Lung Cancer 79 (2013) 46–53

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Lung Cancer
journal homepage: www.elsevier.com/locate/lungcan

Treatment of depression in people with lung cancer: A systematic review

Jane Walker a,∗ , Aarti Sawhney b , Christian Holm Hansen b , Stefan Symeonides c ,
Paul Martin b , Gordon Murray d , Michael Sharpe a
a
Psychological Medicine Research, Department of Psychiatry, University of Oxford, UK
b
Psychological Medicine Research, Edinburgh Cancer Research Centre, University of Edinburgh, UK
c
Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
d
Centre for Population Health Sciences, University of Edinburgh, UK

a r t i c l e i n f o a b s t r a c t

Article history: Lung cancer commonly occurs in older adults who live in deprived areas and have multiple medical
Received 7 August 2012 comorbidities. As well as suffering severe physical deterioration they are aware of their poor prognosis.
Received in revised form It is therefore unsurprising that people with lung cancer have a high rate of depression. Whilst there are
10 September 2012
effective treatments for depression in people who do not have cancer, it is uncertain which treatments, if
Accepted 23 September 2012
any, are effective in depressed cancer patients; the special characteristics of the condition only increase
that uncertainty for people with lung cancer.
Keywords:
We therefore conducted a systematic review of relevant randomised controlled trials to determine
Depression
Lung cancer
which, if any, treatments have been found to be effective for depression in patients with lung cancer.
Treatment Surprisingly, we found no completed trials of treatments in patients selected for having depression and
Systematic review no trials that had evaluated treatments known to be effective for depression in the general population.
We did, however, find six trials of interventions intended to improve quality of life in unselected patients
with lung cancer. These suggested that enhanced care is more effective in reducing depressive symptoms
than standard care.
Whilst it may be reasonable to treat depression in individuals with lung cancer with standard treat-
ments until more specific evidence is available, clinicians should be aware that the effectiveness and
potential adverse effects of these treatments remain unknown in this patient group. Evidence from
randomised trials is urgently required.
© 2012 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Patients with cancer frequently suffer from depression [1]. Such
comorbid depression has been associated with reduced quality of
life, decreased adherence to anticancer therapies, greater mortality,
increased healthcare costs, and worse satisfaction with care [2–8].
Lung cancer is one of the most common malignancies, account-
ing for 12% of all new cancer cases worldwide [9,10]. It has a
particularly poor prognosis, leading to more deaths in the European
Union and the United States of America than any other malig-
nant disease. Patients diagnosed with lung cancer are commonly
older adults who live in deprived areas and have multiple medical
comorbidities [11,12]. They often suffer rapid and severe physi-
cal deterioration and they are aware of their poor prognosis. It is
therefore unsurprising that they also suffer an especially high rate
of depression [13].
We know that depression can be effectively treated in peo-
ple who do not have cancer, using antidepressant medication and
psychological treatments such as cognitive behavioural and inter-
personal therapies [14–16]. There is uncertainty, however, whether
these treatments are also effective in depressed cancer patients. The
special characteristics of the condition only increase that uncer-
tainty for patients with lung cancer [17,18].
We therefore aimed to determine which, if any, treatments have
been found to be effective in reducing depression in patients with
lung cancer by conducting a systematic review of relevant ran-
domised controlled trials.
2. Methods

∗ Corresponding author at: University of Oxford, Department of Psychiatry,

2.1. Search strategy
Warneford Hospital, Oxford OX3 7JX, UK. Tel.: +44 01865 226 477;
fax: +44 01865 793 101. We identified relevant published research articles by a system-
E-mail address: jane.walker@psych.ox.ac.uk (J. Walker). atic search of the following electronic databases: Medline (1948 to

0169-5002/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.lungcan.2012.09.014
 J. Walker et al. / Lung Cancer 79 (2013) 46–53
October week 1, 2011), EMBASE Classic + EMBASE (1947 to week
41, 2011), PsycINFO (1806 to week 2, 2011), CINAHL Plus (1937
to October 2011) and The Cochrane Central Register of Controlled
Trials. Searches were run for the combination of ‘lung cancer’ and
‘depression’ using both standardised subject terms and free text
terms, including synonyms and alternative spellings. Full details of
the searches are given in Appendix 1. We also manually searched
the reference lists of all trials selected for inclusion in the review
and of review articles obtained through the electronic searches.
2.2. Selection criteria
We judged publications to be relevant if they met the following
criteria: (1) the publication reported the results of a randomised
controlled trial; (2) trial participants were adults (aged 18 or older);
(3) trial participants had a definite diagnosis of lung cancer (for
example, histological diagnosis or attending for cancer treatment);
(4) the trial evaluated the efficacy or effectiveness of a pharmaco-
logical or non-pharmacological intervention intended to improve
patients’ symptoms or quality of life; (5) depression outcomes were
assessed using a standardised measure. We excluded trials of anti-
cancer treatments (i.e. chemotherapy or radiotherapy) and we only
included primary publications (i.e. not reviews) for which we could
obtain the full paper for data extraction. When we found abstracts
or posters from conference proceedings we searched for full papers
using the authors’ names. When we found protocols we determined
whether the trials had been completed (by contacting the authors
if necessary) and the results published. We only considered trials
that included both patients with lung cancer and patients with can-
cers in other sites (e.g. breast cancer) if results for the subgroup of
patients with lung cancer were reported separately.
2.3. Data collection and analysis
We imported all articles identified by the searches into a
database and screened their titles and abstracts to determine
whether each might meet the selection criteria. We reviewed the
full text of the article, with the help of a translator where neces-
sary, if there was any possibility that it might be relevant. This
process was conducted independently by two researchers and a
decision whether to include each trial was made by consensus.
Two researchers independently extracted data from all the arti-
cles judged relevant, using a specially designed, standardised data
extraction form, and with the help of a translator for non-English
papers. We extracted data on trial aims, participants, interventions
(experimental and control), outcomes and results.
In order to provide meaningful results for clinicians, we grouped
trials into two categories: first, those that explicitly aimed to recruit
participants who were depressed and second, those that recruited
all-comers (i.e. participants were not specifically selected for hav-
ing depression). In order to include as many relevant trials as
possible we used a broad definition of ‘depression’ (having symp-
toms meeting standard diagnostic criteria for depression or having
a score above a pre-defined cut-off on a depression questionnaire).
We described the characteristics and results of included trials in
both narrative and table format and considered whether meta-
analysis was appropriate for statistical synthesis of findings.
2.4. Assessment of risk of bias
During data extraction we assessed the risk of bias in each trial
included in the review using the Cochrane Collaboration’s risk of
bias tool [19]. This tool requires reviewers to evaluate the risk of
five types of bias and to judge each of these risks as either ‘low’,
‘high’ or (usually when there is insufficient information) ‘unclear’.
The types of bias are: selection (high risk means that the allocation
47
of participants to treatments is not random or that treatment
allocations could have been foreseen in advance by study staff or
potential participants); performance (high risk means that there
are likely to be systematic differences between the groups in the
care provided or in exposure to factors other than the interventions
being tested); detection (high risk means that there are likely to
be systematic differences between the groups in the way that out-
comes are determined, usually because outcome assessors are not
blind to treatment allocations); attrition (high risk means that there
are systematic differences between groups in study withdrawals
or substantial missing outcome data); reporting (high risk means
that the outcomes reported are not adequately pre-specified).
3. Results
3.1. Literature overview
Searches and initial screening of titles and abstracts yielded
143 potentially eligible publications, of which five required trans-
lation. After reviewing the full articles, 134 were considered not
relevant, leaving nine. Of these nine articles, six were reports of
completed trials and were included in the review (see Table 1); the
remaining three were published protocols of trials still in progress
(see Table 2). The reasons for exclusion are shown in Fig. 1.
3.2. Characteristics of trials included in the review
3.2.1. Trials of depressed participants
There were no trials that had aimed to evaluate the effectiveness
of treatments for depression in people with lung cancer.
3.2.2. Trials of all-comers
There were six trials of interventions intended to improve symp-
toms or quality of life in people with lung cancer who had not been
selected for having depression.
Bredin et al. evaluated the effectiveness of a nursing inter-
vention for patients who reported breathlessness after first line
treatment for non-small cell lung cancer or mesothelioma, com-
pared with best supportive care [20]. Participants assigned to the
nursing intervention underwent a detailed assessment of their
breathlessness and the factors that might ameliorate or exacerbate
it (including problems that warranted pharmacological or medical
treatment) before receiving advice and support, training in breath-
ing techniques and the opportunity to discuss their feelings about
their disease, symptoms and future. Depressive symptoms were
assessed at 8 weeks as a secondary measure and the researchers
found that depression scores worsened in both groups but less so
in those assigned to the nursing intervention.
Carlson et al. compared the efficacy of three versions of dis-
tress screening in breast and lung cancer outpatient clinics [21].
All participants were given an educational package that included
information about self-referral to local psychosocial resources.
In addition, participants were randomly assigned to minimal
screening (participants completed a distress thermometer measure
and were asked for their demographic details), full screening (par-
ticipants completed a number of symptom questionnaires, received
a personalised feedback report and a summary of their responses
was placed on their electronic medical record) or triage (partic-
ipants completed the full screening and were also offered the
opportunity to speak to a member of the psychosocial team who
used an algorithm to discuss referral options with interested par-
ticipants). Depressive symptoms were assessed at 3 months as a
secondary measure and no statistically significant differences were
found between the groups.
Linn et al. assessed the effects of counselling for patients
with incurable cancer compared with usual medical care [22].
 48
Table 1
Characteristics of trials included in the review.

Trial Trial aim Participants with Interventions Primary Depression Participants’ Results
lung cancer outcome(s) measure depression status
at baseline

Bredin et al. (1999) (UK) To evaluate the 119 patients with 1. Best supportive Distress due to HADSa Depression Median HADS Both groups’ median
effectiveness of a lung cancer who care (N = 52)i breathlessness Subscale at 8 weeks Depression depression scores
nursing had completed first 2. Nurse clinic for Subscale scores: increased but patients who
intervention for line treatment and breathlessness Group 1 = 6 received the breathlessness
breathlessness in reported weekly up to 8 Group 2 = 5 intervention (group 2) did
patients with lung breathlessness weeks (N = 51)i significantly better
cancer Change from baseline
reported:
Group 1 = 6 (range −7 to
+7)
Group 2 = 0.5 (range −10 to
+7)
(p = 0.02)

J. Walker et al. / Lung Cancer 79 (2013) 46–53

Carlson et al. (2010) (Canada) To compare the 549 patients aged 1. Minimal Distress PSSCANb Mean PSSCAN No differences found
efficacy of 3 over 18 attending a screening – Depression Depression between the 3 screening
versions of lung cancer patients completed Subscale at 3 Subscale scores: groups.
screening for outpatient clinic, 1 questionnaire months Group 1 not At 3 months mean PSSCAN
distress in breast newly diagnosed or (N = 176) measured scores:
and lung cancer new to that clinic 2. Full screening – Group 2 = 8.46 Group 1 = 7.91
outpatient clinics or oncologist patients completed Group 3 = 8.58 Group 2 = 7.47
multiple Group 3 = 7.25
questionnaires,
results put on
electronic medical
record (N = 174)
3. Triage – full
screening plus
offer to speak to
psychosocial team
(N = 199)

Linn et al. (1982) (USA) To assess the 64 patients with 1. Usual medical Multiple outcomes POMSc depression Mean POMS Participants who received
impact of incurable cancer care (N = 31) including factor at 1, 3, 6, 9 depression factor counselling had better
psychosocial (distant 2. Counselling – depression and 12 months scores: depression scores at 3
counselling on metastases), several sessions Group 1 = 12.8 months and 12 months but
quality of life, prognosis 3–12 per week with Group 2 = 13.0 not at the other
functional status months, alert and experienced time-points
and survival in able to counsellor (N = 33) At 3 months mean POMS
end-stage cancer communicate depression factor scores:
patients Group 1 = 14.2
Group 2 = 10.8
(p < 0.01)
At 12 months mean POMS
depression factor scores:
Group 1 = 14.8
Group 2 = 11.0
(p < 0.05)
Table 1 (Continued)

Trial Trial aim Participants with Interventions Primary Depression Participants’ Results
lung cancer outcome(s) measure depression status
at baseline

Porter et al. (2011) (USA) To test the efficacy 233 patients with 1. Multiple outcomes BDIf immediately Not reported No significant difference
of a early stage lung Education/support including after intervention reported between the
caregiver-assisted cancer (NSCLCd – 14 telephone depression and at 4 month groups
coping-skills Stage 1–3, SCLCe sessions for follow-up (4
training protocol limited stage), no patients and carers months after the
for patients with other cancer in the (N = 116) end of treatment)
lung cancer preceding 5 years, 2.
able to read and Caregiver-assisted
speak English, coping skills
caregiver willing to training – 14
participate telephone sessions
over 8 months
(N = 117)

Temel et al. (2010) To examine the effect 151 ambulatory 1. Standard cancer care Quality of life HADSa Depression Percentage Significantly fewer

J. Walker et al. / Lung Cancer 79 (2013) 46–53

(USA) of early palliative care patients with newly (N = 74) Subscale (cut-off ≥7 depressed in each participants who had
integrated with diagnosed metastatic 2. Early palliative care used for depression) group on HADS received early palliative
standard oncologic care NSCLC, ECOGg – meetings with a and PHQ-9h (algorithm Depression care were depressed
on patient-reported performance status member of the used for major Subscale: according to both criteria
outcomes, the use of 0–2, not already palliative care team depression) at 12 Group 1 = 25% at 12 weeks
health services and receiving palliative within 3 weeks of weeks Group 2 = 22% HADS Depression Subscale:
quality of end-of-life care, able to respond to enrolment then at least Group 1 = 38%
care in patients with questions in English monthly until death Group 2 = 16%
metastatic NSCLC following general (p = 0.01)
guidelines (N = 77) Percentage PHQ-9:
depressed in each Group 1 = 17%
group on PHQ-9: Group 2 = 4%
Group 1 = 17% (p = 0.04)
Group 2 = 12%

Wu and Wang (2003) To explore the effect of 120 patients with lung 1. Standard Depression and anxiety Self-rating Depression Baseline means Significantly fewer
(China) supportive cancer, without brain chemotherapy and Scale (cut-off ≥50 used scores: participants who had
psychotherapy on metastases, psychiatric complementary for depression) after 1 Group 1 = 43 received additional
depression and anxiety symptoms or history; therapy (N = 57) month of treatment Group 2 = 44 psychotherapy met criteria
in patients with lung not suicidal; not drug 2. Additional for depression at 1 month
cancer or alcohol dependent psychotherapy – Percentage Percentage depressed in
cognitive therapy, depressed in each each group at 1 month:
patient support, group at baseline: Group 1 = 39%
relaxation, family Group 1 = 39% Group 2 = 17%
support (N = 63) Group 2 = 38% (p < 0.05)
a
Hospital Anxiety and Depression Scale.
b
Psychological Screen for Cancer Part C.
c
Psychiatric Outpatient Mood Scale.
d
Non-small cell lung cancer.
e
Small cell lung cancer.
f
Beck Depression Inventory.
g
Eastern Cooperative Oncology Group.
h
9 item Patient Health Questionnaire.
i
16 patients excluded post-randomisation.

49
50 J. Walker et al. / Lung Cancer 79 (2013) 46–53

Table 2
Characteristics of trials in progress from published protocols identified in the review.

Trial Trial aim Participants with Interventions Primary Depression

lung cancer outcome(s) measure

Griffiths 2009 (UK) To assess impact on Aiming for 2200 1. Anti-cancer treatment Overall survival HADSb – both
overall survival of aged over 18 according to local practice depression and
adding LMWHa to attending for 2. Anti-cancer treatment as anxiety subscales,
standard oncology anticancer above plus daily dalteparin time points not
treatment with treatment with subcutaneous injection for 24 confirmed but
secondary primary lung weeks patients to be seen
measures including cancer of any stage 3–4 times weekly
impact on anxiety or histology until week 24 then
and depression at 9 months, 12
months, then
annually

Jones et al. (USA)
To investigate the Aiming for 160 1. Aerobic training alone – 3× Cardio-respiratory CES-Dd Scale time
efficacy of different patients aged 21 30–60 min sessions/week fitness VO2 peak points not defined
types of exercise and over with stage 2. Resistance training alone –
training on I–III NSCLC who 3× 30–60 min sessions/week
cardio-respiratory have had complete 3. Combination of aerobic and
fitness in surgical resection resistance training – 3×
post-operative with curative 30–60 min sessions/week
NSCLCc patients intent in last 6 4. Attention-control
months to 3 years (progressive stretching) – as
control group – matched to 3×
30–60 min sessions/week

Walker et al. (2009) (UK) To evaluate an Aiming for 200 1. Usual care – GP and Average depression Average SCL-20Df
adapted form of a adult patients oncologist informed of severity score at 4, 8, 12, 16,
complex attending lung depression diagnosis 20, 24, 28 and 32
intervention cancer outpatient 2. Usual Care plus Depression weeks
(Depression Care clinics with Care for People with Cancer –
for People with prognosis of at sessions with a specially
Cancer) for patients least 3 months and trained nurse, supervised by a
with lung cancer a diagnosis of psychiatrist focussing on
major depression depression education,
(on SCIDe ) antidepressants, behavioural
activation and problem solving
treatment
a
Low molecular weight heparin.
b
Hospital Anxiety and Depression Scale.
c
Non-small cell lung cancer.
d
Centre for Epidemiologic Studies Depression Scale.
e
Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders.
f
Symptom Checklist Depression Scale.

Participants assigned to the counselling intervention were seen
several times per week by an experienced counsellor who aimed
to develop a relationship of trust, reduce denial, maintain hope
and encourage meaningful activities for as long as possible. In
addition, the counsellor often developed close relationships with
participants’ families and assisted with funeral arrangements.
Depressive symptoms were assessed, along with a number of
other outcomes, at 1, 3, 6, 9 and 12 months. The researchers
noted that participants who had received counselling had better
depression scores than those assigned to usual medical care at 3
months and 12 months but not at the other time points.
Porter et al. tested the efficacy of a coping skills training (CST)
protocol compared with education and support for patients with
lung cancer and their caregivers [23]. Both interventions were
delivered by telephone (14 sessions over 8 months) by registered
nurses who had been trained by psychologists and medical oncolo-
gists. Participants assigned to CST were given training in a number
of symptom management strategies, including progressive muscle
relaxation, and their caregivers were encouraged to act as coaches
in this process. Participants assigned to education and support were
given information about lung cancer and its treatment and they and
their caregivers were encouraged to discuss the participant’s can-
cer treatment. Depressive symptoms were assessed, along with a
number of other outcomes, after completion of treatment and 4
months later. No statistically significant difference was reported
between the groups.
Temel et al. evaluated the effectiveness of introducing palliative
care early after diagnosis for patients with metastatic non-small-
cell lung cancer, compared with standard oncologic care alone [24].
Participants assigned to early palliative care met with a mem-
ber of the ambulatory palliative care team within 3 weeks of
enrolment and at least monthly thereafter until death. Palliative
care clinicians delivered care according to a protocol based on
national guidelines which included assessing physical and psy-
chosocial symptoms, establishing goals of care, assisting with
treatment-related decision-making and coordinating care. Depres-
sive symptoms were assessed at 12 weeks as a secondary outcome
measure. The researchers reported that significantly fewer partici-
pants who had received early palliative care were depressed (using
questionnaire cut-offs) compared with those who had received
usual oncologic care alone.
Wu and Wang evaluated the effectiveness of supportive psy-
chotherapy on symptoms of depression and anxiety in patients
with lung cancer who were receiving combined chemotherapy
and radiotherapy, compared with the anti-cancer treatments alone
[25]. The supportive psychotherapy intervention was designed by
a psychiatrist and an oncologist and included psychological assess-
ment, cognitive therapy, education about the patient’s cancer and
its treatment, encouragement to communicate with other patients
through clubs, spending time with other patients in the com-
pany of a physician, relaxation therapy and communication with
patients’ relatives. Depressive symptoms were assessed at 1 month.
 J. Walker et al. / Lung Cancer 79 (2013) 46–53 51

Electronic database search

n = 3962

MEDLINE 811
EMBASE 2762
CENTRAL 85
PsycINFO 157
CINAHL 147
Duplicate paper1
n = 873
Titles and abstracts
reviewed
n = 3089
Not relevant
n = 2950
Titles obtained from review
articles
n= 4
Full papers for review
n = 143

Excluded n= 134

Not a trial 51
No control 3
Not randomised 3
Trial of anti-cancer treatment 5
Not lung cancer 2
Efficacy on depression outcome not
reported2 15
Not standardised depression
measure 4
Not primary research paper 29
Outcome not reported for lung cancer
subgroup 22

Relevant randomised controlled trials

n=9
Trial still in progress
(protocol only)
n= 3
Included in review
n= 6

1. Duplicates of the same paper due to searching multiple databases.

2. Depression not measured as an outcome or efficacy not evaluated (feasibility studies)

Fig. 1. Selection of studies for inclusion in the review. Duplicates of the same paper due to searching multiple databases. Depression not measured as an outcome or efficacy
not evaluated (feasibility studies).

The researchers reported that significantly fewer participants who
had received the additional psychotherapy were depressed (using
questionnaire cut-offs) compared with those who had received
anti-cancer treatment alone.
Authors of these trials reported reasons for participant with-
drawal but none explicitly discussed potential harms from the
interventions they had evaluated. Due to the clinical heterogeneity
of these trials we did not consider meta-analysis of their findings
to be appropriate.
3.2.3. Risk of bias
Table 3 shows the risk of bias in each of the trials included in the
review. We found that the reporting of procedures for participant
recruitment and outcome data collection was frequently lacking
in detail. This lack of information meant that we often judged the
risks of selection bias (due to poor allocation concealment) and of
detection bias (through unblinded data collection) to be unclear.
The risk of performance bias was judged to be high in the majority
of trials due to lack of blinding, which is a common issue in non-
pharmacological trials. The risk of attrition bias was also commonly
high due to a combination of missing data and limited explanation
of how the problem of missing data had been dealt with by the
researchers.
3.3. Trials in progress
Table 2 shows the characteristics (taken from the published
protocols) of the three trials that met our selection criteria but
were still in progress. One of these trials was designed by our
own research group to evaluate a multi-component intervention
(involving both pharmacological and psychological treatments) for
depressed patients with lung cancer [26]. The other two trials were
designed to evaluate the efficacy of different types of exercise train-
ing on cardio-respiratory function and of low molecular weight
heparin on survival; both planned to measure depressive symp-
toms as a secondary outcome [27,28].
4. Discussion
We did not find any completed trials of treatments for depres-
sion in people with lung cancer. Nor did we find any trials of
treatments known to be effective for depression in other patient
groups, such as antidepressant medication or cognitive behavioural
therapy. Consequently, and surprisingly, we do not have an evi-
dence base to guide the treatment of depressed lung cancer
patients.
52 J. Walker et al. / Lung Cancer 79 (2013) 46–53
Table 3
Risk of bias in trials included in the review.
Study Selection bias Performance bias
Random sequence Allocation Blinding of participants
generation concealment and clinicians
Bredin et al. [20] Low Low High
Carlson et al. [21] Low Low Low
Linn et al. [22] Low Unclear High
Porter et al. [23] Low Unclear High
Temel et al. [24] Low Unclear High
Wu and Wang [25] Low Unclear Unclear
We did, however, find six trials of interventions that were
intended to improve the quality of life of patients with lung cancer
in general, that is patients who were not selected for having depres-
sion. These trials were subject to some biases but their results do
suggest that enhanced care approaches are more effective in reduc-
ing depressive symptoms than standard medical care.
This review has a number of strengths: we searched for articles
systematically and included studies using clearly defined criteria
to minimise selection bias as well as using rigorous methods for
data extraction. Our review also has limitations: we included all
randomised controlled trials of interventions intended (at least in
part) to improve depressive symptoms and did not limit the review
to interventions designed specifically for depression or to trials
of participants with depression at enrolment. Had we done this,
we would not have been able to include any trials in the review.
Secondly, we did not attempt to include grey literature by con-
tacting relevant experts for unpublished manuscripts. However,
we did make substantial efforts to find all relevant published trials
through inclusive search strategies and the use of translators and
we contacted the authors of published trial protocols to determine
whether their trials had been completed.
Previous systematic reviews of treatments for depression in can-
cer patients have come to varying conclusions. A number have
suggested that psychological interventions might be beneficial for
cancer patients in general, whereas others have concluded that
the evidence for psychological and pharmacological treatments
for depressed cancer patients is limited and of only modest qual-
ity [17,18,29–34]. Notably, the authors of a recent meta-analysis
concluded that the severity of pre-intervention distress was a sig-
nificant moderator of the effect of psychosocial interventions [35].
In practical terms, this means that psychosocial interventions may
be most beneficial for those cancer patients who have a diagno-
sis of depression. Whilst the reviews that have focused on patients
with incurable disease or those receiving palliative care have noted
encouraging results from trials of psychological treatments they
have also noted the lack of clinical trials in patients with a diagnosis
of depression [29,34].
5. Conclusion
We have some evidence to suggest that improvements in the
care of patients with lung cancer reduce their levels of depressive
symptoms. However, it is a matter of some concern that we found
no randomised trials of treatments for patients with lung cancer
who have a diagnosis of depression and no trials of treatments that
are known to be effective for depression in the general population.
The consequence is a lack of high quality evidence to guide the
treatment of depression in people who have lung cancer. Whilst
it is probably reasonable to use standard depression treatments in
depressed lung cancer patients until more specific evidence is avail-
able, clinicians should be aware that the effectiveness and potential
adverse effects of these treatments remain unknown in this patient
group. Better evidence from well conducted randomised trials is
Detection bias Attrition bias Reporting bias
Blinding of Incomplete Selective reporting
outcome assessors outcome data
Unclear High Low
Unclear High Low
Low Low Unclear
Low High Unclear
Unclear Low Low
Low Low Unclear
urgently required to guide the treatment of depression in patients
with lung cancer.
Conflict of interest statement
None declared.
Acknowledgements
This work was funded by the charity Cancer Research UK. The
funder had no role in the study design or in the collection, analysis
and interpretation of data. The authors would also like to thank
Rachel Chen for her assistance with translations.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/j.lungcan.
2012.09.014.
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