Post on 22-Apr-2023
Vol. - No. - - 2014 Journal of Pain and Symptom Management 1
Review Article
How Are the Patient PopulationsCharacterized in Studies InvestigatingDepression in Advanced Cancer? ResultsFrom a Systematic Literature ReviewElene Janberidze, MD, Marianne Jensen Hjermstad, PhD,Dagny Faksv�ag Haugen, MD, PhD, Katrin Ruth Sigurdardottir, MD,Erik Torbjørn Løhre, MD, Hanne Cathrine Lie, PhD, Jon H�avard Loge, MD, PhD,Stein Kaasa, MD, PhD, and Anne Kari Knudsen, MD, PhD, on behalf of EUROIMPACTEuropean Palliative Care Research Centre (PRC) (E.J., M.J.H., D.F.H., K.R.S., E.T.L., S.K.,
A.K.K.), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian
University of Science and Technology (NTNU), Trondheim; Department of Oncology (E.J., E.T.L.,
S.K., A.K.K.), St. Olavs Hospital, Trondheim University Hospital, Trondheim; Regional Centre for
Excellence in Palliative Care (M.J.H.), South Eastern Norway, Oslo University Hospital, Oslo;
Regional Centre of Excellence for Palliative Care (D.F.H., K.R.S.), Western Norway, Haukeland
University Hospital, Bergen; Sunniva Centre for Palliative Care (K.R.S.), Haraldsplass Deaconess
Hospital, Bergen; Department of Behavioural Sciences in Medicine (H.C.L., J.H.L.), Institute of Basic
Medical Science, Faculty of Medicine, University of Oslo; and National Resource Centre for Late Effects
after Cancer Treatment (J.H.L.), Oslo University Hospital, Oslo, Norway
Abstract
Context. Prevalence rates of depression in patients with advanced cancer varyconsiderably. This may be because of heterogeneous samples and use of differentassessment methods. Adequate sample descriptions and consistent use ofmeasures are needed to be able to generalize research findings and apply them toclinical practice.
Objectives. Our objective was twofold: First, to investigate which clinicallyimportant variables were used to describe the samples in studies of depression inpatients with advanced cancer. Second, to examine the methods used for assessingand classifying depression in these studies.
Methods. PubMed, PsycINFO, Embase, and CINAHL were searched combiningsearch term groups representing ‘‘depression,’’ ‘‘palliative care,’’ and ‘‘advancedcancer’’ covering 2007e2011. Titles and abstracts were screened, and relevant full-text articles were evaluated independently by two authors. Information on 32predefined variables on cancer disease, treatment, sociodemographics,
Address correspondence to: Elene Janberidze, MD, Euro-pean Palliative Care Research Centre (PRC), Depart-ment of Cancer Research and Molecular Medicine,Faculty ofMedicine, NorwegianUniversity of Scienceand Technology (NTNU), Kunnskapssenteret 4.etg.,
St. Olavs Hospital, N-7006 Trondheim, Norway.E-mail: elene.janberidze@ntnu.no
Accepted for publication: December 12, 2013.
� 2014 U.S. Cancer Pain Relief Committee.Published by Elsevier Inc. All rights reserved.
0885-3924/$ - see front matterhttp://dx.doi.org/10.1016/j.jpainsymman.2013.11.013
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depression-related factors, and assessment methods was extracted from thearticles.
Results. After removing duplicates, 916 citations were screened of which 59articles were retained. Age, gender, and stage of the cancer disease were the mostfrequently reported variables. Depression-related variables were rarely reported,for example, antidepressant use (17%) and previous depressive episodes (12%).Only 25% of the studies assessed and classified depression according to a validateddiagnostic system.
Conclusion. Current practice for describing sample characteristics and assessingdepression varies greatly between studies. A more standardized practice isrecommended to enhance the generalizability and utility of findings.Stakeholders are encouraged to work toward a common standard for sampledescriptions. J Pain Symptom Manage 2014;-:-e-. � 2014 U.S. Cancer Pain ReliefCommittee. Published by Elsevier Inc. All rights reserved.
Key Words
Advanced cancer, palliative care, depression, generalizability, assessmentIntroductionDepression is probably the most studied psy-
chiatric disorder in advanced cancer patients,1
with reported prevalence rates ranging from3% to 58%.2,3 The great variability in preva-lence rate estimates reflects in part the hetero-geneity of the populations studied and in partthe lack of agreed-on standards for definingand assessing depression in this patient group.Thus, clear descriptions of the study sampleand of the assessment methods are necessaryto judge the generalizability of study findingsand their relevance for clinical practice.4
Common symptoms of advanced cancer dis-ease, such as fatigue, lack of appetite, and sleepproblems, are also used as diagnostic criteria fordepression (e.g., Diagnostic and Statistical ManualofMental Disorders, FifthEdition [DSM-V]; Interna-tional Statistical Classification of Diseases and RelatedHealth Problems, Tenth Revision [ICD-10]).5,6 De-pending on which symptoms are included inthe different depression assessment methods,the extent of the cancer disease may to varyingdegrees inflate the number of false-positivedepression cases and consequently threaten thevalidity of the depression assessment and influ-enceprevalencerateestimates.7e12Furthermore,a systematic literature review published in 2009,covering the period from 1966 to 2007, demon-strated that 106 different assessment tools fordepression were applied in studies in palliativecancer care and that a validateddiagnostic system
was used only in a minority of the studies.13 Ifthese diverse assessment practices still dominate,is not known. However, to reduce the problem ofthe great variation in sample descriptions anddepression assessment methods as presented inthe literature, theEuropeanUnion-fundedEuro-pean Palliative Care Research Collaborative(www.epcrc.org) worked toward developing astandardizedassessment andclassification systemfor common symptoms in palliative care cancerpatients.14 This work has been continued withinthe European Palliative Care Research Centre(www.ntnu.edu/prc), an international researchcollaborative with the overall aim to improvesymptom management and research quality inpalliative care.Adding to the problem of a valid assessment
of depression, is the heterogeneous nature ofadvanced cancer populations with regard toage, diagnosis, extent of the cancer disease, sur-vival, symptom burden, comorbidity, physicalfunctioning, and need for treatment andfollow-up.15e17 A precise characterization of thestudy sample is needed to be able to compare re-sults across studies and transfer researchfindingsto clinical practice.4,18,19 An international expertgroup recently emphasized poor and unsystem-atic reportingof sample characteristics in clinicalstudies in palliative care as an important barrierfor conducting high-quality research.20 Stan-dardized descriptions of patient samples havebeen advocated for clinical studies in general.
Vol. - No. - - 2014 3Patient Characterization in Depression Studies
The Consolidated Standards of Reporting TrialsStatement was developed 20 years ago and in-cludes a 25-item checklist and a participantflow diagram to guide the reporting from ran-domized controlled trials (RCTs), also includingspecifications onhow to describe the populationstudied.21 Similarly, the Strengthening the Re-porting of Observational Studies in Epidemi-ology statement recommends a checklist of 22items, including sample characteristics, for re-porting studies in epidemiology.22 For clinicalstudies in palliative care, Currow et al.19,23 haveproposed a similar checklist of core variables todescribe populations and service characteristics,also applicable for advanced cancer populationsbecause these terms overlap. The list includes in-formation related to five domains: ‘‘individualparticipant’s demographics,’’ ‘‘caregiver,’’ ‘‘ser-vice,’’ ‘‘health and social policy,’’ and ‘‘research.’’Demographics cover age, gender, socioeco-nomic status, ethnicity, life-limiting illness, per-formance status, and days from referral untildeath.23 However, despite these statements andinitiatives, a recent literature review investigatingthe description of palliative care cancer patientsamples included in RCTs concluded that veryfew demographic or disease-related variableswere consistently registered and reported.24
Previous research has identified several riskfactors for development of depression in can-cer patients:25 female gender,26 poor perfor-mance status,27 and certain cancer diagnosessuch as pancreatic,28 lung,29,30 and breast can-cer.31 Furthermore, a prior psychiatric history,previous depressive episodes, and alcoholdependence are known risk factors for devel-oping depression during the cancer diseasetrajectory.32,33 In addition to these risk factors,the duration of depressive symptoms, theirfunctional consequences, and ongoing treat-ment in terms of drugs and/or psychotherapyare relevant variables to include in a report ondepression in advanced cancer.32,34e36
To the best of our knowledge, no studieshave systematically examined the extent of re-porting relevant sample characteristics instudies on depression in advanced cancer.Thus, the overall aim of the present study isto identify candidate variables to includewhen reporting clinical studies of depressionin advanced cancer patients as well as informa-tion on how depression is assessed and classi-fied. The following research questions were
addressed in the present systematic literaturereview:
� How were patient samples described in re-ports on clinical studies of depression inadvanced cancer?
� How was depression assessed and classi-fied in these studies?
MethodsThe databases PubMed, CINAHL (through
EBSCOhost), PsycINFO, and Embase (throughOvidSP) were searched for relevant studies.The search strings were designed for each data-base using both free text and controlled vocabu-lary (e.g., MeSH, CINAHL Headings, APAThesaurus, EMtree) and consisted of combina-tions of terms representing ‘‘depression,’’ ‘‘palli-ative care,’’ and ‘‘advanced cancer’’ (Appendix I;available at jpsmjournal.com). The searchescovered the years 2007e2011with the last searchdate being January 3, 2012. Search details andthe specific search strings for all bibliographicaldatabases will be provided on request by the cor-responding author.
Titles, abstracts, and keywords of the 916 iden-tified citations were independently screened bytwo authors (E. J. and A. K. K. or M. J. H. andD. F. H. or K. R. S. and E. T. L.) to judge their po-tential relevance. The following inclusioncriteria were applied: clinical study with adultadvanced cancer patients (18 years and older)and primary study outcome including the termdepressionordepressive disorder. The exclusioncriteria were non-English publications, reviews,commentaries, case reports, publications ad-dressing tool development (e.g., validationstudies), and studies with noncancer patientsincluded in the sample.
The term ‘‘advanced cancer patients’’ wasdefined to include patient samples describedwith the following terminology: ‘‘palliative,’’ ‘‘met-astatic,’’ ‘‘terminally ill,’’ ‘‘end-of-life,’’ and/or‘‘not curable.’’
References deemed eligible for inclusion inthe screening process were then independentlyexamined in full text by two of the authors. Anydiscrepancies between the reviewers’ selectionswere discussed to obtain consensus, or a thirdauthor (M. J. H.) was consulted.
A predefined checklist (Appendix II; avail-able at jpsmjournal.com) was used to extractdata from the identified full-text articles. The
Fig. 1. Flowchart presenting the study selection pro-cess. *The study addresses other symptoms of can-cer patients and/or cancer treatment.
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list was partially based on the content of theEuropean Association for Palliative Care(EAPC) Basic Dataset,37 holding a set of itemsrecommended for use when reporting resultsfrom studies in palliative cancer care,including sociodemographic, disease-related,and patient-reported variables. Specific vari-ables of relevance for diagnosing and treatingdepression were also included in the list, suchas psychiatric history, previous depressive epi-sodes, duration of the depressive episode, his-tory of alcohol and/or drug abuse, andongoing treatment for depression (pharmaco-logical and nonpharmacological). The check-list also contained information on methodsused for assessment and classification (i.e.,diagnostic system) of depression.13
This was intended as a descriptive study ofsample descriptors and assessment methods,thus quality rating of the included studieswas beyond the scope of the present report.Standard statistical procedures were used foranalysis of frequencies. Extracted data werestored and analyzed in PASW, version 18.0(SPSS, Inc., Chicago, IL).
ResultsCitations and Publications
The search yielded 1669 potentially relevantcitations, of which 753 were duplicates. Afterthe initial screening of titles, keywords, andabstracts, 125 (14%)publications of the remain-ing 916 were retained for full-text examination.These 125 articles were assessed according tothe predefined inclusion and exclusion criteria,resulting in the inclusion of 59 publications.The main reasons for exclusion were publica-tions not reportingon advanced cancer patients(13%) and publications not having depressionas a primary outcome (18%) (Fig. 1).
Overview of the Included StudiesAll 59 publications (Table 1) addressed
advanced cancer patients having depression asa study endpoint. Most studies (23 [39%])were cross sectional, 32% were prospective,and 12% were RCTs. The sample size rangedfrom 23 to 1439 patients. The most commonstudy locations were general hospital depart-ments, such as oncology departments (26[44%]), followed by hospice/palliative careunits (14 [24%]). Outpatient services (36%)
were the most common setting, followed byinpatient care (30%); 17% of the studies pro-vided no information about the setting.
Description of the Patient PopulationsTable 2 shows results for description of the
patient samples. Age and gender were themost frequently reported sociodemographicvariables, reported in 93% and 90% of thestudies, respectively. Twenty-nine (49%) studiesreportedmarital status. Informationon religionwas reported in six (10%) and social networkalso in six (10%) studies. Performance statuswas reported in 38 (65%) studies; nine (15%)of these studies used performance status as aninclusion criterion. Information about cogni-tive function was reported in 23 (38%) studies,being an inclusion criterion in 21 of these 23.The stage of the cancer disease was
described as locally advanced, advanced, ormetastatic in 44 (75%) of the studies. Differentterminology to describe the sample for diseasestatus was applied as follows; ‘‘advanced’’ in 26
Table 1Assessment and Classification of Depression in the 59 Studies Included in the Review
First Author,Ref Year,Country N
TerminologyUsed,a Setting Design Main Outcome
DiagnosticSystem
Assessment Methods
ResultsType ofInterview
Depression-SpecificQuestionnaires
QoLQuestionnaires
Classification of depression based on a diagnostic system (n ¼ 15)
Akechi,67 2010,Japan
728 Metastatic,inpatients
Retrospective Gender differences forsuicide
DSM-IV Structured clinicalinterview
d d 100% with depression.Poor physical functioningand advanced stage weresignificant risk factorsamong male patients
Akechi,53 2009,Japan
122 Not operable,no information
Prospective,two-yearfollow-up
Psychological factors andsurvival
DSM-III-R Structured clinicalinterview
HADS POMS 7% with depression. Noneof the psychosocial factorswere associated with survival
Capozzo,58 2009,Italy
50 Terminal,inpatients
Intervention,two-weekfollow-up
Efficacy of ADs DSM-IV No information HADS d 100% with depression. ADs areeffective for reducing depressivesymptoms on HADSsubscale
Inagaki,38 2007,Japan
21 No information,no information
Cross-sectional Regional cerebral glucosemetabolism
DSM-IV Structured clinicalinterview SCID-I
HDRSb MDASI 2% with depression. Higherglucose metabolism indepressed patients
Jacobsen,46
2010, USA123 Advanced, no
informationProspective Distinguish grief from
depressionDSM-IV and
Endicottcriteria(substitute)
Structured clinicalinterview SCID-I
d BRC, ICG-R 38% with depression. Grief wasdistinct from depression andwas associated with wish to die
Lichtenthal,47
2009, USA289 Advanced, no
informationCross-sectional If prevalence of mental
disorders increases atthe end of life
DSM-IV andEndicottcriteria(substitute)
Structured clinicalinterview SCID-I
d MQOL, ICG-R 11% with mental disorders.No association was found
Okamura,59
2008, Japan60 Advanced,
inpatientsRetrospective If treatment algorithm was
followed in patientswith MDD
DSM-IV No information d d 100% with depression.Applicability rates werehigh, but several problemswere identified
Rabkin,44 2009,USA
58 Advanced, in-and outpatients
Prospective To determine if new clinicaldepression emerges overtime
DSM-IV Semistructuredinterview byPHQ-9
d PANAS, VAS 7% with depression, 3% werealways depressed, 14% weredepressed for the first time.MDD is not an inevitable partof dying process
Reeve,45
2007, UK70 Terminal,
outpatientsProspective Prevalence of depression ICD-10 Structured clinical
interview CIS-rEDS d 4% with depression
Ruijs,68
2011, TheNetherlands
64 End-of-life,outpatients
Prospective,two-monthfollow-up
Prevalence of depressionand relationship toeuthanasia
DSM-IV Semistructuredinterview SCAN
HADS, single-itemdepressionquestion(from ESAS)
d 2% with depression. 27%requested euthanasia.No association found
Schillani,61 2008,Italy
23 Terminal,inpatients
Intervention,two-weekfollow-up
Examine depression, anxiety,and mental adaptation tocancer in relation to ADtreatment
DSM-IV Structured clinicalinterview
HADS d 100% with depression. Scores ofanxiety and depression onHADS scale were reduced aswell as the scores of subscale ofMini-Mac
Schillani,62 2011,Italy
46 Advanced,inpatients
Intervention,two-weekfollow-up
Effect of ADs on depression,anxiety, and mentaladaptation to cancer
DSM-IV No information HADS d 100% with depression.Anxiety subscale scoreson HADS were decreased
(Continued)
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Studies
Table 1Continued
First Author,Ref Year,Country N
TerminologyUsed,a Setting Design Main Outcome
DiagnosticSystem
Assessment Methods
ResultsType ofInterview
Depression-SpecificQuestionnaires
QoLQuestionnaires
Shimizu,39
2007, Japan20 End-of-life,
inpatientsRetrospective,
three-monthfollow-up
Effect of AD treatment andintervention
DSM-IV Structuredclinical interview
d d 100% with depression. Noresponse achieved whentime was less than threeweeks
Warmenhoven,2
2012, TheNetherlands
64 Advanced,outpatients
Prospective Prevalence of depression DSM-IV Structured clinicalinterview SCAN
HADS d 3% with depression. Lowprevalence rates
Wilson,52 2007,Canada
381 Palliative, in-and outpatients
Prospective Prevalence and comorbidityof depression
DSM-IV Semistructuredinterview PRIMEMD modified
d SISCb 13% with depression, 10% withcomorbidities
Classification of depression independent of diagnostic system (n ¼ 44)
Chen,40 2011,China
90 Advanced, in-and outpatients
Prospective Effect of depressive symptomson survival
d d HADS-D d 22% with depression. Survival timewas shorter in depressedpatient group
Delgado-Guay,72
2009, USA216 Advanced, in-
and outpatientsRetrospective Relationship between
frequency of physicalsymptoms and depression
d d HADS ESAS 37% with depressed mood. Patientswith depressed mood had higherfrequency of symptoms
Du-Quiton,73
2010, USA84 Advanced, in-
and outpatientsProspective Measuring depression and
anxietyd d HADS d 25% with depression, 40%
with anxietyJacobson,97
2008, USA73 Advanced,
inpatientsCross-sectional Relationship between
depression andinterleukin-6
d d HDRSb d Low levels of depression.No correlation found
Kandasamy,41
2011, India50 Advanced,
inpatientsCross-sectional Association of SpWB with
distressing symptoms,anxiety, and depression
d d HADS MDASI,FACT-pal,FACT-G,FACIT-Sp
No percent presented. SpWB isrelated to physical andpsychological symptoms ofdistress
Lloyd-Williams,88
2009, UK87 Advanced,
outpatientsProspective, four-
and eight-weekfollow-up
Association of depressionwith survival
d d EDS Seven-item VRS 29% with depression.No association was found
Lo,83 2010,Canada
342 Advanced,outpatients
Prospective Whether age correlates toattachment securityand SpWB
d d BDI-II MSAS, FACIT-Sp 36% younger age with depression.Age was inversely associatedwith depression
Lo,27 2010,Canada
365 Metastatic,outpatients
Prospective Course and predictors ofdepressive symptoms
d d BDI-II BHS, FACIT-Sp,MSAS
35% with mild depression, 16%moderate to severe. Predictorsof depressive symptomswere identified
Maric,96 2010,Serbia
100 Advanced, in-and outpatients
Cross-sectional Frequency of symptoms ofdepression and anxiety
d d HDRSb SF-36, EORTCQLQ-C30
25% with mild, 19% moderate,and 2% severe depression
McMillan,89
2009, USA275 No information, in-
and outpatientsCross-sectional Relationship between
depressive symptomsand symptom distress
d d CES-D MSAS 38% with depression. Moderatecorrelation was found betweenCES-D scores and totalnumber of symptoms
Miller,84 2011,Canada
569 Advanced,outpatients
Cross-sectional Prevalence of depressionin males and females
d d BDI-II MSAS 22% with depression. Nosignificant genderdifferences were found
Moorey,64
2009, UK80 Advanced,
outpatientsRCT, 6-, 10-,
and 16-weekfollow-up
To reduce symptoms ofdepression and anxiety
d d HADS d 17% in CBT and 19% in TAUgroups with depression. Groupof CBT had lower anxiety scores
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Mystakidou,74
2008, Greece94 Advanced,
outpatientsCross-sectional Relationship between
preparatory grief withhopelessness, depression,and anxiety
d d HADS, PGAC BHS Severe 3%, possible 32%, andprobable 34% depression.Significant relation was found
Mystakidou,48
2009, Greece102 Terminal,
inpatientsCross-sectional Relationship between sleep
quality, depression, andhopelessness
d d BDI BHS 10% mild to moderate and 20%moderate to severe depression.Hopelessness was highlycorrelated with depression
Mystakidou,54
2007, Greece102 Advanced,
inpatientsCross-sectional Prevalence of clinical
characteristics forhastened death
d d BDI BHS 10% mild to moderate and 20%moderate to severe depression.Strong association foundbetween desire for death,depression, and hopelessness
Mystakidou,49
2007, Greece102 Terminal,
inpatientsCross-sectional Sleep quality and its
relationship with pain,depression, andhopelessness
d d BDI BHS, MDASI No percent presented.Hopelessness, interferenceof pain, and opioids seemed toinfluence patients’ sleep quality
Mystakidou,75
2009, Greece94 Multiple terms,
outpatientsCross-sectional Relationship of hopelessness,
anxiety, distress, andpreparatory grief
d d HADS, PGAC BHS 34% with probable and 3% withsevere depression. Depression,preparatory grief, and age werepredictors of hopelessness
Mystakidou,55
2008, Greece100 Multiple terms, in-
and outpatientsCross-sectional Relationship between
posttraumatic growthand psychological distress
d d HADS d No percent presented. Negativeassociation was found betweenPTGI-II (‘‘new possibilities’’)and HADS-depression
Mystakidou,85
2008, Greece102 Multiple terms,
inpatientsCross-sectional Relationship of QOL
and psychologicalmorbidities
d d BDI BHS, SF-12 No percent presented. Associationwas found between gender, PS,opioids, and depression
Mystakidou,56
2007, Greece82 Multiple terms,
inpatientsCross-sectional Relationship between
depression, hopelessness,cognitive status, pain,and spirituality
d d BDI BHS 20% with moderate to severe and12% with severe depression.Association found betweenhopelessness, depression, andcognitive status
Neron,76 2007,Canada
49 Multiple terms,outpatients
Prospective, threetime follow-up
Prevalence and incidenceof disease-specificdepression
d d HADS, MADRSb d 49% depressed with MADRSand 18% with HADS
O’Connor,42
2010, Australia266 Palliative, in-
and outpatientsProspective Prevalence and
predictors of anxietyand depression
d d HADS d 46% with possible and 20%with probable depression.Past anxiety in the familypredicted probable depression
Okuyama,77
2009, Japan60 Advanced,
outpatientsRCT If patients reluctance
to discuss psychologicaldistress was associated withunder recognition ofdepression by physicians
d d HADS, single-item depressionscreenerb
d 30% with depression.No association was found
Pirl,60 2008,USA
52 Advanced, noinformation
RCT, six- and12-monthfollow-up
Development of depressivesymptoms and fatigue
d d BDI d 10e16% with depression.No difference was found
Pirl,43 2008,USA
43 Advanced,outpatients
Prospective,two-monthfollow-up
Association betweendepression and survival
d d HADS d 23% with depression. Patients withdepression had poor survival
Popa-Velea,65
2010, Romania60 Advanced, no
informationRCT, follow-up
every twomonths
Effect of personalizedapproach on psychiatricmorbidity
d d HADS SF-36 No percent presented.QOL, depression, andanxiety scores were lowerin personalized care group
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Studies
Table 1Continued
First Author,Ref Year,Country N
TerminologyUsed,a Setting Design Main Outcome
DiagnosticSystem
Assessment Methods
ResultsType ofInterview
Depression-SpecificQuestionnaires
QoLQuestionnaires
Rodin,86 2009,Canada
406 Metastatic,outpatients
Cross-sectional Relationship betweendepression andhopelessness
d d BDI-II BHS,FACIT-Sp-12,MSAS
No percent presented.Depression andhopelessness weremutually reinforcingbut distinct constructs
Rodin,87 2007,Canada
326 Multiple terms,outpatients
Cross-sectional Relationship between diseaseburden and depression
d d BDI-II MSAS 23% with depression.Attachment securitybuffered the effect ofdisease-related factorson depression
Rolke,78 2010,Norway
479 No information,no information
Intervention,three-weekfollow-up
Change of QOL, depression,and anxiety
d d HADS EORTCQLQ-C30,EORTCQLQ-LC 13
No percent presented. Depressedpatients experienced improvedsocial functioning and appetite
Salvo,70 2012,Canada
1439 Advanced, in-and outpatients
Retrospective Prevalence of depressionand anxiety by ESAS
d d d ESAS 55% mild and 11% with severedepression
Sela,90 2007,Canada
132 Palliative,outpatients
Prospective Prevalence of depressionby BZSRDS
d d BZSRDS, VAS(single question)
d 32% moderate and 19% with severedepression
Sephton,91
2009, USA125 Metastatic, no
informationCross-sectional Depression, stress, and
immune functionresponses
d d CES-D d 29% women with depression.Women reported moredepressive symptoms
Slovacek,92
2009, Czechrepublic
41 Palliative,inpatients
Cross-sectional Prevalence of depressionsymptoms and levelsof HRQOL
d d ZSRDS EQ-5D 12% with severe depression.Low level of HRQOL
Slovacek,93
2009, Czechrepublic
30 Palliative,inpatients
Cross-sectional Incidence and prevalenceof depressive symptoms
d d ZSRDS d 30% with severe depression
Slovacek,94
2009, Czechrepublic
64 Metastatic,inpatients
Cross-sectional Screening of depression infemales
d d ZSRDS d 12% with severe depression
Steel,57 2007,USA
28 Multiple,outpatients
RCT, three monthfollow-up
To improve HRQOL anddecrease psychologicaldistress
d d CES-D d No percent presented. Interventiongroup reported reductionin depressive symptoms
Stockler,63
2007, Australia189 Advanced, no
informationRCT, four- and
eight-weekfollow-up
Effect of ADs d d HADS, CES-D,SPHERE
FACT-G, UBQ-C,Pt DATA Form,SQLIb
25% consistent with clinicaldepression. No effectfound
Teunissen,79
2007, TheNetherlands
79 Multiple terms,inpatients
Prospective Depressed mood, anxiety, andphysical symptoms
d d HADS, single-itemdepressionscreener
ESAS 56% depressed mood by HADS,37% by single question, and 44%depressed by ESAS
Tian,95 2009,China
233 Advanced, noinformation
Prospective Association between coping,nutrition, psychologicalstatus, and PS
d d DSI d No percent presented. Depression,low scores of confrontation, andHB may be risk factorsof poor PS
Tsai,80 2007,Taiwan
77 Terminal,inpatients
Cross-sectional Examine levels of fatigueand its related factors
d d HADS Modified SDS 47% with depression. Fatigue wasassociated with depression,anxiety, overall symptomdistress, and PS
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Turner,81
2007, UK191 Palliative,
outpatientsProspective,
two-monthfollow-up
Psychological distress andpatients’ concerns
d d HADS Concernschecklist,EORTCQLQ-C30
21% with depression. All agegroups had similar concerns andlevels of depression and anxiety
Uchida,50
2011, Japan85 Advanced,
outpatientsRCT Frequency of unmet needs d d HADS EORTC
QLQ-C30,SCNS-SF34
14% with depression. Medianof 10 unmet needs identifiedincluding psychological domain
Ugalde,51 2012,Australia
108 Not curableand not operableoutpatients
Cross-sectional Levels of anxiety, depression,global distress, and unmetneeds
d d HADS NA-ALCP, DT 19% with clinical andsubclinical depression.40% reported distress.Unmet needs wererelated to medicalcommunication
Waller,66 2011,Australia
219 Multiple terms,outpatients
Intervention Impact of using guidelinesand assessment tools onanxiety and depression
d d HADS EORTC-QLQ-C30,SCNS-SF34
11% with depression.Moderate to high needsacross all domainswere found
QOL ¼ quality of life; DSM-IV ¼ Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; DSM-III-R ¼ Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised; HADS ¼ HospitalAnxiety and Depression Scale;71 POMS ¼ Profile of Mood States;122 ADs ¼ antidepressants; SCID-I ¼ Structured Clinical Interview for the DSM-IV Axis I Disorders; HDRS ¼ Hamilton Depression RatingScale;98 MDASI ¼ M.D. Anderson Symptom Inventory;124 BRC ¼ Pargament’s Brief RCope;125 ICG-R ¼ Inventory of Complicated Grief-Revised;126 MQOL ¼ McGill Quality of Life Questionnaire;127
MDD ¼ major depressive disorder; PHQ-9 ¼ Patient Health Questionnaire-9;114 PANAS ¼ Positive and Negative Affect Schedule;128 VAS ¼ Visual Analogue Scale;129 ICD-10 ¼ International Statistical Classi-fication of Diseases and Related Health Problems, Tenth Revision; CIS-R ¼ Revised Clinical Interview Schedule;154 EDS ¼ Edinburgh Depression Scale;130 ESAS ¼ Edmonton Symptom Assessment System;131 PRIMEMD ¼ Primary Care Evaluation of Mental Disorders;155 SISC ¼ Structured Interview of Symptoms and Concerns;133 FACT-pal ¼ Functional Assessment of Cancer Therapy-Palliative Care;135 FACT-G ¼ Func-tional Assessment of Cancer Therapy Scale-G;117 FACIT-Sp ¼ Functional Assessment of Chronic Illness Therapy Spiritual Well-Being Scale;134 SpWB ¼ spiritual well-being; VRS ¼ Visual Rating Scale; BDI ¼Beck Depression Inventory;82 BDI-II ¼ Beck Depression Inventory-II;136 MSAS ¼Memorial Symptom Assessment Scale;137 BHS ¼ Beck Hopelessness Scale;123 SF-36 ¼ Short Form Health Survey-36;138 EORTCQLQ-C30 ¼ The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30116 CES-D ¼ Clinical Epidemiological Scale-Depression;139 RCT ¼ randomized controlledtrial; CBT ¼ cognitive behavioral therapy; TAU ¼ treatment as usual; PGAC ¼ Preparatory Grief in Advanced Cancer Patients;140 PTG ¼ posttraumatic growth; SF-12 ¼ Short Form Health Survey-12;141 PS ¼performance status; MADRS ¼ Montgomery-�Asberg Depression Rating Scale;142 FACIT-Sp-12 ¼ Functional Assessment of Chronic Illness Therapy Spiritual Well-Being Scale-12;117 EORTC QLQ-LC 13 ¼ TheEuropean Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Lung Cancer-13;143 BZSRDS ¼ Brief Zung Self-Rating Depression Scale;144 ZSRDS ¼ Zung Self-Rating DepressionScale;145 EQ-5D ¼ European Quality of Life Questionnaire;146 HRQoL ¼ health-related quality of life; SPHERE ¼ Somatic and Psychological Health Report;147 UBQ-C ¼ Utility-Based Questionnaire;148 PtDATA Form ¼ questionnaire designed for the study assessing 17 symptoms and seven aspects of well-being;63 SQLI ¼ Spritzer’s Quality of Life Index;149 DSI ¼ Depression Status Inventory;150 Modified SDS ¼Modified Symptom Distress Scale;151 SCNS-SF34 ¼ Short-Form Supportive Care Needs Survey Questionnaire;152 NA-ALCP ¼ Needs Assessment for Advanced Lung Cancer Patients;153 DT ¼ DistressThermometer.132aTerminology used to describe the sample of advanced cancer/palliative care population. Wording used throughout the articles, especially in title, introduction, and aims.bInterview conducted by health care provider.
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tCharacterization
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Studies
Table 2Reporting of Patient Characteristics in the 59 Included Studies
Characteristics
No Informationin the Publication,
N (%)Information in thePublication, N (%)
Assessed in the Study,But Not Reported in the
Publication, N (%)
Sociodemographic variablesAgea 1 (2) 55 (93) 3 (5)Gendera 1 (2) 53 (90) 5 (8)Ethnicitya 47 (80) 9 (15) 3 (5)Marital status 28 (48) 29 (49) 2 (3)Educationa 29 (49) 25 (42) 5 (9)Religion 52 (88) 6 (10) 1 (2)
Medical information (disease-specific variables)Principal diagnosisa 2 (3) 57 (97)Time since diagnosisa 43 (73) 16 (27)Stage of cancer diseasea 15 (25) 44 (75)Metastases 36 (61) 23 (39)Site of metastasesa 53 (90) 6 (10)Additional diagnoses (comorbidity)a 51 (86) 8 (14)Expected survival 51 (86) 8 (14)Real survival 44 (75) 15 (25)Weight lossa 57 (97) 2 (3)Performance statusa 19 (32) 38 (65) 2 (3)Cognitive functiona 28 (48) 23 (38) 8 (14)
TreatmentPresent anticancer treatmenta 24 (41) 35 (59)Medicationa 43 (73) Opioids 13 (22);
neuroleptics 3 (5)Caregiver issues
Living situationa 49 (83) 10 (17)Social network 53 (90) 6 (10)
SettingPlace of carea 5 (9) 54 (91)Provision of carea 10 (17) 49 (83)
aVariables included in the European Association for Palliative Care Basic Dataset.37
10 Vol. - No. - - 2014Janberidze et al.
(44%) studies, ‘‘palliative’’ in six (10%)studies, ‘‘metastatic’’ in five (8%),‘‘terminallyill’’ in six (10%), ‘‘end-of-life’’ in two studies(3%), and ‘‘not curable’’ in two (3%).
The following eight of the 17 variablesincluded in the EAPC Basic Dataset37 weremost often reported: age (93%), gender(90%), principal cancer diagnosis (97%),stage of the cancer disease (75%), perfor-mance status (65%), anticancer treatment(59%), place of care (91%), and provision ofcare (83%). The remaining nine variables ofthe EAPC Basic Dataset were less often re-ported: education (42%), cognitive function(38%), time since diagnosis (27%), medica-tion (opioids in 22% and neuroleptics in5%), living situation (17%), ethnicity (15%),additional diagnoses (comorbidities) (14%),site of metastasis (10%), and weight loss(3%). Expected survival was recorded in eight(14%) of the studies, and real survival was re-corded in 15 (25%) of the studies (Table 2).
Depression-Related VariablesClinical information related to depression
was rarely reported (Table 3). The durationof the present depressive episode was reportedin two studies (3%).38,39 Information on previ-ous depressive episodes and psychiatric historywas provided in seven (12%)39e45 and 10(17%)39,41,45e52 studies, respectively. Historyof alcohol and/or drug abuse was reportedin eight (13%)41,48,49,53e57 studies. The use ofantidepressant medication was reported in 10(17%) studies,27,39,44,52,58e63 whereas differenttypes of psychotherapies were reported in four(7%) studies.57,64e66
Assessment and Classification of DepressionDepression was classified according to a
diagnostic system in 15 (25%) studies(Table 1). The DSM-IV criteria were used in13 studies,2,38,39,44,46,47,52,58,59,61,62,67,68 theICD-10 in one,45 whereas one study53 used
Table 3Reporting of Depression-Specific Clinical Information in the 59 Included Studies
CharacteristicsNo Information,
N (%)Information,
N (%)
Assessed in theStudy, But Not Reportedin the Publication, N (%)
Use of antidepressants 49 (83) 10 (17) dDifferent types of psychotherapy 55 (93) 4 (7) dPsychiatric history 40 (68) 10 (17) 9 (15)Duration of present depressive episode 57 (97) 2 (3) dPrevious depressive episodes 48 (81) 7 (12) 4 (7)History of alcohol and/or drug abuse 50 (85) 8 (13) 1 (2)
Vol. - No. - - 2014 11Patient Characterization in Depression Studies
the revised DSM-III criteria.69 Different assess-ment methods were applied in these 15studies: structured clinical interviews wereused in nine,2,38,39,45e47,53,61,67 semistructuredinterviews were used in three studies,44,52,68
whereas the remaining three studies58,59,62
gave no information on the assessmentmethods used for establishing a diagnosis ofdepression.
Forty-four (75%) of the studies did not use adiagnostic system for classifying depression(Table 1). However, all but one study70 hadused depression-specific assessment tools.Among these, patient-reported tools were mostcommonly used: the Hospital Anxiety andDepression Scale71 was used in 21 (48%)studies40e43,50,51,55,63e66,72e81 and different ver-sions of the Beck Depression Inventory82 in 11(25%),27,48,49,54,56,60,83e87 whereas nine studiesused other depression-specificquestionnaires.57,88e95 Two studies96,97 used theinterviewer-administered Hamilton DepressionRating Scale.98 In most studies, more than oneassessment method was used.
DiscussionThis systematic literature review included 59
full-text articles on depression in patients withadvanced cancer published during the five-yearperiod 2007e2011. The description of the pa-tient samples and how depression was assessedand classified varied considerably across studies.Our findings confirm that the reporting ofimportant characteristics of advanced cancer pa-tient samples is unsystematic. Age, gender, andcancer diagnosis were the most frequently re-ported sociodemographicandmedical variables,confirming the previous findings by Sigurdar-dottir et al.24 As a novel finding, clinically impor-tant information related to depression, such aspsychiatric history, duration of the present
depressive episode, and treatment (drug treat-ment with antidepressants and/or psychologicaltherapy), was rarely reported. In 25% of thestudies, depression was classified according to avalidated diagnostic system. This result is similar(23%) to the finding in an earlier review ofstudies published before 2007.13
The prevalence rate estimates of depressionin the included publications varied between2% and 56%, except for six studies39,58,59,61,62,67
having depression as an inclusion criterion andthus a prevalence rate of 100%. This variabilityconfirms previous findings13,99,100 and under-lines the need for standardization of how tocharacterize patient samples and of how toassess and classify depression in advanced can-cer patients. The European Clinical Guidelinesfor the Management of Depression in PalliativeCare stress the importance of assessingdepression-related variables such as use of anti-depressants, psychiatric history, and duration ofthedepressive episodewhendiagnosingdepres-sion.101 Information regarding medication is acrucial part of anymedical history, and informa-tion on previous and ongoing treatment withantidepressants is part of a complete descrip-tion of a patient with depressive symptoms.However, only 11 (17%) of the studies includedin the present work reported information abouttreatment with antidepressants. A history ofdepressive disorder (e.g., major depressive dis-order or dysthymia) and long duration of thedepressive episode heighten the risk for devel-oping new or subsequent depressive epi-sodes.102,103 Despite this knowledge, data onthese variables were rarely reported in the re-viewed publications. If research is to influenceclinical practice, the assessments performed inresearch should mirror best clinical practice.Thus, one might question the external validityof many of the published studies on depressionin advanced cancer patients.
12 Vol. - No. - - 2014Janberidze et al.
Classificationofdepression is basedoncriteriaof diagnostic systems such as DSM-V.5 To diag-nose adepressivedisorder in anadvanced cancerpatient may be challenging as these patientscommonly experience similar somatic symptomsfrom the cancerdisease itself. Itmay beproblem-atic to decide which of the somatic symptomsidentified in the DSM-V criteria are attributableto depression and which are because of cancerdisease.8 Possible confoundingeffects of the can-cer disease should thus be taken into consider-ation when investigating depression in patientswith advanced cancer. This can be done byincludingmeasures of disease load, for example,time to death, performance status, and how thecancer disease influences symptoms of depres-sion, particularly the somatic symptoms.104
Most investigated studies did in fact report in-formation about the cancer disease (97%) andits stage (75%).However, despite thewidespreaduse of the tumor, node, metastasis classificationsystem in oncology in general,105 it might notbe expected that staging information can bepresented similarly for all different types ofcancer. Anticancer treatment should be takeninto consideration in studies including cancerpatients, especially with advanced disease. How-ever, information on present anticancer treat-ment was only reported in 59% of the studies.The terminology related to describing the sam-ple as palliative care patients vs. patients withadvanced disease differed across studies. Forexample, the term ‘‘palliative’’ was used in 10%of the studies, whereas ‘‘advanced’’ was used in44%. This may reflect different existing views ofwhat ‘‘palliative care’’ is. In some settings, pallia-tive care is viewed as only the last few weeksbefore death, whereas others define palliativecare from the day the patient is beyond cure.Integration of palliative care into oncology hasin recent years been in focus.106e108
Furthermore, it is important to take into ac-count information on other symptoms, asmost patients with advanced cancer report mul-tiple coexisting distressing symptoms72 thathave been shown to be interdependent.109
Even if the direction of causality of these rela-tionships is unclear,110 the presence of symp-toms common in advanced cancer patients,such as uncontrolled pain or cachexia,111,112
may influence the presence of depression. Assuch, information about pain treatment is alsoimportant to report. However, only 22% of
the studies provided information about treat-ment with, for example, opioids.Ethnicity may be of clinical relevance, for
example, in a patient with depression whohas moved from one country to another, andit is well known that depressive feelings andsymptoms are reported in different ways indifferent cultures. However, there is no stan-dardized manner in how to address this, asfar as we know, other than acknowledging cul-ture as a relevant factor.Wasteson et al.13 demonstrated that depres-
sion was frequently not classified according to adiagnostic system and that more than 100different assessment methods were used. Thus,our systematic literature review confirms thatthe unsystematic use of assessment methods fordiagnosing depression in advanced cancer pa-tients continues. Among the included studies,only 15 used structured or semistructured inter-views based on an approved classification systemfor diagnosing depression. A structured clinicalinterview is currently the reference standard fordiagnosing depression in clinical practice.113
However, a structured interview is timeconsuming and may be difficult to conduct infrail and fatiguedcancerpatientswithapoorper-formance status. Several self-reporting screeningtools have been designed to assess depression,butmost often they assess the intensity of variousdepressive symptoms and are insufficient fordiagnostic purposes.When deciding on which assessment method
to use, a clear understanding of what is to be as-sessed is paramount: depressive disorder or psy-chological distress/depressive symptoms. Ourrecommendation is that for the assessment ofdepressive disorders, a self-report tool based onthe standardized diagnostic criteria of the DSMshould be applied, when a structured clinicalinterview cannot be undertaken. The PatientHealth Questionnaire-9 is such a tool,114 whichhas been validated in patients with cancer.115 Us-ing the same tool across depression studies canfacilitate more accurate comparisons.For the assessment of psychological distress/
depressive symptoms, several more generalassessment tools are available, either in theform of general symptom assessment tool,quality-of-life tools, and symptom-specific tools.Examples of frequently used tools are the Euro-pean Organization for Research and Treatmentof Cancer Quality of Life Questionnaire-C30,116
Vol. - No. - - 2014 13Patient Characterization in Depression Studies
Functional Assessment of Cancer TherapyScale,117 and the Distress Thermometer.118
Among specific depression tools, the HospitalAnxiety and Depression Scale for self-report ofboth depression and anxiety71 and Beck Depres-sion Inventory82 are well-known instruments.Furthermore, the new Patient-Reported Out-comes Measurement Information System(PROMIS)-Depression instrument from thePROMIS119 is currently being developed.120,121
This tool is intended for use by computers anduses a computer-adaptive testing algorithm aspart of the software, which makes it easier totailor the questions to the individual patient.However, both the methods and tools itselfneed to be validated against structured clinicalinterviews, in cancer and other patient groups.
A potential limitation in all reviews is whetherall relevant publications are identified. In thissystematic literature review, we only includedpublications from studies investigating advancedcancer patients and explicitly defining depres-sion as a primary outcome. This was donebecause we hypothesized that the descriptionof the patient samples and the assessment ofdepression would be as optimal as possible in aclearly defined population. An extension of theinclusion criteria to cover cancer patients in gen-eral and/or depressive symptoms in a broadersense may of course have given other results. Apredefined relatively comprehensive checklistwas used for data extraction; however, it cannever be ruled out that the use of an even moreextensive checklistmay haveprovidedadditionalinformation. The limitations of the selectionprocedure regarding period and language implythat we might have missed publications of inter-est. The search covered the five-year period2007e2011. This was chosen because an exten-sive systematic literature review by Wastesonet al.13 on assessment and classification ofdepression in palliative care covered the perioduntil 2007. The search was confined to studiespublished in English language according to thelanguage skills of our research group andbecause this is a common procedure for mostreviews. Our selection of the well-known majordatabases representing various disciplines, andthe use of recognized search strategy to identifyrelevant literature in advanced cancer wasapplied,13 make us think that the restriction tothe English language is not a major study limita-tion. Despite the limitations, we think that the
present review presents valuable new informa-tion onhow patients are characterized in clinicalstudies having depression as a primary outcome.
Further work toward a consensus on how tocharacterize study samples in advanced cancerpatients with depression should in our opinioninclude patients’ sociodemographic character-istics, disease-related information, and infor-mation on depression-specific risk factors. Inaddition, information on common symptomsand conditions such as pain and depressionshould be reported. Our general recommen-dation for clinical studies investigatingadvanced cancer samples is to include theEAPC Basic Dataset37 as well as informationabout the cancer disease and anticancer treat-ment. In addition, for depression-specificstudies, we recommend to assess duration ofthe depressive episode, psychiatric history,and ongoing treatment for depression as aminimum of depression-related variables.
Stakeholders such as the European Associa-tion for Palliative Care Research Network(EAPC RN) in collaboration with core journalsand other relevant bodies could bring thiswork forward by agreeing on a common setof core variables that precisely describe a studypopulation. Furthermore, editors of medicaljournals could be requested to use the agreedcommon data set as a checklist.
ConclusionsOur systematic literature review demon-
strates unsystematic and inconsistent reportingof core sociodemographic and medical samplecharacteristics in populations with advancedcancer and depression. The major findingwas the lack of reporting of importantdepression-related variables in studies investi-gating depression in advanced cancer patients.Validated diagnostic tools for depression wererarely used. Assessment methods for depres-sion continued to vary greatly. There is anobvious need for a more stringent character-ization of study populations to increase thegeneralizability of results from studies ondepression in patients with advanced cancer.We hope our results will inspire journals andother central stakeholders to produce recom-mendations for sample descriptions and assess-ment methods in future studies.
14 Vol. - No. - - 2014Janberidze et al.
Disclosures and AcknowledgmentsThis article is part of the European Intersec-
torial and Multidisciplinary Palliative CareResearch Training (EURO IMPACT) project.EURO IMPACT is funded by the EuropeanUnion Seventh Framework Programme (FP7/2007e2013, under grant agreement number264697). EURO IMPACT aims to develop amultidisciplinary, multiprofessional, and inter-sectorial educational and research trainingframework for palliative care research in Eu-rope. EURO IMPACT is coordinated by ProfLuc Deliens and Prof Lieve Van den Block ofthe End-of-Life Care Research Group, GhentUniversity and Vrije Universiteit Brussel, Brus-sels, Belgium. Other partners are VU Univer-sity Medical Center, EMGO Institute forHealth and Care Research, Amsterdam, TheNetherlands; King’s College London, CicelySaunders Institute, London, Cicely SaundersInternational, London, and International Ob-servatory on End-of-Life Care, Lancaster Uni-versity, Lancaster, United Kingdom; EAPCRN, Trondheim, Norway; Fondazione IRCCSIstituto Nazionale dei Tumori, Milan, Italy,and Cancer Research and Prevention Institute,Florence, Italy; EUGMS European Union Geri-atric Medicine Society, Geneva, Switzerland;Springer Science and Business Media, Houten,The Netherlands.
The authors declare no conflicts of interest.In recognition of the collaborative nature of
EURO IMPACT, the authors thank thefollowing EURO IMPACT members for theircontribution, namely: Van den Block Lieve(End-of-Life Care Research Group, Ghent Uni-versity and Vrije Universiteit Brussel, Brussels,Belgium), De Groote Zeger (End-of-Life CareResearch Group, Ghent University and VrijeUniversiteit Brussel, Brussels, Belgium), Brear-ley Sarah (International Observatory on End-of-Life Care, Lancaster University, Lancaster,United Kingdom), Caraceni Augusto (EAPCRN, Trondheim, Norway; Fondazione IRCCS Is-tituto Nazionale dei Tumori, Milan, Italy), Co-hen Joachim (End-of-Life Care ResearchGroup, Ghent University and Vrije UniversiteitBrussel, Brussels, Belgium), Francke Anneke(VUUniversityMedical Center, EMGOInstitutefor Health andCare Research, Amsterdam, TheNetherlands),HardingRichard (King’s CollegeLondon, Cicely Saunders Institute, London;
Cicely Saunders International, London), Hig-ginson Irene J (King’s College London, CicelySaunders Institute, London; Cicely SaundersInternational, London), Linden Karen(Springer Science andBusinessMedia,Houten,The Netherlands), Miccinesi Guido (CancerResearch and Prevention Institute, Florence,Italy),Onwuteaka-PhilipsenBregje (VUUniver-sity Medical Center, EMGO Institute for Healthand Care Research, Amsterdam, TheNetherlands), Pardon Koen (End-of-Life CareResearch Group, Ghent University and VrijeUniversiteit Brussel, Brussels, Belgium), Pas-man Roeline (VU University Medical Center,EMGO Institute for Health and Care Research,Amsterdam, The Netherlands), Pautex Sophie(EUGMS European Union Geriatric MedicineSociety, Geneva, Switzerland), Payne Sheila(International Observatory on End-of-LifeCare, Lancaster University, Lancaster, UnitedKingdom), and Deliens Luc (End-of-Life CareResearch Group, Ghent University and VrijeUniversiteit Brussel, Brussels, Belgium; VUUni-versity Medical Center, EMGO Institute forHealth and Care Research, Amsterdam, TheNetherlands). The authors thank Ingrid I. Ri-phagen, Unit for Applied Clinical Research,Faculty of Medicine, Norwegian University ofScience and Technology, for her help withsearching the computerized bibliographicdatabases.
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Appendix I
Search Strategy PubMed(Depressive disorder[mh] OR Depression[mh] OR depression[tiab] OR depressive[tiab]) AND
(Palliative care[mh] OR palliat* [tiab] OR Terminal care[mh] OR terminal care[tiab] OR end-of-life care[tiab] OR supportive care[tiab] OR comfort care[tiab] OR Hospices[mh] OR hospice*[tiab] OR Terminally ill[mh] OR (terminal*[tiab] AND (ill[tiab] OR illness*[tiab])) OR (advanced[tiab] AND cancer[tiab])) AND cancer[sb] e Limits: Publication Date from 2007.
Categories Alternatives
Author Name of the first authorYear Publication yearCountry If the study is multinational please, write ‘‘multinational’’Journal Name of the journalStudy design 0 ¼ Prospective/longitudinal, 1 ¼ Cross-sectional,
2 ¼ Retrospective, 3 ¼ Intervention, 4 ¼ RCTSample size Indicate number at inclusionTerminology used to describe the sample 0 ¼ No information, 1 ¼ Advanced, 2 ¼ Palliative,
3 ¼ Metastatic, 4 ¼ Terminally ill, 5 ¼ End-of-life,6 ¼ Not curable/not operable, 7 ¼ Multipleterminology used
Follow-up Provide time of the follow-upStudy main outcomeAssessment and classification of depression
Is depression classified according to a diagnostic system? 0 ¼ No information, 1 ¼ Yes, 2 ¼ NoIf ‘‘yes,’’ which system was used 0 ¼ DSM-IV, 1 ¼ DSM-III, 2 ¼ ICD-10, 4 ¼ OtherIf ‘‘other,’’ please specifyWhich type of interview was used for diagnosingdepression?
0 ¼ No information, 1 ¼ Structured, 2 ¼ Unstructured
Please provide the name of the interviewPercentage of patients with depression 0 ¼ No information, 1 ¼ InformationSpecify percentage of patientsIs depression assessed by using depression-specificinstruments?
0 ¼ No, 1 ¼ Yes
If ‘‘yes,’’ please, specifyAre QoL instruments used for assessment of depression 0 ¼ No, 1 ¼ YesIf ‘‘yes,’’ please specify
Depression-related variablesUse of antidepressants 0 ¼ No information, 1 ¼ InformationDifferent types of psychotherapy 0 ¼ No information, 1 ¼ InformationDuration of present depressive episode 0 ¼ No information, 1 ¼ Information, 2 ¼ Assessed but
not reportedPrevious depressive episodes 0 ¼ No information, 1 ¼ Information, 2 ¼ Assessed but
not reportedPsychiatric history 0 ¼ No information, 1 ¼ Information, 2 ¼ Assessed but
not reportedHistory of alcohol and/or drug abuse 0 ¼ No information, 1 ¼ Information, 2 ¼ Assessed but
not reportedDescription of patient samples
Sociodemographic variablesAge/date of birtha 0 ¼ No information, 1 ¼ Information, 2 ¼ Assessed but
not reportedGendera 0 ¼ No information, 1 ¼ Information, 2 ¼ Assessed but
not reportedEthnicitya 0 ¼ No information, 1 ¼ Information, 2 ¼ Assessed but
not reportedMarital status 0 ¼ No information, 1 ¼ Information, 2 ¼ Assessed but
not reportedEducationa 0 ¼ No information, 1 ¼ Information, 2 ¼ Assessed but
not reportedReligion 0 ¼ No information, 1 ¼ Information, 2 ¼ Assessed but
not reportedMedical information (disease-specific variables)Principal diagnosisa 0 ¼ No information, 1 ¼ InformationTime since diagnosesa 0 ¼ No information, 1 ¼ InformationStage of cancer diseasea 0 ¼ No information, 1 ¼ Described as locally advanced,
advanced, or metastatic/disseminated (informationprovided)
(Continued)
Appendix II
Extraction Log
Vol. - No. - - 2014 21Patient Characterization in Depression Studies
Continued
Categories Alternatives
Metastases 0 ¼ No information, 1 ¼ InformationSite of metastasesa 0 ¼ No information, 1 ¼ InformationPatients’ additional diagnoses (comorbidities)a 0 ¼ No information, 1 ¼ InformationExpected survival 0 ¼ No information, 1 ¼ InformationReal survival 0 ¼ No information, 1 ¼ InformationWeight lossa 0 ¼ No information, 1 ¼ InformationPerformance statusa 0 ¼ No information, 1 ¼ Inclusion criterion, 2 ¼ Specified,
3 ¼ Both 1 and 2, 4 ¼ Assessed but not reportedCognitive functiona 0 ¼ No information, 1 ¼ Inclusion criterion, 2 ¼ Specified,
3 ¼ Both 1 and 2, 4 ¼ Assessed but not reportedTreatmentPresent anticancer treatment 0 ¼ No information, 1 ¼ InformationMedication
Opioidsa 0 ¼ No information, 1 ¼ InformationNeurolepticsa 0 ¼ No information, 1 ¼ Information
Caregiver issuesLiving situationa (information about caregiver issues
or household/living with, more than marital status)0 ¼ No information, 1 ¼ Information
Information about social network 0 ¼ No information, 1 ¼ InformationInformation about settingPlace of carea 0 ¼ No information, 1 ¼ Home, 2 ¼ Long-term care
facilities, 3 ¼ Hospice/palliative care unit, 4 ¼ Hospital,general departments including oncology department,5 ¼ Other, 6 ¼ Two/multiple locations
Provision of carea 0 ¼ No information, 1 ¼ Inpatients, 2 ¼ Outpatients,3 ¼ Both 1 and 2
Comments
RCT ¼ randomized controlled trial; DSM-IV¼ Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; DSM-III ¼ Diagnostic and Statis-tical Manual of Mental Disorders, Third Edition; ICD-10 ¼ International Statistical Classification of Diseases and Related Health Problems, Tenth Revision;QoL ¼ quality of life.aVariables included in the EAPC Basic Dataset.
Appendix II
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