Screening, Assessment, and Care of Anxiety and Depressive Symptoms in Adults With Cancer

All patients should be screened for depressive symptoms at their initial visit, at appropriate intervals, and as clinically indicated, especially with changes in disease or treatment status (ie, post-treatment, recurrence, progression) and transition to palliative and end-of-life care.

○ The Canadian Association of Psychosocial Oncology (CAPO) and the Canadian Partnership Against Cancer (the Partnership) guideline Assessment of Psychosocial Health Care Needs of the Adult Cancer Patient suggests screening at initial diagnosis, start of treatment, regular intervals during treatment, end of treatment, post-treatment or at transition to survivorship, at recurrence or progression, advanced disease, when dying, and during times of personal transition or reappraisal such as family crisis, during post-treatment survivorship and when approaching death.

Screening should be done using a valid and reliable measure that features reportable scores (dimensions) that are clinically meaningful (established cut-offs).

When assessing a person who may have depressive symptoms, a phased screening and assessment is recommended that does not rely simply on a symptom count.

○ As a first step for all patients, identification of the presence or absence of pertinent history or risk factors (see depression algorithm) is important for subsequent assessment and treatment decision making.

○ As a second step, two items from the nine-item Personal Health Questionnaire (PHQ-9) can be used to assess for the classic depressive symptoms of low mood and anhedonia. For individuals who endorse either item (or both) as occurring for more than half of the time or nearly every day within the last 2 weeks (ie, a score of ≥2), a third step is suggested in which the patient completes the remaining items of the PHQ-9. It is estimated that 25% to 30% of patients would need to complete the remaining items. The traditional cutoff for the PHQ-9 is ≥10. The Panel's recommended cutoff score of ≥8 is based on a study of the diagnostic accuracy of the PHQ-9 with cancer outpatients. A meta-analysis by Manea et al also supports the ≥8 cutoff score.

○ For patients who complete the latter step, it is important to determine the associated sociodemographic, psychiatric or health comorbidities, or social impairments, if any, and the duration of depressive symptoms.

○ Of special note, one of remaining seven items of the PHQ-9 assesses thoughts of self harm (ie, “Thoughts that you would be better off dead or hurting yourself in some way”). Among patients with moderate to severe or severe depression, such thoughts are not rare. Having noted that, it is the frequency and/or specificity of the thoughts that are most important vis-à-vis risk. Some clinicians may choose to omit the item from the PHQ-9 and administer eight items. It should be noted, however, that doing so may artificially lower the score, with the risk of some patients appearing to have fewer symptoms than they actually do. Such changes also weaken the predictive validity of the score and the clarity of the cutoff scores. It is important to note that individuals do not typically endorse a self-harm item exclusively or independent of other symptoms; rather, it occurs with several other symptom endorsements. Thus, it is the patient's endorsement of multiple symptoms that will define the need for services for moderate to severe symptomatology.

Consider special circumstances in the assessment of depressive symptoms. These include but are not limited to the following:

(1) use culturally sensitive assessments and treatments as is possible,
(2) tailor assessment or treatment for those with learning disabilities or cognitive impairments,
(3) be aware of the difficulty of detecting depression in the older adult.

Specific concerns such as risk of harm to self and/or others, severe depression or agitation, or the presence of psychosis or confusion (delirium) require immediate referral to a psychiatrist, psychologist, physician, or equivalently trained professional.

Assessments should be a shared responsibility of the clinical team, with designation of those who are expected to conduct assessments as per scope of practice.

The assessment should identify signs and symptoms of depression, the severity of cancer symptoms (eg, fatigue), possible stressors, risk factors, and times of vulnerability. A range of problem checklists is available to guide the assessment of possible stressors. Examples of these are accessible at www.asco.org/adaptations/depression. Clinicians can amend checklists to include areas not represented or ones unique to their patient populations.

Patients should first be assessed for depressive symptoms using the PHQ-9.

If moderate to severe or severe symptomatology is detected through screening, individuals should have further diagnostic assessment to identify the nature and extent of the depressive symptoms and the presence or absence of a mood disorder.

Medical or substance-induced causes of significant depressive symptoms (eg, interferon administration) should be determined and treated.

As a shared responsibility, the clinical team must decide when referral to a psychiatrist, psychologist, or equivalently trained professional is needed. This includes, for example, all patients with a PHQ-9 score in the severe range or patients in moderate range but with pertinent history and/or risk factors. Such would be determined using measures with established reliability, validity, and utility (eg, cutoff or normative data available) or standardized diagnostic interviews for assessment and diagnosis of depression.

For any patient who is identified as at risk of harm to self and/or others, refer to appropriate services for emergency evaluation. Facilitate a safe environment and one-to-one observation, and initiate appropriate harm-reduction interventions.

First, treat medical causes of depressive symptoms (eg, unrelieved symptoms such as pain and fatigue) and delirium (eg, infection or electrolyte imbalance).

For optimal management of depressive symptoms or diagnosed mood disorder, use pharmacologic and/or nonpharmacologic interventions (eg, psychotherapy, psycho-educational therapy, cognitive-behavioral therapy, and exercise) delivered by appropriately trained individuals.

These guidelines make no recommendations about any specific antidepressant pharmacologic regimen being better than another. The choice of an antidepressant should be informed by the adverse effect profiles of the medications; tolerability of treatment, including the potential for interaction with other current medications; response to prior treatment; and patient preference. Patients should be warned of any potential harm or adverse effects.

Offer support and provide education and information about depression and its management to all patients and their families, including what specific symptoms and what degree of symptom worsening warrants a call to the physician or nurse.

Special characteristics of depressive disorders are relevant for diagnosis and treatment, including the following.

○ Many individuals (50% to 60%) with a diagnosed depressive disorder will have a comorbid anxiety disorder, with generalized anxiety being the most prevalent.

○ If an individual has comorbid anxiety symptoms or disorder(s), the usual practice is usually to treat the depression first.

○ Some people have depression that does not respond to an initial course of treatment.

It is recommended to use a stepped care model and tailor intervention recommendations based on variables such as the following:

○ Current symptomatology level and presence or absence of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) diagnosis

○ Level of functional impairment in major life areas

○ Presence or absence of risk factors

○ History of and response to previous treatments for depression

○ Patient preference

○ Persistence of symptoms after receipt of an initial course of depression treatment

Psychological and psychosocial interventions should derive from relevant treatment manuals for empirically supported treatments that specify the content and guide the structure, delivery mode, and duration of the intervention.

Use of outcome measures should be routine (minimally pre- and post-treatment) to

(1) gauge the efficacy of treatment for the individual patient,
(2) monitor treatment adherence, and
(3) evaluate practitioner competence.

It is common for persons with depressive symptoms to lack the motivation necessary to follow through on referrals and/or to comply with treatment recommendations. With this in mind, do the following on a biweekly or monthly basis, until symptoms have remitted.

○ Assess follow-through and compliance with individual or group psychological or psychosocial referrals, as well as satisfaction with these services.

○ Assess compliance with pharmacologic treatment, patient's concerns about adverse effects, and satisfaction with the symptom relief provided by the treatment.

○ If compliance is poor, assess and construct a plan to circumvent obstacles to compliance, or discuss alternative interventions that present fewer obstacles.

○ After 8 weeks of treatment, if symptom reduction and satisfaction with treatment are poor, despite good compliance, alter the treatment course (eg, add a psychological or pharmacologic intervention, change the specific medication, refer to individual psychotherapy if group therapy has not proved helpful).