Depressive disorders and symptoms are common in cancer patients (up to 38% having major depression) [1
], worsen over the course of cancer treatment, persist long after cancer therapy [4
], reoccur with the recurrence of cancer [5
], and significantly impact quality of life [6
]. Unfortunately, clinicians and patients often perceive depression as an expected and reasonable reaction to cancer, thus depression is frequently under-recognized and under-treated in oncology practice [10
]. Low-income patients are particularly unlikely to receive mental health treatment [17
Patient, provider, and health system barriers to care contribute to the failure to effectively manage depression symptoms. Patients may be reluctant to report symptoms or to see a mental health professional and if prescribed treatment may not adhere to prescribed treatment, citing concerns about side-effects and/or preoccupation with active cancer treatment. Providers may be reluctant to raise the issue, and be less aware of effective treatments, while organizational barriers reduce timely and integrated access to mental health professionals. Culturally based preferences for depression care can become a barrier to care if the preferred mode of care is not available [19
], while culturally based explanations for depression symptoms may influence symptom expression and patient-provider communication [20
]. Perceived stigma, family perceptions, and practical barriers such as cost and transportation to therapy may also impede receipt of care among low-income populations [24
Depression care quality improvement strategies are effective in reducing barriers to depression care - including among racial/ethnic minorities [26
]. Organizational strategies [27
] generally include multifaceted quality improvement disease management interventions that change the way depression care is delivered, such as the implementation of routine depression screening, systematic application of evidence-based practice guidelines, clinical decision-making protocols and algorithms (cancer specific available on the NCI and NCCN websites), 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, where expertise in psychopharmacology in treating depression is provided by a psychiatrist and psychotherapy and supportive care management is provided by depression specialist nurses or social workers, have been found to be effective in primary care [28
]. An adapted model for oncology was found to be effective in a randomized pilot study of 55 low-income, predominantly Latina breast or cervical cancer patients who met criteria for major depression [29
] suggesting that cancer patients in public sector oncology clinics can benefit from depression treatment. What was learned from this preliminary study led to further adaptations for low-income minority patients and the public sector that serves them. We present here the design of the Alleviating Depression Among Patients with Cancer (ADAPt-C) randomized clinical trial, sociocultural adaptations in the care management model and the baseline characteristics of the sample.