meet diagnostic criteria have not been prescribed antidepressants or are not receiving adequate dosage.^26-28 There is also evidence that low-income patients with cancer are less likely to receive mental health services,²⁹ which is evidence that is consistent with numerous primary care studies in which low-income, underinsured, and ethnic minority primary care patients are found to have relatively high rates of depression but are less likely to receive care for depression or to be prescribed antidepressants.^30-36

Using baseline data from an ongoing randomized trial of a structured case management intervention to improve adherence to cancer treatment and reduce potential barriers to treatment, of which depression is one probable barrier, we describe the following: (1) the prevalence of depressive disorders, based on results of a valid and reliable diagnostic screen, among low-income, ethnic minority women with breast or gynecologic cancer; (2) correlates of depression, such as pain, anxiety, perceived social support, functional status, and potential barriers to cancer care; and (3) patients' self-reported receipt of antidepressant medications or supportive counseling.

	PATIENTS AND METHODS

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Participants
Data on 472 women were drawn from the baseline survey of the National Cancer Institute–funded study Improving Patient Access and Adherence to Cancer Treatment (IMPAACT), which is an ongoing randomized trial of a structured case management intervention to improve adherence to cancer treatment among 500 women with breast or gynecologic cancer. Patients were approached for study participation in outpatient oncology clinics at a large urban public sector medical center. Participants were enrolled onto the study if they were 18 years or older, had a primary diagnosis of breast (stage 0 to III) or gynecologic cancer (International Federation of Gynecology and Obstetrics stage 0 to IVB), and were undergoing active treatment or in active follow-up. Patients were excluded if they were receiving only palliative care or were cognitively impaired to the extent of being unable to participate. Of 621 potentially eligible IMPAACT patients, 500 women (80.5%) were enrolled onto the clinical trial. There were no statistically significant differences between enrolled and nonenrolled patients by age, ethnicity, or cancer stage. Of the 500 women who were enrolled, 250 (50%) were diagnosed with breast cancer, and 250 (50%) were diagnosed with a gynecologic cancer. Of the 250 gynecologic cancer patients, 28 women diagnosed with International Federation of Gynecology and Obstetrics stage IV cancer were excluded from this report to reduce sample stage differences between the two cancer sites. Of the 222 gynecologic patients, 120 women (54%) had cervical cancer, 53 (24%) had uterine cancer, 42 (19%) had ovarian cancer, and seven (3%) had other gynecologic cancer.

Procedures
Informed written consent was obtained for all study patients using a consent form approved by the University of Southern California–Health Sciences Institutional Review Board. Baseline interviews were conducted in person or via telephone in either Spanish or English based on patient preference by trained bilingual interviewers. For patients who were not comfortable in speaking English or Spanish, an in-person interview was conducted with the help of translation by a family member or friend.

Measures
Depression status. The Patient Health Questionnaire (PHQ) -9, a diagnostic screen, was administered in person or via telephone by trained study recruiters. The PHQ-9 is a subset of questions from the PHQ, a self-report version of the PRIME-MD (Primary Care Evaluation of Mental Disorders, Pfizer Inc, New York, NY).³³ The PHQ-9 assesses for the presence of depressive disorder^37-39 using modified Diagnostic and Statistical Manual, Fourth Edition,⁴⁰ criteria⁴¹ that is reflected in a threshold score. For MDD, the threshold score for the PHQ-9 is 10 or greater. Among patients with major depression, a PHQ-9 score of 10 to 14 indicates moderate depression, and a score of 15 to 27 indicates severe depression. The instrument is valid and reliable,⁴² accurately diagnoses major depression,^37-39,43 can be administered in person or via telephone,⁴⁴ and has been used with cancer patients.⁴⁵ The Spanish version of the PHQ-9 was used for monolingual patients. Two additional questions from the PRIME-MD were used to assess dysthymia.⁴¹ Anxiety was assessed using a six-item anxiety module from the Brief Symptom Inventory (BSI),⁴⁶ which was found to be a reliable measure among monolingual-speaking Hispanics.⁴⁷ A BSI score of 14 to 24 indicated clinically significant anxiety.

Demographic and clinical variables. Age, marital status, education, birthplace, primary language, employment, and health insurance status were assessed. Data on personal or household income was not collected given that the study site population is consistent with national and state poverty guidelines. Cancer site, stage, and oncology treatment status at study enrollment were abstracted from medical records. Among women reporting pain, further assessment was made using the Brief Pain Inventory (BPI) Short Form.^48,49 A clinically significant cutoff score of 7 or greater indicates severe pain. The reliability and validity of the BPI have been examined for the Spanish version, and it has been used with similar patients at the reported study site.⁵⁰ The alpha reliability coefficient in this study was .84.

Functional status. Functional status was assessed by self-report at baseline using the Karnofsky performance status scale, which is an 11-point rating scale that ranges from normal functioning (100) to death (0).⁵¹ The Functional Assessment of Cancer Therapy Scale–General,⁵² a valid and reliable 27-item health-related quality-of-life questionnaire, assessed physical, functional, social and family, and emotional well-being. The Spanish version (Functional Assessment of Cancer Therapy Scale–Spanish)⁵³ was used with monolingual patients. The alpha reliability coefficients for the subscales in this study were .85 for physical well-being, .81 for functional well-being, .79 for social and family well-being, and .78 for emotional well-being. Mean subscale scores are presented, and cut points of each subscale based on a median score were created for analytic purposes. The presence of six comorbid health conditions (ie, hypertension, heart disease, diabetes, stroke, arthritis, and kidney disease) was obtained from patient self-report.

Treatment adherence and perceived barriers to cancer care. Patients were asked a series of questions about the following: completion of treatment to date; number of missed appointments; the reason for missed appointments; whether they were currently taking medication for depression, anxiety, or pain; and whether they had missed taking prescribed medications along with a reason for failure. After a lead statement ("There are different reasons that women may have for not being able to keep scheduled appointments or to follow treatment recommendations. I'm going to name some of these and I'd like you to tell me if any of these problems may be true for you."), a battery of 18 perceived barriers to cancer care were presented. Patients were allowed to choose multiple barriers that included lack of comprehension about treatment recommendations, worries about treatment side effects, economic concerns about cost of care or lost wages, and problems related to personal and family issues or comorbid illness.

Analysis Plan
Descriptive statistics were conducted to present the overall characteristics of the study sample. ² tests were used for categoric variables, and t tests were used for continuous variables to assess associations between demographic, clinical, and functional characteristics and the dependent variable, depression. Odds ratios and CIs were calculated for each variable found to be statistically significant (P .05). CIs that do not contain 1.0 are considered to indicate statistical significance. Each independent factor found to be statistically significant at the univariate level was considered for entry into the final logistic regression model. A good-fitting model would yield a high P value (P > .7) in the Hosmer and Lemeshow⁵⁴ goodness-of-fit ² test.⁵⁵

	RESULTS

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Demographic, Clinical, and Functional Status
Study participants had a mean age of 50.0 years (standard deviation, 11.8 years); were primarily Latina (79%), Spanish speaking (75%), foreign born (88%), and without a partner (59%); and had completed less than 9 years of education (56%). The majority of women (72%) reported receiving Medi-Cal or state and local government financed short-term, episodic assistance in paying for specific types of care (eg, state cancer treatment funds). Of the 472 women, 213 (45%) were employed in the past 12 months; however, the baseline rate of unemployment was high (81%; Table 1).

View larger version (30K): [in this window] [in a new window]   Fig 1. Depression prevalence and receipt of care.

Self-reports of perceived barriers to cancer treatment were common among all women, with the majority (70%) reporting four or more barriers. The most commonly cited barriers were concerns about side effects (n = 318, 69%), treatment process (n = 292, 62%), and lack of understanding of what to expect when getting treatment (n = 177, 39%). Economic concerns were also frequent. Patients cited the inability to get all medications (n = 125, 30%), lost wages as a result of sick time (n = 127, 46% of 274 women who responded to questions regarding wage), and/or keeping medical appointments (n = 117, 43%). Personal and family problems were reported as interfering with keeping appointments (n = 132, 28%), as was medical comorbidity (n = 95, 20%). Women reported that they relied primarily on family and friends (52%) and public transportation (31%) to attend their medical appointments.

Correlates of Depression
Demographic, clinical, and functional characteristics. Age was significantly correlated with depression, with younger women (< 50 years old) more likely to report depression (P = .015). Ethnicity, education, marital status, birthplace, primary language, health insurance, and employment status were not correlated with depression. Cancer site (P = .001), report of pain (P < .001), suicidal ideation (P < .001), anxiety (P < .001), and arthritis (P = .006) were significantly correlated with depression. Depressed women were significantly more likely to report poorer physical and functional status and social and family and emotional well-being (P < .001; Table 3).

Receipt of Depression Care
Fourteen of the women (12%) with major depression and 11 of the women (16%) with dysthymia alone reported currently receiving medications for depression. Five additional women who did not meet criteria for major depression or dysthymia reported antidepressant medication use at baseline. Women who reported receiving antidepressants, compared with depressed women who did not receive antidepressants, were less likely to have major depression (47% v 87%, respectively) and pain symptoms (47% v 67%, respectively) and more likely to report anti-anxiety medication use (27% v 2%, respectively). Of the depressed women, four (4%) reported currently seeing a social worker or mental health counselor; two (2%) had participated in a cancer support group; 17 (15%) reported talking with a priest or religious counselor or participating in religious activities; and seven (6%) reported receiving emotional support from family or friends.

Logistic Regression Model
The logistic regression analysis was conducted using a backward stepwise selection (P < .05) with the following 12 main effects: cancer site, age, physical functioning (Karnofsky performance status scale), social and family well-being, anxiety, arthritis, pain, and the five barriers of difficulties understanding recommendations, fears about receiving treatment, fears about treatment side effects, inability to get all prescribed medication, and forgetting medical appointment. The final model consisted of seven main effects, which explained 40% of the variance in depression and resulted in a ² of 5.23 (P = .73), an indication of a good fit (Table 4).

	DISCUSSION

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Although this report does not address patient or provider explanations for receipt of care, it is likely that data reflect provider failure to routinely assess and treat depressive disorders that are common across oncology practices²⁸ as well as known barriers to receipt of depression care among low-income populations. In either case, study findings present evidence supporting the utility of routine depression screening^59-62 among low-income cancer patients. At the same time, active screening for depression within already burdened and under-resourced public care systems raises additional considerations, including the potential high prevalence of depression symptoms frequently found in low-income and medically underserved populations,^63-64 the needs and preferences of culturally diverse patients,^65-66 and lack of availability of low-cost depression care in the community.^26,67 Despite these considerations, screening can be effective for indigent patients.⁶⁸

Fortunately, there is also evidence that quality-improvement depression interventions are effective among low-income and ethnic minority primary care patients.^69-71 Ethnic minority patients' preference for receiving depression care within the general health sector⁶⁶ suggests a need to integrate depression care within the oncology care system. Nurses and social workers might be trained to provide depression care for cancer patients.^72-73 In a pilot randomized study of 55 depressed, low-income, Latina breast or cervical cancer patients in public sector oncology clinics, onsite depression care management by a medical social worker that included Problem-Solving Therapy (PST)⁷⁴ and medication follow-up and psychiatric consultation significantly reduced depression symptoms compared with usual care.⁷³

In addition, although the majority of depressed women reporting significant levels of pain were receiving pain medication, a significant number reported limited pain relief. This finding raises questions that are consistent with a previous study of ethnic minority cancer patients in which inadequate pain assessment by physicians (particularly among women), patient reluctance to report pain, and lack of staff time were perceived as barriers to optimal pain management for ethnic minority cancer patients.⁴⁴ Additional correlates of depression, such as economic worries, less satisfaction with support, and lack of cancer support participation, may be specific to low-income patients with cancer. Lack of participation in cancer support groups may result from both a lack of access and barriers to participation.⁷⁵ The identification of economic concerns, social support needs, and potential barriers to supportive cancer services suggest the need for supplementary case management services similar to those reported to be effective among impoverished primary care and cancer patients from ethnic minority groups.⁷⁰

Study limitations include the following: specific diagnostic evaluation of patients' depression was unavailable, the data does not provide conclusive evidence about the causal relationship between identified correlates and depression, and the findings are limited to low-income minority women with cancer receiving care in an urban, public sector setting. In addition, information obtained on functional status, pain, use of medications, social support resources, and barriers to cancer care relied on self-report, although patient self-report of antidepressant use is reasonably accurate.⁷⁶ However, the collection of longitudinal and medical record data on this cohort of women with cancer is underway. Results from the ongoing randomized intervention study will enable us to examine actual cancer treatment adherence and the effects of the intervention, which includes systems navigation and supportive case management as well as algorithm-guided depression care.

Despite limitations, we believe that the study contributes to the existing literature on depression among low-income, minority women with cancer and that, taken together, evidence encourages oncology care providers to consider ways to improve depression care practices and interventions designed for low-income patients. Use of a diagnostic depression screen for these women is likely to identify relatively high rates of clinically significant and undertreated depression. The screen might be used by cancer care providers to aid in targeting women who are likely to benefit from further evaluation, treatment with antidepressant medications, and/or efforts to link these women to mental health specialists and supportive psychosocial care providers within and outside of the oncology care system.

	Authors' Disclosures of Potential Conflicts of Interest

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The authors indicated no potential conflicts of interest.

	NOTES

 
Supported by National Cancer Institute (Bethesda, MD) grant No. R01 CA94827-01 (K.E.).

Authors' disclosures of potential conflicts of interest are found at the end of this article.

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Submitted August 5, 2004; accepted February 1, 2005.

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