Sunday, February 1, 2015
As we care for patients with serious illness, we frequently encounter depressed mood. Multiple studies have shown depression independently contributes to morbidity and mortality, and yet most of us do not systematically screen for it. This is again illustrated in Lloyd-Williams’ et. al recent study of 629 patients with advanced cancer attending palliative care day centers in England. Patients in this study identified as moderately to severely depressed on the PHQ-9 died three weeks sooner than those with no or only mild depression. A similar result was identified in patients who reported consideration of self-harm. Notably, in the majority of cases, involved health care providers did not know of their patient’s self-harm thoughts.
I don’t think this is unique to palliative care centers in England. The complexity of differentiating depression from symptoms of serious illness interferes with diagnosis. (See Fast Fact #7 - Depression in Advanced Cancer ). We, as a field, have not yet decided upon a simple tool that can be used to screen for depression or standardization of when it should be completed. (Although some helpful suggestions are found on Fast Fact 146 - Screening for Depression in Palliative Care ). Also, it can be a helpless feeling to identify a depressed patient when their treatment options for the depression may be very limited due to short prognosis and multiple, irreversible, contributing factors.
So while there is no simple answer to this challenge, I tend to think that we can do better with our current tools. Any effort is better than no effort, right?
In our community cancer institute, we recently began standard administration of the NCCN Distress Thermometer with all new patients. Any patients who had a score of 4 or greater were referred to appropriate support services. Like the Lloyd-Williams’ study, we uncovered distress which the health care team had not previously identified, resulting in a 47% increase in referrals to support services, the majority of which were related to “emotional problems”. While studies to validate the NCCN Distress Thermometer as a depression screening tool have had conflicting results, I can’t help but think that the 745 more people who were referred for increased assessment and assistance would not care about sensitivity and specificity. I can’t prove it yet, but maybe some of them had improvement in their mood and maybe they even lived a day or two longer as a result. I’m just glad that there is a tool out there that is palatable to oncology practices so they are willing to use it, in a standardized way.
Our next steps are to identify what to do with the information we find. What happens when we do refer patients? Do depressed patients live longer if they get treatment? With estimates of 15-50% of palliative care patients experiencing depression, we should figure this out.
But first, we have to ask them about it.
Kristina Newport MD (@kbnewport) practices Hospice and Palliative Medicine in Lancaster, PA where she also spends time running after her children, 4 and 6.
Lloyd-Williams M, Payne S, Reeve J, Dona RK (2014). Thoughts of self-harm and depression as prognostic factors in palliative care patients. Journal of Affective Disorders, 166, 324-9 PMID: 25012448
Image credit: "Depression Ahead" by Christian Sinclair for Pallimed, Photo Credit: "Sad Eggs" by Christian Sinclair