Elsevier

General Hospital Psychiatry

Volume 26, Issue 2, March–April 2004, Pages 121-128
General Hospital Psychiatry

Psychiatry and primary care
Distress, psychiatric morbidity, and prescriptions for psychotropic medication in a breast cancer waiting room sample

https://doi.org/10.1016/j.genhosppsych.2003.08.012Get rights and content

Abstract

We examined relationships among psychiatric screening, the prevalence of psychiatric morbidity, and prescription rates for psychotropic medication in a waiting room sample of breast cancer patients (N=113). Rates of distress (29%), major depressive disorder (MDD; 9%), and generalized anxiety disorder (GAD; 6%) were low and similar to those found in primary care settings. A substantial proportion of patients (52%) had received psychotropic medication during treatment, including almost half (48%) of those without a current psychiatric diagnosis. Most individuals with MDD received pharmacotherapy during cancer treatment (80%), although only half of those with GAD were treated. Overall high rates psychotropic medication negatively impacted the efficiency of screening, and individuals with elevated distress were about 6 times less likely to represent a case of untreated psychiatric morbidity than to be a new case. We conclude that the risk of psychiatric morbidity attributable to breast cancer may be lower and treatment rates for psychiatric morbidity higher than previously believed and that screening is unlikely to provide efficient identification of untreated psychiatric morbidity. Adequacy of follow-up care is unclear and medication may be prescribed nonspecifically. The low rate of untreated psychiatric morbidity may signal a need for multisite collaborations to generate adequate numbers of participants in clinical trials.

Introduction

Although rates of psychiatric morbidity are assumed to be elevated among cancer patients [1], [2], morbidity is believed to go largely undetected and untreated. Routine use of brief screening instruments has been proposed as a solution to this problem [3], [4], [5]. The relevant literature, however, is limited and may be outdated, given recent increases in the rate of psychotropic medication prescribed in both the community and medical settings [6], [7].

Breast cancer has the greatest 1-year incidence of any cancer among women, and breast cancer survivors constitute the largest group of female cancer survivors at 5 years and beyond [8]. Although early in the 20th century the life-expectancy after diagnosis was about 3 years, [9] detection of breast cancer is now more likely to initiate a long-term stress process than an acute health crisis ending in early death, and the 5-year relative survival rate is 86% [10]. Yet, as the second leading cause of cancer-related death among women, breast cancer remains a life-threatening and life-altering experience that can be associated with significant psychological distress [11].

The performance of psychiatric screening instruments has been well studied in general medical populations, primarily with respect to depression, and the general consensus is that with appropriate cutpoints most instruments perform comparably [12], [13]. Routine screening alone, however, is not sufficient to improve the outcome of psychiatric morbidity, although it may be a crucial component of more extensive practice modifications to improve care for psychiatric comorbidity among general medical patients [14], [15], [16].

It is unclear how such screening instruments perform in routine cancer care. Unpublished data (Maunsell, 1999, personal communication) suggest that more than half of breast cancer patients present with elevated distress at some point during treatment, which is a lower estimate than others [17]. The degree to which such distress indicates a need for intervention is unclear, as two thirds of distressed patients may be expected to improve in the absence of formal intervention [18]. There may be a typical trajectory such that most patients experience a reduction in distress within weeks of diagnosis and considerable improvement within 3 to 4 months [19], [20], [21], [22]. On the other hand, there is a consensus that not all distress among breast cancer patients resolves so readily [23].

Estimates of the prevalence of major depression among breast cancer patients range from 2 to 48% [11], while estimates of anxiety disorders among cancer patients range from less than 1 to 49% [24]. Higher estimates variously reflect use of symptom rather than syndrome definitions of disorder, self-report questionnaires, and reliance on psychiatric referrals or oversampling of the most ill or dying patients. Estimates relying on semistructured interviews tend to suggest that 9 to 24% of breast cancer patients meet criteria for major depression during cancer care [25], [26], [27], [28] and 10 to 30% of cancer patients meet criteria for anxiety disorder [24].

Primary care physicians fail to diagnose much of the psychiatric disorder presented to them [29], [30], [31], [32], and there is reason to assume that oncologists would perform even more poorly because of competing demands and less training in mental health issues [33], [34], [35], [36], [37]. Although the literature is limited, one study found that oncologists missed 60% of the depression in a sample of cancer patients [38]. Similarly, Fallowfield and colleagues [39] found that oncologists failed to detect elevated distress 71% of the time, while Passik and colleagues [40] found that physicians misclassified cancer patients reporting moderate-to-severe depression on the Zung Self-rating Depression Scale [41] 87% of the time. Indeed, 49% of those reporting moderate-to-severe depressive symptoms in the Passik [40] study were rated by their oncologists as having essentially no symptoms of depression. However, the bulk of such studies use self-reported distress as the criterion for evaluating clinician performance and the extent to which distress warrants intervention remains unclear. Nondetection of distress in the absence of demonstrated clinical need or effective treatment options does not necessarily indicate poor care. Yet, evidence exists that a substantial number of cancer patients are incorrectly identified with major depression, and that patients identified with major depression receive inadequate treatment [35], [40].

There is a need to update statements about the detection and treatment of psychiatric morbidity in medical settings, as much of the extant data were gathered before the mid-1990s and may not reflect increases in the rate of antidepressant prescriptions over the past decade. From 1991 to 1997, the annual number of antidepressant prescriptions written in the United States by primary providers increased from 25 million to 50 million, and there was an increase from 15 million to 33 million for prescriptions by psychiatrists [42]. In some segments of the population, the proportion of individuals who have received an antidepressant may exceed the prevalence of depression [43], [44]. Data concerning cancer patients are limited, but one recent study found that the prevalence of major depression in hospice care was 17%, although 40% of all patients had an antidepressant prescription [45].

We examined psychiatric morbidity and prescription of psychotropic medication in a sample of women being treated for breast cancer in a comprehensive cancer center. Our aims were 3-fold: 1) to assess the yield of routine screening in the waiting room of a specialty breast cancer clinic; 2) to establish the prevalence of major depression, generalized anxiety disorder, and research diagnosis of minor depression in this sample, 3) to assess rates of prescription for psychotropic medication and their relationship to diagnoses.

Section snippets

Participants

Participants were a waiting room sample of 113 women undergoing treatment at a tertiary care facility specializing in breast cancer. In total, 153 women were approached, 98% (n=150) gave consent and contributed partial data, and 75% completed diagnostic interviews. Individuals completing diagnostic interviews did not differ from those who did not in years since cancer diagnosis, or, when applicable, years since metastases or relapse, all ts <.90, ns. Similarly, there was no difference between

Demographics

Participants were primarily middle aged (M=55.8 years; R=34–89 years), European American (80%), married or living in a marriage-like situation (72%), parents (90%), and about equally likely to be employed (54%) as not. This was a well-educated group, with 60% having received at least a 2-year college degree and 24% having completed a graduate degree. Time since diagnosis of cancer varied, with 31% being initially diagnosed more than 5 years previously, 35% between 2 and 5 years, 14% between 1

Discussion

Screening of a breast cancer waiting room sample found that 29% of patients were in the distressed range. Follow-up interviews found that approximately 9% met criteria for major depression, 7% met research criteria for minor depression, and 6% met criteria for GAD. Consistent with research in other populations, the HSCL-25 functioned moderately well as a screening instrument. However, as a clinical tool, it would have missed about one-third of patients with MDD, more than one-half of those with

Conclusions

Our findings have implications for the conduct of clinical research concerning psychiatric morbidity among breast cancer patients. Given the rates of disorder, such trials may require larger pools of patients than anticipated to ensure adequate sample sizes, making multi-site trials a necessity. This problem may be compounded by the relatively large proportion of patients already identified and receiving psychotropic medication.

Note

1For analyses examining false positive classification errors using the HSCL-25 as a screen for psychiatric morbidity, only individuals without a diagnosable condition (MDD, MinD, or GAD) are included.

Acknowledgements

This study was supported by NIMH Center Grant, MH 52129-06.

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