Psychiatry and primary careDistress, psychiatric morbidity, and prescriptions for psychotropic medication in a breast cancer waiting room sample
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 The relevant literature, however, is limited and may be outdated, given recent increases in the rate of psychotropic medication prescribed in both the community and medical settings [6], [7].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 Unpublished data (Maunsell, 1999, personal communication) suggest that more than half of breast cancer patients present with elevated distress at some point during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.
References (84)
- et al.
Psycho-oncologyWhere have we been? Where are we going?
Eur J Cancer
(1999) - et al.
Trends in the prescribing of antidepressant pharmacotherapyoffice-based visits, 1990–1995
Clin Ther
(1998) - et al.
Should we screen for depression? Caveats and potential pitfalls
Appl Prev Psychol
(2000) - et al.
Identifying depression in primary carea literature synthesis of case-finding instruments
Gen Hosp Psychiatry
(2002) - et al.
Screening for depression in medical carepitfalls, alternatives, and revised priorities
J Psychosom Res
(2003) - et al.
Mastectomy or conservation for early breast cancerpsychological morbidity
Eur J Cancer
(1992) Psychiatric morbidity following mastectomypreoperative predictors and types of illness
J Psychosom Res
(1987)- et al.
Nondetection of depression by primary care physicians reconsidered
Gen Hosp Psychiatry
(1995) - et al.
Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary careHampshire Depression Project randomised controlled trial
Lancet
(2000) - et al.
Screening for anxiety and depression in women with breast cancerpsychiatry and medical oncology gear up for managed care
Psychosomatics
(1999)
The recognition of psychiatric morbidity on a medical oncology ward
J Psychosomatic Res
Depression in the normal aged
Psychosomatics
Impairment in major depressionimplications for diagnosis
Compr Psychiatry
Agreement between face-to-face and telephone administered versions of the depression section of NIMH Diagnostic Interview Schedule
J Psychiat Res
Assessment of psychiatric-illness severity by family physicians
Soc Sci Med
The prevalence, nature and co-morbidity of depressive disorders in primary care
Gen Hosp Psychiatry
Sociological influences on antidepressant prescribing
Soc Sci Med
Anxiety and depression in breast cancer patients at low risk of recurrence compared with the general populationa valid comparison?
J Clin Epidemiol
Psychosocial adjustment and quality of life in women with breast cancer and benign breast problemsa controlled comparison
J Clin Epidemiol
The prevalence of psychiatric disorders among cancer patients
JAMA
Cancer and depression
Br J Psychiat
Depressive disorders in an out-patient oncology settingprevalence, assessment, and management
Psychooncology
Preliminary guidelines for the treatment of distress
Oncology
Pharmacological treatment of depression in nursing home residentsa mental health services perspective
J Geriatr Psychiatry Neurol
The prevalence of cancer among adults in the United States
Cancer
Occupational and psychotherapy in the treatment of cancer
Medical J Rec
Breast cancer facts and figures 2001–2002
Cancer and depressiontheory and treatment
Psychiatr Ann
The relationship of self-reported distress to psycho-pathology
J Consult Clin Psychol
Screening for depression in adultsa summary of the evidence for the U.S. Preventive Services Task Force
Ann Intern Med
Randomized trial of a psychological distress screening program after breast cancereffects on quality of life
J Clin Oncol
Screening procedures for psychosocial distress
The prevalence of psychological distress by cancer site
Psychooncology
Psychological interventions for cancer patients to enhance the quality of life
J Consult Clin Psychol
Psychosocial impact of breast cancera critical review
Ann Behav Med
Psychological distress after initial treatment of breast cancerassessment of potential risk factors
Cancer
Can mood disorder in women with breast cancer be identified preoperatively?
Br J Cancer
Anxiety disorders in cancer patientstheir nature, associations, and relation to quality of life
J Clin Oncol
Quality of life in the first year after breast cancer surgeryrehabilitation needs and patterns of recovery
Br Cancer Res Treat
Depressive phenomena, physical symptom distress, and functional status among women with breast cancer
Nurs Res
Who is at risk of nondetection of mental health problems in primary care?
J Gen Intern Med
Mental health in older adult recipients of primary care servicesis depression the key issue? Identification, treatment and the general practitioner
Int J Geriatr Psychiatry
Cited by (102)
How many patients enter endometrial cancer surgery with psychotropic medication prescriptions, and how many receive a new prescription perioperatively?
2019, Gynecologic OncologyCitation Excerpt :A very short duration (one to four days) of anxiolytic (n = 19/22) or antidepressant (n = 3/14) prescriptions was observed for some patients (Table 2D). This indicates that they may have been prescribed for symptom relief including to treat insomnia [30,31], pain [29–32], nausea or vomiting [27,28] (Table 2D), or that side-effects emerged. Our data shows that 28 anxiolytic (such as diazepam, lorazepam) and 29 antidepressant prescriptions (such as citalopram, venlafaxaine) were received by patients for reasons other than anxiety and depression (Table 2E).
Comparison of four brief depression screening instruments in ovarian cancer patients: Diagnostic accuracy using traditional versus alternative cutpoints
2017, Gynecologic OncologyCitation Excerpt :If the patient completes a paper-based version of the PHQ-9, the two-phase scoring method rather than the traditional summation of all 9 items can be applied to gain a more accurate screening result for major depressive episode. With very few exceptions, existing studies do not exclude cases that are already detected and in treatment [13,14]. While the goal of screening for depression should be to detect patients whose depression is undetected and untreated, it is interesting to note that 9 of the 14 true cases were already being treated with antidepressants, yet still met criteria for major depression.
Mental Health and Physical Health (Including HIV/AIDS)
2016, International Encyclopedia of Public HealthA commentary on the importance of controlling for medication use within trials on the effects of exercise on depression and anxiety
2015, Mental Health and Physical ActivityCitation Excerpt :We also examined if any RCT that compare exercise vs. no exercise included in the above mentioned reviews had attempted to control for medication use either at baseline or during the exercise intervention through sensitivity analysis. Finally, although large-scale cohorts of breast cancer patients 11–30% report using antidepressant (Azzone, Frank, Pakes, Earle, & Hassett, 2009; Ng, Boks, Smeets, Zainal, & de Wit, 2013) and 25–30% use anxiolytics (Azzone et al., 2009; Coyne, Palmer, Shapiro, Thompson, & DeMichele, 2004), it is worth noting that in a recent systematic review of 20 RCTs to test the effects of exercise on anxiety and depression in breast cancer patients (see details in Carayol, Delpierre, Bernard, & Ninot, 2015), we were not able to test the moderation effect of medication as only one study reported information about anxiolytics and/or antidepressants use. In summary, no clear difference was observed in the effect of exercise alone and antidepressant/anxiolytic medications alone on depression or anxiety.