Research That Matters (January 17 - 20, 2008)

PURPOSE: The 2002 NIH State-of-the-Science Panel on Symptom Management in Cancer identified depression as one of the most common comorbid symptoms of cancer. An alarming 58% of cancer patients have depressive symptoms and up to 38% have major depression. Cancer patients reveal that they occasionally have persistent thoughts of suicide as a means of escaping the threat of being overwhelmed by cancer. Psychotherapeutic interventions, combined with antidepressant treatment have favorable effects on depressive symptoms, immune response, treatment adherence, and quality of life, which becomes especially important as disease advances and as cancer treatments become more aggressive. Despite the importance of treatment, depression often remains undetected and untreated in cancer patients due to treatment non-adherence and dropout, especially in low-income, minority populations. The aim of this review is to critically and systematically review the literature to identify correlates of non-adherence and dropout among low-income, minority depressed cancer patients. METHOD: A systematic literature review of empirical studies, unlimited by year, involved a search for relevant articles in electronic databases: MEDLINE, CINAHL, PsycINFO, and PROQUEST, using search terms: depression, mental health, psychosocial, psychotherapy, antidepressant, cancer, attrition, retention, dropout, adherence, compliance, intervention. Reference lists of eligible articles were examined to identify additional articles. Exclusion criteria included articles: not from peer-reviewed journals; not involving adults, and studies involving homeless, substance abusers or health behavioral interventions. FINDINGS: This systematic literature review reveals predominantly descriptive, empirically-based correlates of dropout: younger age, male, unmarried, lower education, being minority, unemployed, low social support, increased practical barriers, caregiving demands, childcare responsibilities, transportation problems, time constraints, knowledge, attitudes, belief s about medication and counseling, low SES, medication costs, medical-related problems, poorer self-rated health, anti-depressant side effects, being in cancer treatment, patient-provider conflict, lack of satisfaction, and low motivation contributing to non-adherence and dropout. Additionally, two patterns of knowledge gaps emerge: 1) Paucity of depression treatment dropout studies in low-income, minority populations, with most study populations including primarily Whites, older adults, and other illness (e.g., HIV, hypertension, diabetes) in a non-public care system. Studies fail to describe ethnic composition of the sample, completely omit discussion of ethnic minority sample description, combine different minority groups together, or provide little explanation of reasons for dropout; and 2) Most related studies have been mostly atheoretical in nature and lack guiding explanatory theoretical models, essential to understanding and subsequently intervening with non-adherence and dropout. IMPLICATIONS: This review has implications for social work research, practice, and policy initiatives with underserved populations with comorbid illness. This review clearly justifies the need for: 1) further dropout research (explanatory theoretical models, exploratory and confirmatory analysis, and qualitative studies); 2) customized interventions and feasible provider strategies for oncology practice and depression treatment to reduce non-adherence and dropout among such populations; and 3) policy recommendations for more funding earmarked towards hospital patient navigation services and the expansion of benefits to include depression treatment coverage for all uninsured and underinsured cancer patients in treatment, similar to California's Breast Cancer Treatment Fund.