Stepped care and depression

STEP-study

Stepped care to improve symptoms of anxiety and depression in cancer patients

In the Netherlands over 10.000 patients are diagnosed with lung cancer (LC) or head and neck cancer (HNC) every year of whom 25-50% has comorbid anxiety or depression after treatment. Although there is evidence on efficacy of psychosocial cancer care in general, patients with poor survival rates (LC) or less prevalent tumours (HNC) are often not involved, while these patients are among the most distressed patients. Barriers to admission to psychosocial care are a lack of adequate screening instruments in oncology settings, and that traditional models of the delivery of psychosocial care do not meet current demand. A stepped care approach including a web-based self-help intervention has the potential to improve the efficiency of psychosocial care. Stepped care is a psychosocial program consisting of 4 evidence based steps: 1. Watchful waiting, 2. Internet-based self-help, 3. Problem Solving Therapy applied by a nurse, and 4. Specialised psychological interventions and/or antidepressant medication.

The main goal of this project is to assess (cost-)effectiveness of a stepped care strategy applied in an oncological setting compared to care as usual in patients treated for LC or HNC to improve symptoms of anxiety or depression. In total, 156 patients were randomly assigned to stepped care or care as usual.

This stepped care (SC) program was found to be effective in improving distress levels of patients with head and neck cancer or lung cancer.

Intervention costs, direct medical costs, direct nonmedical costs, productivity losses, and health-related quality-of-life data during the intervention or control period and 12 months of follow-up were calculated by using Trimbos and Institute of Medical Technology Assessment Cost Questionnaire for Psychiatry, Productivity and Disease Questionnaire, and EuroQol-5 Dimension measures and data from the hospital information system. The SC program’s value for the cost was investigated by comparing mean cumulative costs and quality-adjusted life years (QALYs). Results After imputation of missing data, mean cumulative costs were -€3,950 (95% CI, -€8,158 to -€190) lower, and mean number of QALYs was 0.116 (95% CI, 0.005 to 0.227) higher in the intervention group compared with the control group. The intervention group had a probability of 96% that cumulative QALYs were higher and cumulative costs were lower than in the control group. Four additional analyses were conducted to assess the robustness of this finding, and they found that the intervention group had a probability of 84% to 98% that cumulative QALYs were higher and a probability of 91% to 99% that costs were lower than in the control group. Conclusion SC is highly likely to be cost-effective; the number of QALYs was higher and cumulative costs were lower for SC compared with CAU.

Funding
ZonMw and Fonds NutsOhra

Publications

  • Jansen F, Lissenberg-Witte BI, Krebber AMH, Cuijpers P, de Bree R, Becker-Commissaris A, Smit EF, van Straten A, Eeckhout GM, Beekman ATF, Leemans CR, Verdonck-de Leeuw IM. Stepped care targeting psychological distress in head and neck cancer and lung cancer patients: which groups specifically benefit? Secondary analyses of a randomized controlled trial. Support Care Cancer. 2019 Mar 27.
  • Jansen F, Krebber AMH, Coupé VHM, Cuijpers P, de Bree R, Becker-Commissaris A, Smit EF, van Straten A, Eeckhout GM, Beekman ATF, Leemans CR, Verdonck-de Leeuw IM. Cost-utility of stepped care targeting psychological distress in head and neck cancer and lung cancer patients. J Clin Oncol. 2017;35(3):314-324.
  • Krebber AH, van Uden-Kraan CF, Melissant HC, Cuijpers P, van Straten A, Becker-Commissaris A, Leemans CR, Verdonck-de Leeuw IM. A guided self-help intervention targeting psychological distress among head and neck cancer and lung cancer patients: motivation to start, experiences and perceived outcomes. Support Care Cancer. 2017;25(1):127-135.
  • Jansen F, van Zwieten V, Coupé VM, Leemans CR, Verdonck-de Leeuw IM. A Review on Cost-Effectiveness and Cost-Utility of Psychosocial Care in Cancer Patients.Asia Pac J Oncol Nurs. 2016;3(2):125-136.
  • Krebber AM, Jansen F, Witte BI, Cuijpers P, de Bree R, Becker-Commissaris A, Smit EF, van Straten A, Eeckhout AM, Beekman AT, Leemans CR, Verdonck-de Leeuw IM. Stepped care targeting psychological distress in head and neck cancer and lung cancer patients: a randomized, controlled trial. Ann Oncol. 2016;27(9):1754-60.

Questions?
For questions, please contact prof dr IM Verdonck-de Leeuw via s.biemans@amsterdamumc.nl