By Kurt Ullman Cancer, anxiety, and depression have been linked together for many years. The problem is big enough that the National Comprehensive Cancer Network (NCCN) includes an algorithm for identifying and treating distress among their guidelines for supportive care.
Cancer, anxiety, and depression have been linked together for many years. The problem is big enough that the National Comprehensive Cancer Network (NCCN) includes an algorithm for identifying and treating distress among their guidelines for supportive care.
“There are few reliable population-based estimates available, but multiple small surveys show higher prevalence of depression and anxiety among cancer patients when compared to the general population,” says Paul Jacobsen, PhD, chair of the Department of Health Outcomes and Behavior at the Moffitt Cancer Center in Tampa, FL. “More importantly, those with other pre-existing morbidities, those with more severe disease and/or undergoing more aggressive treatment, as well as younger patients, are at even higher risk.”
As with cancer, one of the first concerns is case-finding. The NCCN suggests the use of a “Distress Thermometer” that has numbers on it from 0 to 10. Patients are asked to circle the number that best describes how much distress they have been experiencing during the past week, including today. A score of 4 or higher indicates that follow-up questions should be asked to clarify what is causing the problem.
Simply asking the patient whether he or she is depressed may improve identification of those with depression. In many instances, a single-item interview question has been found to be useful. Screening can be as simple as asking “Are you depressed?”
If either of these techniques yield reason for concern, the Hospital Anxiety and Depression Scale, the Psychological Distress Inventory, and the Edinburgh Depression Scale have all been validated in cancer populations.
“The next question becomes why the patient is depressed,” says Jacobsen. “Are they having trouble paying their bills, are there family troubles, are there side effects that are causing concerns? Different sources of distress would lead to different interventions.”
If depression is suspected, an assessment for suicidality should be done by asking the patient if they are having feelings that they want to die. Some studies show that, at best, the incidence of suicidality in cancer patients is equal to the general population, while others suggest the rate might be up to twice as high. The risk appears to peak within the first few months following diagnosis.
Patients who have suicidal thoughts require careful assessment. The risk of suicide increases if the patient reports ideation (thoughts of suicide) plus a plan (description of the means). Risk continues to increase to the extent that the plan is likely to cause death—also known as lethality. Things to consider when assessing lethality include the availability of the means outlined in the plan, can the plan be stopped once it is started, and overall proximity to help.
The decision to treat the patient or refer to a psychiatric professional is initially a personal preference of the oncologist.
“Some oncologists have an interest in depression and do a great job treating it,” says Jacobsen. “Others may not feel comfortable with these patients and refer them to other practitioners right away. Either model is fine as long as the patient receives proper treatment.”
Jacobsen notes, however, that finding psychotherapy resources is not always easy. “Just as there are some oncologists who do not like to work with psychosocial issues, there are some psychiatrists who are hesitant to treat those with cancer,” he says.
Area Cancer Centers will have knowledge of which area psychiatrists, psychologists, or advanced practice nurses work with cancer patients. Local chapters of the American Cancer Society or Mental Health America often will have listings of group meetings for those with cancers.
Even for those patients who are treated by their oncologist, guidelines generally say that all people with suicidal ideation and thoughts should be immediately referred to a mental health professional. Suicidality should be treated as a true life-threatening emergency.
The other group who should be considered for referral to a mental health professional would be those who do not respond to first-line antidepressant therapy within 2 weeks.
“Depression management is not all that different from pain management,” says Jacobsen. “Most oncologists are pretty adept at starting people on an extended-release opioid. Once the patient is beyond that, and still not doing well, they need to see a specialist.”
Primary care has developed a collaborative care model for depression, with dozens of trials showing such coordination to be an effective way to treat the disease. Important parts of the intervention include routine screening, having a treatment algorithm that includes specific medications and counseling, as well follow-up and reevaluation.
There are many resources available to the oncologist to help develop their treatment models. As mentioned earlier, the NCCN has a specific guideline for stress management that includes information on depression. In addition, the National Cancer Institute has an extensive depression resource as part of its PDQ® series.
“It is increasingly important that we are able to destigmatize mental health problems,” says Jacobsen. “Just like we managed to destigmatize cancer.”