Last updated December 18, 2021

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

RECOMMENDATIONS

DEPRESSIVE SYMPTOMS

Screening

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.

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

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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.

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Assessment

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.
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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.
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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.
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Patients should first be assessed for depressive symptoms using the PHQ-9.
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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.
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Medical or substance-induced causes of significant depressive symptoms (eg, interferon administration) should be determined and treated.
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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.
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Treatment and Care Options

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

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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

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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.
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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.

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Follow-Up and Reassessment

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).

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ANXIETY SYMPTOMS

Screening

All health care providers should routinely screen for the presence of emotional distress and specifically symptoms of anxiety from the point of diagnosis onward.
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All patients should be screened for distress at their initial visit, at appropriate intervals and as clinically indicated, especially with changes in disease status (ie, post-treatment, recurrence, progression) and when there is a transition to palliative and end-of-life care.

○ The CAPO and 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.

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Screening should identify the level and nature (problems and concerns) of the distress as a red flag indicator.
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Screening should be done using a valid and reliable tool that features reportable scores (dimensions) that are clinically meaningful (established cut-offs).

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Anxiety disorders include specific phobias and social phobia, panic and agoraphobia, generalized anxiety disorder (GAD), obsessive compulsive disorder, and post-traumatic stress disorder (PTSD).
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It is recommended that patients be assessed for GAD, as it is the most prevalent of all anxiety disorders and it is commonly comorbid with others, primarily mood disorders or other anxiety disorders (eg, social anxiety disorder).
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Use of the Generalized Anxiety Disorder (GAD) -7 scale is recommended. 
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Patients with GAD do not necessarily present with symptoms of anxiety, per se. The pathognomic GAD symptom (ie, multiple excessive worries) may present as “concerns” or “fears.” Whereas cancer worries may be common for many, GAD worry or fear may be disproportionate to actual cancer-related risk (eg, excessive fear of recurrence, worry about multiple symptoms or symptoms not associated with current disease or treatments). Importantly, an individual with GAD has worries about a range of other, noncancer topics and areas of his or her life.
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It is important to determine the associated home, relationship, social, or occupational impairments, if any, and the duration of anxiety-related symptoms. As noted above, problem checklists can be used. Examples of these are accessible at www.asco.org/adaptations/depression. Clinicians can amend the checklists to include additional key problem areas or ones unique to their patient populations.
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As with depressive symptoms, consider special circumstances in screening and assessment of anxiety, including using culturally sensitive assessments and treatments and tailoring assessment or treatment for those with learning disabilities or cognitive impairments.
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Assessment

Specific concerns such as risk of harm to self and/or others, severe anxiety or agitation, or the presence of psychosis or confusion (delirium) require referral to a psychiatrist, psychologist, physician, or equivalently trained professional.
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When moderate to severe or severe symptomatology is detected through screening, individuals should have a diagnostic assessment to identify the nature and extent of the anxiety symptoms and the presence or absence of an anxiety disorder or disorders.
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Medical and substance-induced causes of anxiety should be diagnosed and treated.
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As a shared responsibility, the clinical team must decide when referral to a psychiatrist, psychologist or equivalently trained professional is needed (ie, all patients with a score in the moderate to severe or severe range, with certain accompanying factors and/or symptoms, identified using valid and reliable measures for assessment of symptoms of anxiety).
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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.
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The assessment should identify signs and symptoms of anxiety (eg, panic attacks, trembling, sweating, tachypnea, tachycardia, palpitations, and sweaty palms), severity of symptoms, possible stressors (eg, impaired daily living), risk factors, and times of vulnerability, and should also explore underlying problems/causes.
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A patient considered to have severe symptoms of anxiety after the further assessment should, where possible, have confirmation of an anxiety disorder diagnosis before any treatment options are initiated (eg, DSM-V, which may require making a referral).
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Treatment and Care Options

For any patient who is identified as at risk of harm to self and/or others, clinicians should refer to appropriately trained professionals for emergency evaluation. Facilitate a safe environment and one-to-one observation, and initiate appropriate harm-reduction interventions.
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It is suggested that the clinical team making a patient referral for the treatment of anxiety review with the patient, in a shared decision process, the reason(s) for and potential benefits of the referral. Further, it is suggested that the clinical team subsequently assess the patient's compliance with the referral and treatment progress or outcomes.
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First treat medical causes of anxiety (eg, unrelieved symptoms such as pain and fatigue) and delirium (eg, infection or electrolyte imbalance).
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For optimal management of moderate to severe or severe anxiety, consider pharmacologic and/or nonpharmacologic interventions delivered by appropriately trained individuals. Management must be tailored to individual patients, who should be fully informed of their options.
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For a patient with mild to moderate anxiety, the primary oncology team may choose to manage the concerns by usual supportive care.
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The choice of an anxiolytic 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. Caution is warranted with respect to the use of benzodiazepines in the treatment of anxiety, specifically over the longer term. These medications carry an increased risk of abuse and dependence and are associated with adverse effects that include cognitive impairment. As a consequence, use of these medications should be time limited in accordance with established psychiatric guidelines.
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Offer support and provide education and information to all patients and their families about anxiety and its treatment and what specific symptoms or symptom worsening warrant a call to the physician or nurse.
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It is recommended to use a stepped care model to tailor intervention recommendations on the basis of variables such as the following:

○ Current symptomatology level and presence/absence of DSM-V diagnoses

○ Level of functional impairment in major life areas

○ Presence/absence of risk factors

○ Chronicity of GAD and response to previous treatments, if any

○ Patient preference

○ Persistence of symptoms after receipt of the current anxiety treatment.

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Psychological and psychosocial interventions should be derived from relevant treatment manuals of 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.

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Follow-Up and Reassessment

Because cautiousness and a tendency to avoid threatening stimuli are cardinal features of anxiety pathology, it is common for persons with symptoms of anxiety not to follow through on potentially helpful referrals or treatment recommendations. With this in mind, it is recommended that the mental health professional or other member of the clinical team treating the patient's anxiety, on a monthly basis or until symptoms have subsided:

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

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

○ Consider tapering the patient from medications prescribed for anxiety if symptoms are under control and if the primary environmental sources of anxiety are no longer present. Longer periods of tapering are often necessary with benzodiazepines, particularly with potent or rapidly eliminated medications.

○ 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).

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Recommendation Grading

Overview

Title

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

Authoring Organization

Publication Month/Year

April 14, 2014

Document Type

Other

External Publication Status

Published

Country of Publication

US

Target Patient Population

Adults (age 18 years and older) at any phase of the cancer continuum and regardless of cancer type

Target Provider Population

Medical, surgical, and radiation oncologists; psychiatrists; psychologists; primary care providers; nurses

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Home health, Hospice, Hospital

Intended Users

Social worker, psychologist, physician assistant, physician, occupational therapist, nurse practitioner, nurse, counselor

Scope

Counseling, Assessment and screening, Management

Keywords

cancer, depression, anxiety

Source Citation

DOI: 10.1200/JCO.2013.52.4611 Journal of Clinical Oncology 32, no. 15 (May 20, 2014) 1605-1619.