ATLANTA—Screening for depression in cancer patients can be as simple as asking two quick questions, according to a plenary study reported here at the American Society for Radiation Oncology Annual Meeting: “Over the last two weeks how often have you been bothered by either of the following problems: (1) Little interest or pleasure in doing things; and (2) feeling down, depressed, or hopeless?
Patients could select 0 for “not at all”; 1 for “several days”; 2 for “more than half the days”; and 3 for “nearly every day.” A total of 3 or more for the questionnaire was scored as positive for depression.
“Detection of depression in cancer patients is an important public health priority, and the ability to screen and treat cancer patients for depression can have a major impact on a patient's quality of life,” said the first author of the study, William Small, Jr, MD, Chair of the Department of Radiation Oncology at Loyola University. “This simple two-item screening might be used as a standard of care for the assessment of depression in cancer patients receiving radiotherapy.”
In the study (Abstract 3—accessible via online.myiwf.com/astro2013/Abstract.aspx), depression screening was performed before treatment or within two weeks of treatment for first diagnosis of any tumor. The screening evaluations included the nine-item Patient Health Questionnaire (PHQ-9), the Hopkins Symptom Checklist (HSCL-25), and the single-item National Comprehensive Cancer Network Distress Thermometer (NCCN-DT). The first two questions of the PHQ-9 formed the PHQ-2.
Patients who screened positive on the PHQ-9, HSCL-25, or NCCN-DT were then given the Structured Clinical Interview for DSM IV Disorders (SCID) Mood Disorder modules by telephone. A sample of patients who screened negative were also administered the SCID by telephone, as controls.
Small said 454 eligible patients were accrued from 37 sites—95 percent of which were part of the Community Clinical Oncology Program. The patients' median age was 59 years, two thirds were female, 83 percent were Caucasian, approximately 14 percent were taking psychotropic medications, and the most common malignancy was breast cancer, in 45 percent.
All eligible patients completed the screening questionnaires, Small reported, and 16 percent (75 patients) screened positive for depressive symptoms.
PHQ-9 and the PHQ-2 had similar accuracy in detecting depression—nine and 7.9 percent positive, respectively, he said. “The PHQ-2 and PHQ-9 demonstrated good psychometric properties for identifying major depressive episode,” but the NCCN-DT did not.
Assistance Generally Available
Small said approximately three-quarters of the sites participating in the study routinely screen patients for depression at their radiotherapy facility, and about half of all participating sites screen patients at the initial visit.
Mental health services were available at 23 of the 34 radiotherapy facilities (68%), but two-thirds of the sites had only social workers and few had psychologists or psychiatrists.
In a news conference at the meeting, Small said the two-item questionnaire could be administered in just one or two minutes, by a physician, nurse, or technician.
Regarding limitations, Small said the main caveat was that almost half of the participants in the study had breast cancer, so the results may not be generalizable. In addition, the questionnaire could diagnose depression but not its severity.
The study's conclusions, though, he said, were straightforward: (1) that screening for depression in a radiotherapy settings was feasible and acceptable to patients; and (2) that most radiotherapy facilities were equipped for psychosocial care.
“Since the PHQ-2 demonstrated psychometric properties equivalent to the PHQ-9 and superior to the NCCN-DT, the PHQ-2 should be used to identify patients in need of further assessment and treatment for depression,” he concluded. “I think this should be the standard of care, and I think every radiation oncologist should administer a depression questionnaire.”
The study was supported by RTOG and CCOP grants from the National Cancer Institute.
Discussant: Some Patients Might Be Missed
The Discussant for the study, Andrew Miller, MD, Professor of Psychiatry and Behavioral Sciences at Emory University and Director of Psychiatric Oncology at Winship Cancer Center Institute, picked up on the limitation of the study that Small had acknowledged, regarding how well the PHQ-2 questionnaire diagnoses the severity of depression.
Miller said it's important to remember that depression is a syndrome made up of a series of symptoms that represent many domains of mental functioning, only two of which are represented on the PHQ-2. Other domains include motor activity, metabolism, energy, sleep, cognition, self perception, and other factors important to a patient's quality of life.
“What we're doing in psychiatry is throwing all our diagnoses out the window, and we're moving to seeing these domains as representing different neural circuits in the brain,” he explained. “We also realize that these domains, like depressed mood, anhedonia, or fatigue, cut across multiple disorders and are not owned by any one disorder or diagnosis.”
In measuring depression, the more questions asked the better, in order to understand how severe the depression is and what treatment is appropriate, he said. For mild depression, psychiatric therapy or counseling may be sufficient; for moderate depression the patient probably needs medications; and for severe depression one might need to be in the hospital.
“The PHQ-2 is good for diagnosis. but unfortunately is not very good in terms of severity because there are only two items,” he said. “With the longer PHQ-9 with nine questions, you can begin to get an idea in your patient population about which domains are changing and which ones are not; it gives you a more nuanced picture of what's going on in the brain that is related to the circuits that regulate these different domains. The PHQ-2 may not pick up on symptoms in the other domains and so the patients might not be properly referred.”