Effect of Telecare Management on Pain and Depression in Patients With Cancer: A Randomized Trial | Depressive Disorders | JAMA | JAMA Network
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Carr D, Goudas L, Lawrence D,  et al.  Management of Cancer Symptoms: Pain, Depression, and Fatigue. Rockville, MD: Agency for Healthcare Research and Quality; 2002. Evidence Report/Technology Assessment 61. AHRQ publication 02-E032
Bottomley A. Depression in cancer patients: a literature review.  Eur J Cancer Care (Engl). 1998;7(3):181-1919793010PubMedGoogle ScholarCrossref
Caraceni A, Portenoy RK.International Association for the Study of Pain.  An international survey of cancer pain characteristics and syndromes.  Pain. 1999;82(3):263-27410488677PubMedGoogle ScholarCrossref
Portenoy RK, Lesage P. Management of cancer pain.  Lancet. 1999;353(9165):1695-170010335806PubMedGoogle ScholarCrossref
Given CW, Given B, Azzouz F, Kozachik S, Stommel M. Predictors of pain and fatigue in the year following diagnosis among elderly cancer patients.  J Pain Symptom Manage. 2001;21(6):456-46611397603PubMedGoogle ScholarCrossref
Given CW, Given BA, Stommel M. The impact of age, treatment, and symptoms on the physical and mental health of cancer patients: a longitudinal perspective.  Cancer. 1994;74(7):(suppl)  2128-21388087780PubMedGoogle ScholarCrossref
Kurtz ME, Kurtz JC, Stommel M, Given CW, Given B. Predictors of depressive symptomatology of geriatric patients with colorectal cancer: a longitudinal view.  Support Care Cancer. 2002;10(6):494-50112353129PubMedGoogle ScholarCrossref
Kurtz ME, Kurtz JC, Stommel M, Given CW, Given B. Physical functioning and depression among older persons with cancer.  Cancer Pract. 2001;9(1):11-1811879268PubMedGoogle ScholarCrossref
Kurtz ME, Kurtz JC, Stommel M, Given CW, Given B. The influence of symptoms, age, comorbidity and cancer site on physical functioning and mental health of geriatric women patients.  Women Health. 1999;29(3):1-1210466507PubMedGoogle ScholarCrossref
Stommel M, Given BA, Given CW. Depression and functional status as predictors of death among cancer patients.  Cancer. 2002;94(10):2719-272712173342PubMedGoogle ScholarCrossref
Fallowfield L, Ratcliffe D, Jenkins V, Saul J. Psychiatric morbidity and its recognition by doctors in patients with cancer.  Br J Cancer. 2001;84(8):1011-101511308246PubMedGoogle ScholarCrossref
Passik SD, Dugan W, McDonald MV, Rosenfeld B, Theobald DE, Edgerton S. Oncologists' recognition of depression in their patients with cancer.  J Clin Oncol. 1998;16(4):1594-16009552071PubMedGoogle Scholar
Sharpe M, Strong V, Allen K,  et al.  Major depression in outpatients attending a regional cancer centre: screening and unmet treatment needs.  Br J Cancer. 2004;90(2):314-32014735170PubMedGoogle ScholarCrossref
Cleeland CS, Gonin R, Hatfield AK,  et al.  Pain and its treatment in outpatients with metastatic cancer.  N Engl J Med. 1994;330(9):592-5967508092PubMedGoogle ScholarCrossref
Cleeland CS. Undertreatment of cancer pain in elderly patients.  JAMA. 1998;279(23):1914-19159634265PubMedGoogle ScholarCrossref
Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes.  Arch Intern Med. 2006;166(21):2314-232117130383PubMedGoogle ScholarCrossref
Williams JW Jr, Gerrity M, Holsinger T, Dobscha S, Gaynes B, Dietrich A. Systematic review of multifaceted interventions to improve depression care.  Gen Hosp Psychiatry. 2007;29(2):91-11617336659PubMedGoogle ScholarCrossref
Williams LS, Kroenke K, Bakas T,  et al.  Care management of post-stroke depression: a randomized controlled trial.  Stroke. 2007;38(3):998-100317303771PubMedGoogle ScholarCrossref
Rollman BL, Belnap BH, LeMenager MS,  et al.  Telephone-delivered collaborative care for treating post-CABG depression: a randomized controlled trial.  JAMA. 2009;302(19):2095-210319918088PubMedGoogle ScholarCrossref
Dobscha SK, Corson K, Perrin NA,  et al.  Collaborative care for chronic pain in primary care: a clustered randomized trial.  JAMA. 2009;301(12):1242-125219318652PubMedGoogle ScholarCrossref
Kroenke K, Bair MJ, Damush TM,  et al.  Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial.  JAMA. 2009;301(20):2099-211019470987PubMedGoogle ScholarCrossref
Kroenke K, Theobald D, Norton K,  et al.  Indiana Cancer Pain and Depression (INCPAD) trial: design of a telecare management intervention for cancer-related symptoms and baseline characteristics of enrolled participants.  Gen Hosp Psychiatry. 2009;31(3):240-25319410103PubMedGoogle ScholarCrossref
Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: Validity of a brief depression severity measure.  J Gen Intern Med. 2001;16(9):606-61311556941PubMedGoogle ScholarCrossref
Kroenke K, Spitzer RL. The PHQ-9: a new depression and diagnostic severity measure.  Psychiatr Ann. 2002;32:509-521Google Scholar
Cleeland CS. Pain assessment in cancer. In: Osoba D, ed. Effect of Cancer on Quality of Life. Boca Raton, FL: CRC Press; 1991:293-305
Williams LS, Jones WJ, Shen J, Robinson RL, Kroenke K. Outcomes of newly referred neurology outpatients with depression and pain.  Neurology. 2004;63(4):674-67715326241PubMedGoogle ScholarCrossref
Callahan CM, Unverzagt FW, Hui SL, Perkins AJ, Hendrie HC. A six-item screener to identify cognitive impairment among potential subjects for clinical research.  Med Care. 2002;40(9):771-78112218768PubMedGoogle ScholarCrossref
Unützer J, Katon W, Callahan CM,  et al;  IMPACT Investigators.  Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial.  JAMA. 2002;288(22):2836-284512472325PubMedGoogle ScholarCrossref
Kroenke K, West SL, Swindle R,  et al.  Similar effectiveness of paroxetine, fluoxetine, and sertraline in primary care: a randomized trial.  JAMA. 2001;286(23):2947-295511743835PubMedGoogle ScholarCrossref
Katon W, Von Korff M, Lin E,  et al.  Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial.  Arch Gen Psychiatry. 1999;56(12):1109-111510591288PubMedGoogle ScholarCrossref
Cleeland CS. Measurement of pain by subjective report. In: Chapman CR, Loeser JD, eds. Advances in Pain Research and Therapy. vol 12 Issues in Pain Measurement. New York, NY: Raven Press; 1989:391-403
Cuijpers P, Smits N, Donker T, ten Have M, de Graaf R. Screening for mood and anxiety disorders with the five-item, the three-item, and the two-item Mental Health Inventory.  Psychiatry Res. 2009;168(3):250-25519185354PubMedGoogle ScholarCrossref
McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36), II: psychometric and clinical tests of validity in measuring physical and mental health constructs.  Med Care. 1993;31(3):247-2638450681PubMedGoogle ScholarCrossref
Kroenke K, Bair M, Damush T,  et al.  Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study design and practical implications of an intervention for comorbid pain and depression.  Gen Hosp Psychiatry. 2007;29(6):506-51718022044PubMedGoogle ScholarCrossref
Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity.  Med Care. 1996;34(3):220-2338628042PubMedGoogle ScholarCrossref
Unützer J, Katon W, Williams JW Jr,  et al.  Improving primary care for depression in late life: the design of a multicenter randomized trial.  Med Care. 2001;39(8):785-79911468498PubMedGoogle ScholarCrossref
Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7.  Arch Intern Med. 2006;166(10):1092-109716717171PubMedGoogle ScholarCrossref
Kroenke K, Spitzer RL, Williams JBW, Monahan PO, Lowe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection.  Ann Intern Med. 2007;146(5):317-32517339617PubMedGoogle ScholarCrossref
Sheehan DV, Harnett-Sheehan K, Raj BA. The measurement of disability.  Int Clin Psychopharmacol. 1996;11:(suppl 3)  89-958923116PubMedGoogle ScholarCrossref
Wagner EH, LaCroix AZ, Grothaus LC, Hecht JA. Responsiveness of health status measures to change among older adults.  J Am Geriatr Soc. 1993;41(3):241-2488440846PubMedGoogle Scholar
Rost K, Nutting P, Smith J, Werner J, Duan N. Improving depression outcomes in community primary care practice: a randomized trial of the quEST intervention.  J Gen Intern Med. 2001;16(3):143-14911318908PubMedGoogle ScholarCrossref
Cintron A, Morrison RS. Pain and ethnicity in the United States: a systematic review.  J Palliat Med. 2006;9(6):1454-147317187552PubMedGoogle ScholarCrossref
Lesser IM, Castro DB, Gaynes BN,  et al.  Ethnicity/race and outcome in the treatment of depression: results from STAR*D.  Med Care. 2007;45(11):1043-105118049344PubMedGoogle ScholarCrossref
Rush AJ, Trivedi MH, Wisniewski SR,  et al.  Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report.  Am J Psychiatry. 2006;163(11):1905-191717074942PubMedGoogle ScholarCrossref
 Cancer Pain Version 1.2004. NCCN Practice Guidelines in Oncology - v.1.2004. 2004
Bookbinder M, Coyle N, Kiss M,  et al.  Implementing national standards for cancer pain management: program model and evaluation.  J Pain Symptom Manage. 1996;12(6):334-347, discussion 331-3338973043PubMedGoogle ScholarCrossref
Keller MB. Report of the WHO Expert Committee on Cancer Pain Relief and Active Supportive Care. 2nd ed. Geneva, Switzerland: World Health Organization; 1996. Technical report series 804
 Cancer Pain and End-of-Life Care. Chicago, IL: American Medical Association; 2004. Pain Management; part 4
Keller MB. Past, present, and future directions for defining optimal treatment outcome in depression: remission and beyond.  JAMA. 2003;289(23):3152-316012813121PubMedGoogle ScholarCrossref
Dworkin RH, Turk DC, Wyrwich KW,  et al.  Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations.  J Pain. 2008;9(2):105-12118055266PubMedGoogle ScholarCrossref
Mallinckrodt CH, Clark WS, David SR. Type I error rates from mixed effects model repeated measures versus fixed effects ANOVA with missing values imputed via last observation carried forward.  Drug Inf J. 2001;35:1215-1225Google ScholarCrossref
Kazis LE, Anderson JJ, Meenan RF. Effect sizes for interpreting changes in health status.  Med Care. 1989;27(3):(suppl)  S178-S1892646488PubMedGoogle ScholarCrossref
Fann JR, Fan MY, Unützer J. Improving primary care for older adults with cancer and depression.  J Gen Intern Med. 2009;24:(suppl 2)  S417-S42419838842PubMedGoogle ScholarCrossref
Ell K, Xie B, Quon B, Quinn DI, Dwight-Johnson M, Lee PJ. Randomized controlled trial of collaborative care management of depression among low-income patients with cancer.  J Clin Oncol. 2008;26(27):4488-449618802161PubMedGoogle ScholarCrossref
Strong V, Waters R, Hibberd C,  et al.  Management of depression for people with cancer (SMaRT oncology 1): a randomised trial.  Lancet. 2008;372(9632):40-4818603157PubMedGoogle ScholarCrossref
Simon GE, Ludman EJ, Tutty S, Operskalski B, Von Korff M. Telephone psychotherapy and telephone care management for primary care patients starting antidepressant treatment: a randomized controlled trial.  JAMA. 2004;292(8):935-94215328325PubMedGoogle ScholarCrossref
Given C, Given B, Rahbar M,  et al.  Effect of a cognitive behavioral intervention on reducing symptom severity during chemotherapy.  J Clin Oncol. 2004;22(3):507-51614752074PubMedGoogle ScholarCrossref
Sherwood P, Given BA, Given CW,  et al.  A cognitive behavioral intervention for symptom management in patients with advanced cancer.  Oncol Nurs Forum. 2005;32(6):1190-119816270114PubMedGoogle ScholarCrossref
Sikorskii A, Given CW, Given B,  et al.  Symptom management for cancer patients: a trial comparing two multimodal interventions.  J Pain Symptom Manage. 2007;34(3):253-26417618080PubMedGoogle ScholarCrossref
Coleman K, Mattke S, Perrault PJ, Wagner EH. Untangling practice redesign from disease management: how do we best care for the chronically ill?  Annu Rev Public Health. 2009;30:385-40818925872PubMedGoogle ScholarCrossref
Original Contribution
July 14, 2010

Effect of Telecare Management on Pain and Depression in Patients With Cancer: A Randomized Trial

Author Affiliations

Author Affiliations: Center for Implementing Evidence-Based Practice, Richard Roudebush VA Medical Center, Indianapolis (Dr Kroenke); Department of Medicine (Drs Kroenke and Tu and Mr Wu) and School of Nursing (Dr Carpenter), Indiana University, Indianapolis; Regenstrief Institute Inc, Indianapolis (Drs Kroenke, Morris, and Tu and Ms Norton); Community Cancer Care, Indianapolis (Dr Theobald); and Community Health Network, Indianapolis (Dr Theobald).

JAMA. 2010;304(2):163-171. doi:10.1001/jama.2010.944

Context Pain and depression are 2 of the most prevalent and treatable cancer-related symptoms, yet they frequently go unrecognized, undertreated, or both.

Objective To determine whether centralized telephone-based care management coupled with automated symptom monitoring can improve depression and pain in patients with cancer.

Design, Setting, and Patients Randomized controlled trial conducted in 16 community-based urban and rural oncology practices involved in the Indiana Cancer Pain and Depression (INCPAD) trial. Recruitment occurred from March 2006 through August 2008 and follow-up concluded in August 2009. The participating patients had depression (Patient Health Questionnaire-9 score ≥10), cancer-related pain (Brief Pain Inventory [BPI] worst pain score ≥6), or both.

Intervention The 202 patients randomly assigned to receive the intervention and 203 to receive usual care were stratified by symptom type. Patients in the intervention group received centralized telecare management by a nurse-physician specialist team coupled with automated home-based symptom monitoring by interactive voice recording or Internet.

Main Outcome Measures Blinded assessment at baseline and at months 1, 3, 6, and 12 for depression (20-item Hopkins Symptom Checklist [HSCL-20]) and pain (BPI) severity.

Results Of the 405 participants enrolled in the study, 131 had depression only, 96 had pain only, and 178 had both depression and pain. Of the 274 patients with pain, 137 patients in the intervention group had greater improvements in BPI pain severity over the 12 months of the trial whether measured as a continuous severity score or as a categorical pain responder (≥30% decrease in BPI) than the 137 patients in the usual-care group (P < .001 for both). Similarly, of the 309 patients with depression, the 154 patients in the intervention group had greater improvements in HSCL-20 depression severity over the 12 months of the trial whether measured as a continuous severity score or as a categorical depression responder (≥ 50% decrease in HSCL) than the 155 patients in the usual care group (P < .001 for both). The standardized effect size for between-group differences at 3 and 12 months was 0.67 (95% confidence interval [CI], 0.33-1.02) and 0.39 (95% CI, 0.01-0.77) for pain, and 0.42 (95% CI, 0.16-0.69) and 0.41 (95% CI, 0.08-0.72) for depression.

Conclusion Centralized telecare management coupled with automated symptom monitoring resulted in improved pain and depression outcomes in cancer patients receiving care in geographically dispersed urban and rural oncology practices.

Trial Registration clinicaltrials.gov Identifier: NCT00313573