Anxiety and Depression in Adult Survivors of Cancer

All patients with cancer and any patient-identified caregiver, family member, or trusted confidant should be offered information^a regarding depression and anxiety. They should also be offered resources, such as the providers’ contact information for further evaluation and treatment within or external to the facility whenever available. ( EB , I , B , S )

Clinicians should use a stepped-care model, i.e., selecting the most effective and least resource intensive intervention based on symptom severity when selecting treatment for anxiety and/or depression. Other variables which may inform the choice of treatment approach include the following:

• Psychiatric history, i.e., prior diagnoses, with or without treatment
• History of substance use
• Prior mental health treatment response
• Functional abilities and/or limitations related to self-care, usual activities, and/or mobility
• Recurrent or advanced cancer
• Presence of other chronic disease(s) (e.g., cardiac disease)
• Member of socially and/or economically marginalized group (e.g., Black race, low socioeconomic status [SES])

( EB , I , B , S )

Psychological and psychosocial interventions provided by mental health practitioners should derive from manualized, empirically supported treatments. Manuals for evidence-based treatments specify content, structure, delivery mode, session number, treatment duration, and related topics. Linguistic, cultural, and socioecological contexts need to guide any treatment tailoring. ( EB , I , B , M )

When making a referral for further evaluation or psychological care, clinicians should make every effort to reduce barriers and facilitate patient follow-through. Determining follow through to the first appointment is essential as is discovering any barriers that may have arisen for the patient. Thereafter, determining patient satisfaction and assisting with any new and/or continuing barriers would also be helpful. ( IC , Ins , B , M )

For patients who have symptoms of both depression and anxiety, treatment of depressive symptoms should be prioritized. Alternatively, treatment with a unified protocol (i.e., combining cognitive behavior therapy [CBT] treatments for depression and anxiety) may be used. ( EB , H , B , S )

For patients referred to and receiving psychological treatment, mental health professionals should regularly assess treatment response (e.g., pre-treatment, 4 weeks, 8 weeks, and end of treatment). ( EB , I , B , S )

If pharmacologic treatment is used, the treating clinician should regularly (e.g., 4 and 8 weeks) assess using standardized validated instruments, the extent of a patient’s symptom relief, side effect and adverse event occurrence, and satisfaction. If symptoms are stable or worsening, the treating clinician should re-evaluate the plan and revise. ( IC , Ins , B , S )

After 8 weeks of treatment for depression and/or anxiety, if there is little improvement in symptoms despite good adherence, the treating clinician should adjust the regimen (e.g., add a psychological or pharmacological intervention to a single treatment; if pharmacologic, change the medication; and if group therapy, refer to individual therapy). The same considerations may apply if patient satisfaction with treatment is low and/or barriers to treatment exist. ( IC , Ins , B , M )