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Impact of collaborative care management of depression among patients with cancer.

TO THE EDITOR: It was with great interest that we read the article by Ell et al regarding the role of collaborative care management of depression among predominately female patients with nonadvanced cancer. We congratulate the authors for their first large-scale trial of collaborative care, with intervention protocols specifically designed for minority patients with low income and nonadvanced cancer. However, we were struck by a few unacknowledged limitations. First, the high number of patients lost to follow-up (214 patients [45%] after 12 months) raises questions about the validity of the findings. We were surprised not to find any attempt to account for the fact that patients receiving intervention were more likely than patients of the control group to be foreign born; cultural differences may have rendered them more receptive to intervention, resulting in an overestimation of the benefits of intervention. Furthermore, there was no mention of the proportion of foreign-born patients who were lost to follow-up in the intervention group compared with that in the control group. The authors reported that the percentage of patients at 12-month follow-up with 50% reduction in Patient Health Questionnaire–9 score was 63% in the intervention group and 50% in the control group, with a significant odds ratio of 1.98 (95% CI, 1.16 to 3.38; P .01). However, the 50% reduction in Patient Health Questionnaire–9 score at 12-month follow-up, when adjusted for certain patient demographics (adjusted mean score, 0.74 [95% CI, 1.74 to 0.27; P .15]), did not reflect significant results. This was contrary to the authors’ inference that the adaptation of the collaborative care model results in significant reduction in depressive symptoms in patients with nonadvanced cancer. Finally, no information on patients with cancer that went into remission was provided. Patients who attained remission would have been less likely to be depressed and consequently more likely to have relatively better quality-of-life outcomes, as compared with their counterparts.