(120) Hiding in Plain Sight: Are we missing treatable depression in rural patients with cancer?

Abstract: Background/Significance: People diagnosed with cancer experience acute physical and psychosocial effects, which impacts quality of life (Huang 2019). The presence of significant depression elevates the risk of adverse medical outcomes and increases mortality (Wang, 2020). The Fitzpatrick Cancer Center serves a rural population in the New York Adirondacks, an area historically underserved. Since 1995 there has been a weekly psycho-oncology clinic. A multidisciplinary team — including a C-L psychiatrist — provides comprehensive care for these medically complex patients. In 2023 there were 637 new Oncology patients. The psychiatrist saw 29 new patients, 78 % of referrals, and 5.8% of new patients. Studies show a prevalence of depression in 8-24 % of patients with cancer. Treatment reduces psychiatric symptom burden as well as cancer-related physical complaints and can improve adherence to treatments, QoL, and mortality rates (Caruso 2017). This study examined whether the PHQ-2, a validated tool, accurately identifies patients with clinically significant depression in this rural population.

Methods: Following IRB approval, we invited new patients to complete consent forms and the PHQ-2 and PHQ-9. Each subject’s gender, age, and cancer type were noted. Subjects scoring positively were contacted by telephone to complete the SCID. Patients were excluded if they did not complete any component of the screening package. A call to administer the SCID-DSM-4 followed if PHQ-2 score was ≥ 3 or the PHQ-9 was ≥ 9.

Results: Sixty-nine patients fully qualified for this study. Seventeen patients screened positively on the PHQ-2, PHQ-9, 9 or both and on the SCID, with 17 patients (24.6%) having significant depression.

Discussion: The prevalence of depression in this rural cohort was consistent with previous studies. However, if only the PHQ-2 had been used, six of the 17 (35.3 %) with clinically significant depression would have been missed. There was also one patient who scored just below threshold on the PHQ-9 but who scored positively on the PHQ-2. Some of these patients were also evaluated clinically and two met criteria for PTSD and two for bipolar depression. Conclusion/Implications: To adequately screen new patients with cancer at a rural community cancer center, a broader screening process is recommended. The Distress Thermometer is the only screening instrument used and only patients who “screen in” are referred to the C-L psychiatrist. We recommend a more robust screening system for all new patients using one or more of the following: PHQ-2 (cutoff ≥ 2), PHQ-9, GDS, PCL-5, GAD-7, FCRI-SF, and MDQ; patients would be referred for a comprehensive psychiatric evaluation if they trigger on one or more of these screening devices.

References: 1. Huang L T, et al: Mutual Effects of Depression on Quality of Life in Patients and Family caregivers. Oncol. Nursing Forum, 46, (2), 2019. 2. Sung H, et al: Association of first primary cancer with risk of subsequent primary cancer among survivors of adult-onset cancers in the US. JAMA, 324 (24); 2521-2535, 2020. 3. Caruso R et al: Depressive spectrum disorders in cancer: diagnostic issues and intervention. A critical review. Curr. Psychiatry reports; 19, 1-10, 2017.

Presentation Eligibility: Not previously published or presented.

Diversity, Equity, and Inclusion: Rural populations are underrepresented in studies and yet represent under-served people who are often living in conditions of poverty and suboptimal housing, have lower levels of formal education, and less access to services. This population also tends to have higher rates of nicotine, and alcohol use, as well as work environments that lead to higher exposure to carcinogens. It is vitally important that we look for and adequately identify psychiatric symptoms in these patients when they present with cancer in order to maximize their quality of life, and cancer outcomes.