RESEARCH IN CONTEXT

Depression Screening and Treatment: A Missed Opportunity in Lung 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 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 , mood disturbance, sleep dis- with cancer is associated with prolonged hos- ruption, , 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

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symptoms likely are intertwined with and con- Psychosocial Distress (Depression, ) 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 .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,

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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 a brief course of cognitive VA health care settings. behavioral therapy sessions, another first-line, Overall, there is minimal evidence that de- evidence-based treatment for clinical depression. pression treatment can improve lung cancer sur- Clinician follow-up to ensure patient adher- vival; however, the lack of high-quality studies ence, response, and satisfaction, and to ad- is a considerable limitation. Given the signifi- just treatment as needed is essential. Besides cant impact of depression on survival among pa- ongoing coordination with PC-MHI services, tients with lung cancer, additional funding and including mental health clinicians as part of multi- resources are urgently needed to combat this disciplinary cancer clinics could offer substantial debilitating comorbid disease. added value to patients’ comprehensive cancer care. Indeed, the initiation of multicomponent de- ACKNOWLEDGMENTS This project was supported in part by the National Cancer pression care has been shown to improve QOL Institute of the National Institutes of Health under award and role functioning in patients with cancer.31 K07CA190706 to Dr. Sullivan, a Career Development Award from the Veterans Health Administration Health Service Re- Besides the established benefits on QOL, pa- search and Development (CDA 14-428) to Dr. Teo and the tients with lung cancer who achieve depression HSR&D Center to Improve Veteran Involvement in Care (CIVIC) symptom remission also may enjoy a significant (CIN 13-404) at the VA Portland Health Care System. survival benefit over patients whose depression AUTHOR DISCLOSURES symptoms remain untreated during lung cancer The authors report no actual or potential conflicts of interest treatment as our study suggests.3 with regard to this article. DISCLAIMER CONCLUSION The VA had no role in the design and conduct of the study; Depression is a common comorbid disease collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or de- among patients with lung cancer with impor- cision to submit the manuscript for publication. The opinions tant negative implications for QOL and survival. expressed herein are those of the authors and do not nec- When it occurs after a cancer diagnosis, de- essarily reflect those of Federal Practitioner, Frontline Medi- cal Communications Inc., the U.S. Government, or any of its pression is expected to impact all phases of a agencies. patient’s life through treatment and survivor- ship—ultimately affecting long-term survival. REFERENCES Veterans may be at particularly high risk given 1. Derogatis LR, Morrow GR, Fetting J, et al. The prevalence of psychiatric disorders among cancer patients. JAMA. the increased prevalence of mental illness, in- 1983;249(6):751-757. cluding depression and PTSD in this group 2. Walker J, Holm Hansen C, Martin P, et al. Prevalence of depression in adults with cancer: a systematic review. Ann compared with that of the general population. Oncol. 2013;24(4):895-900. Early detection and prompt treatment can pro- 3. Sullivan DR, Forsberg CW, Ganzini L, et al. Longitudinal mote depression remission, prevent relapse, changes in depression symptoms and survival among patients with lung cancer: a national cohort assessment. J and reduce the eventual emotional and finan- Clin Oncol. 2016;34(33):3984-3991. cial burden of the disease. This approach may 4. Linden W, Vodermaier A, Mackenzie R, Greig D. Anxiety and depression after cancer diagnosis: prevalence rates ultimately diminish the prevalence and persis- by cancer type, gender, and age. J Affect Disord. 2012;141 tence of depression symptoms and decrease (2-3):343-351. the associated negative effects of this disease 5. Massie MJ. Prevalence of depression in patients with can- cer. J Natl Cancer Inst Monogr. 2004;(32):57-71. on patients with lung cancer. 6. Brown Johnson CG, Brodsky JL, Cataldo JK. Lung cancer The importance of integrated systems of de- stigma, anxiety, depression, and quality of life. J Psycho- pression treatment for patients with cancer as soc Oncol. 2014;32(1):59-73. 7. Cataldo JK, Jahan TM, Pongquan VL. Lung cancer stigma, part of comprehensive cancer care cannot be depression, and quality of life among ever and never overstated. Development and implementation of smokers. Eur J Oncol Nurs. 2012;16(3):264-269. 8. Howlader N, Noone AM, Krapcho M, et al. SEER can- these systems should be a priority of lung cancer cer statistics review, 1975-2010. https://seer.cancer.gov clinicians and treatment centers. The integrated /archive/csr/1975_2010/. Revised February 21, 2014. Ac- system within the VA is well positioned to be a cessed July 12, 2017. 9. Li M, Boquiren V, Lo C, et al. Depression and anxiety in leader in this area, and VA clinicians who care supportive oncology. In: Davis M, Feyer P, Ortner P, Zim- for patients with lung cancer are encouraged to mermann C, eds. Supportive Oncology. 1st ed. Philadel- phia, PA: Elsevier; 2011:528-540. take advantage of available mental health re- 10. Brown LF, Kroenke K, Theobald DE, Wu J, Tu W. The asso- sources. Additional research is urgently needed ciation of depression and anxiety with health-related qual- to explore optimal implementation of depression ity of life in cancer patients with depression and/or pain.

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Psychooncology. 2010;19(7):734-741. probable mental disorders and help-seeking behaviors 11. Lazenby M, Ercolano E, Grant M, Holland JC, Ja- among veteran and non-veteran community college stu- cobsen PB, McCorkle R. Supporting Commission on dents. Gen Hosp Psychiatry. 2016;38:99-104. Cancer-mandated psychosocial distress screen- 22. Pickett T, Rothman D, Crawford EF, Brancu M, Fairbank ing with implementation strategies. J Oncol Pract. JA, Kudler HS. Mental health among military personnel and 2015;11(3):e413-e420. veterans. N C Med J. 2015;76(5):299-306. 12. Mystakidou K, Tsilika E, Parpa E, Katsouda E, Gala- 23. U.S. Department of Veterans Affairs, Veterans Health Ad- nos A, Vlahos L. Psychological distress of patients ministration. One in ten older vets is depressed. https:// with advanced cancer: influence and contribution www.va.gov/health/NewsFeatures/20110624a.asp. Up- of pain severity and pain interference. Cancer Nurs. dated April 17, 2015. Accessed July 12, 2017. 2006;29(5):400-405. 24. Fontana A, Rosenheck R. Treatment-seeking veterans of 13. Passik SD, Dugan W, McDonald MV, Rosenfeld B, Theo- Iraq and Afghanistan: comparison with veterans of previ- bald DE, Edgerton S. Oncologists’ recognition of de- ous wars. J Nerv Ment Dis. 2008;196(7):513-521. pression in their patients with cancer. J Clin Oncol. 25. Kessler RC. Posttraumatic stress disorder: the bur- 1998;16(4):1594-1600. den to the individual and to society. J Clin Psychiatry. 14. Rahuma M, Kamel M, Nasar A, et al. Lung cancer patients 2000;61(suppl 5):4-12; discussion, 13-14. have the highest malignancy-associated suicide rate in 26. Kartha A, Brower V, Saitz R, Samet JH, Keane TM, USA: a population based analysis. Am J Respir Crit Care Liebschutz J. The impact of trauma exposure and Med. 2017;195:A6730. post-traumatic stress disorder on healthcare uti- 15. Sullivan DR, Ganzini L, Duckart JP, et al. Treatment receipt lization among primary care patients. Med Care. and outcomes among lung cancer patients with depres- 2008;46(4):388-393. sion. Clin Oncol (R Coll Radiol). 2014;26(1):25-31. 27. National Cancer Institute. Cancer-related post-traumatic 16. Merckaert I, Libert Y, Messin S, Milani M, Slachmuylder stress (PDQ®)–Patient version. https://www.cancer.gov JL, Razavi D. Cancer patients’ desire for psychologi- /about-cancer/coping/survivorship/new-normal/ptsd-pdq. cal support: prevalence and implications for screen- Updated July 7, 2015. Accessed July 12, 2017. ing patients psychological needs. Psychooncology. 28. Andersen BL, DeRubeis RJ, Berman BS, et al; American 2010;19(2):141-149. Society of Clinical Oncology. Screening, assessment, and 17. Harrison JD, Young JM, Price MA, Butow PN, Solomon care of anxiety and depressive symptoms in adults with MJ. What are the unmet supportive care needs of people cancer: an American Society of Clinical Oncology guideline with cancer? A systematic review. Support Care Cancer. adaptation. J Clin Oncol. 2014;32(15):1605-1619. 2009;17(8):1117-1128. 29. Howell D, Keller-Olaman S, Oliver TK, et al. A pan-Cana- 18. Wu HS, Harden JK. Symptom burden and quality of life dian practice guideline and algorithm: screening, assess- in survivorship: a review of the literature. Cancer Nurs. ment, and supportive care of adults with cancer-related 2015;38(1):E29-E54. fatigue. Curr Oncol. 2013;20(3):e233-e246. 19. Mols F, Husson O, Roukema JA, van de Poll-Franse LV. 30. Kroenke K, Wu J, Bair MJ, Krebs EE, Damush TM, Tu W. Depressive symptoms are a risk factor for all-cause mor- Reciprocal relationship between pain and depression: a tality: results from a prospective population-based study 12-month longitudinal analysis in primary care. J Pain. among 3,080 cancer survivors from the PROFILES registry. 2011;12(9):964-973. J Cancer Surviv. 2013;7(3):484-492. 31. Walker J, Hansen CH, Martin P, et al; SMaRT (Symptom 20. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Management Research Trials) Oncology-3 Team. Inte- Koffman RL. Combat duty in Iraq and Afghanistan, men- grated collaborative care for major depression comorbid tal health problems, and barriers to care. N Engl J Med. with a poor prognosis cancer (SMaRT oncology-3): a mul- 2004;351(1):13-22. ticentre randomised controlled trial in patients with lung 21. Fortney JC, Curran GM, Hunt JB, et al. Prevalence of cancer. Lancet Oncol. 2014;15(10):1168-1176.

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TOPICS COVERED IN THIS SPECIAL ISSUE INCLUDE: • Health Care Utilization of Veterans With Serious Mental Illness • Neuromodulation for Treatment-Refractory Posttraumatic Stress Disorder • Hospitalization Risk With Benzodiazepine and Opioid Use in Veterans With PTSD • Teleneurology for Rural Veterans

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