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0817FP SUPP Sullivan.Indd 24 8/2/17 10:38 AM RESEARCH in CONTEXT RESEARCH IN CONTEXT Depression Screening and Treatment: A Missed Opportunity in Lung Cancer Care Donald R. Sullivan, MD, MA; and Alan R. Teo, MD, MS The integrated VA system is well positioned to be a leader in depression screening and treatment, and VA clinicians who care for patients with lung cancer are encouraged to take advantage of available mental health resources. Dr. Sullivan is an ABOUT RESEARCH IN CONTEXT hastened death.9-11 During treatment, depres- investigator, and In this article, the authors of recent scholarship sion can amplify physical symptoms and inter- Dr. Teo is a core 12,13 investigator, both in have been asked to discuss the implications of fere with effective coping. the HSR&D Center their research on federal health care providers Depression also is likely a significant factor to Improve Veteran and specifically the veteran and active-duty ser- for the risk of suicide, which is 4 times higher in Involvement in Care at VA Portland Health vice member patient populations. Because the patients with lung cancer than that of the gen- Care System in Oregon. article does not include new research and can- eral population.14 Most important, as our recent Dr. Sullivan is an not be blinded, it has undergone an abbreviated study demonstrated, depression that develops assistant professor peer review process. The original article can be at cancer diagnosis or during cancer treatment in the Department of Medicine, in the Division found at Sullivan DR, Forsberg CW, Ganzini L, may contribute to worse survival. This effect was of Pulmonary and et al. Longitudinal changes in depression symp- strongest among patients with early stage dis- Critical Care Medicine, toms and survival among patients with lung can- ease, in other words, the patients who are most and Dr. Teo is an 3 assistant professor in cer: a national cohort assessment. J Clin Oncol. likely to achieve cure. This association with the Department of 2016;34(33):3984-3991. early stage disease also has been observed in Psychiatry and School a strictly veteran population from the northwest of Public Health, both lthough depression is common among U.S.15 at Oregon Health & Science University in patients with cancer, patients with lung Another key finding of our study was the Portland. A cancer are at particularly high risk. The similar survival among patients who experi- prevalence of major depressive disorder (MDD) enced a remission of their depression and among patients with cancer can be as high those who were never depressed. This find- as 13%, whereas up to 44% of patients with ing reinforces the importance of effective de- lung cancer experience depression symptoms pression treatment, which has the potential at some point following their cancer diagno- to reduce depression-related mortality; how- sis.1-3 These estimates are consistently higher ever, depression treatment was not fully cap- than those of other types of cancer, possibly tured and could not be directly compared in related to the stigma of the disease and the our study. Unfortunately, comorbid depres- associated morbidity and mortality that are its sion often goes undiagnosed and untreated hallmarks.4-8 This potentially life-threatening in cancer patients as they report unmet emo- cancer diagnosis often evokes psychological tional needs and a desire for psychological distress; however, additional stressors contrib- support during and after completion of cancer ute to the development of depression, includ- treatment.16,17 ing the effects of chemotherapeutic agents, Given the general lack of depression treat- surgical procedures, radiotherapy, and the ment that occurs in patients with cancer, the consequences of physical symptoms and negative consequences of depression can be paraneoplastic syndromes. sustained well into survivorship—defined clin- In addition to the crippling effects of comorbid ically as someone who is free of any sign of depression on patients’ quality of life (QOL), se- cancer for 5 years. Cancer survivors frequently vere and persistent depression among patients report fatigue, mood disturbance, sleep dis- with cancer is associated with prolonged hos- ruption, pain, and cognitive limitations that sig- pital stays, worse treatment adherence, physi- nificantly impact QOL and are associated with cal distress and pain, and increased desire for disability and increased health care use.18 These S24 • ADVANCES IN HEMATOLOGY AND ONCOLOGY • FEDPRAC.COM/AVAHO 0817FP SUPP_Sullivan.indd 24 8/2/17 10:38 AM RESEARCH IN CONTEXT symptoms likely are intertwined with and con- Psychosocial Distress (Depression, Anxiety) tribute to the development and persistence of in Adults With Cancer.28 Per ASCO, the target depression. The ramifications of untreated de- audience for these guidelines is health care pression on long-term cancer survivor outcomes providers (eg, medical, surgical, and radiation are not completely understood, as few high- oncologists; psychiatrists; psychologists; pri- quality studies of depression in cancer survivors mary care providers; nurses; and others in- exist. However, in a mixed group of patients with volved in the delivery of care for adults with cancer, there was a 2-fold risk of mortality in sur- cancer) as well as patients with cancer and vivors with depression symptoms when these their family members and caregivers.28 These patients were assessed from 1 to 10 years into guidelines address the optimum screening, as- survivorship.19 The impact of depression on can- sessment, and psychosocial-supportive care cer survivorship is an important aspect of cancer interventions for adults with cancer who are care that deserves significantly more attention identified as experiencing symptoms of depres- from both a research and clinical perspective. sion. Among the most imperative recommen- dations are periodic assessments across the SPECIAL CONSIDERATIONS FOR trajectory of cancer care, including after cure, VETERANS as well as employing institutional and commu- There is a higher prevalence of mental health nity resources for depression treatment. diagnoses in veterans than that in the general In clinical practice in a VA setting, im- population, and depressive disorders are the plementing these guidelines might involve most common.20-22 According to the VA Na- various interventions. First, it is vital for pro- tional Registry for Depression, 11% of veterans viders to conduct depression screening dur- aged ≥ 65 years have a diagnosis of MDD, a ing periodic health care encounters. Given rate more than twice that in the general popula- the high prevalence of depression in pa- tion of a similar age.23 However, the actual rate tients with lung cancer, we suggest using the of depression among veterans may be even 9-item Patient Health Questionnaire (PHQ- higher, as studies suggest depression is un- 9) as an initial screening tool.30 Unlike the derdiagnosed in the veteran population.24 In abridged 2-item PHQ-2 commonly used in addition to depression, veterans experience the VA, the PHQ-9 provides an assessment other disabling psychological illnesses, such of the full range of depressive symptoms. An el- as posttraumatic stress disorder (PTSD) related evated PHQ-9 score (≥ 10) is consistent with a to deployment and combat duty or combat- major depressive episode and should trigger related injuries, such as traumatic brain inju- next steps.30 ries. The negative consequences of PTSD on Once clinically significant depression is iden- cancer outcomes are largely unexplored, but tified, initiation of treatment should occur next. PTSD can contribute to increased health care The VA is well suited to assist and support non- utilization and costs.25,26 A similar psycholog- mental health clinicians—particularly primary ical construct, cancer-related posttraumatic care—in treatment initiation and monitoring. This stress (PTS), which develops as a result of a model of partnership is frequently called collab- cancer diagnosis or treatment, is associated orative care, or integrated care, and it is well po- with missed medical appointments and proce- sitioned to help patients with lung cancer with dures, which could impact survival.27 concomitant depression. In the VA, this model of care is called primary care-mental health DEPRESSION SCREENING AND integration (PC-MHI). One PC-MHI resource is TREATMENT called TIDES (Translating Initiatives for Depres- Given the negative consequences of comorbid sion into Effective Solutions), and when a patient mental illness, professional oncology societ- is referred, a mental health nurse care manager ies have started developing guidelines regard- helps to track the patients’ antidepressant ad- ing the assessments and care of patients with herence and treatment response while reporting cancer who are experiencing symptoms of de- results to primary care clinicians, who are gener- pression and/or anxiety.11,28,29 Among these, the ally responsible for initiating and continuing the American Society of Clinical Oncology (ASCO) antidepressant prescription. For patients prefer- has adapted the Pan-Canadian Practice Guide- ring nonpharmacologic approaches or for whom line on Screening, Assessment, and Care of an antidepressant may be contraindicated, AUGUST 2017 • A FEDERAL PRACTITIONER/AVAHO SUPPLEMENT • S25 0817FP SUPP_Sullivan.indd 25 8/2/17 10:38 AM RESEARCH IN CONTEXT PC-MHI can provide other assistance. For ex- screening and subsequent treatment delivery to ample, psychologists working in PC-MHI are improve cancer patient outcomes in VA and non- equipped to provide
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