ReCAP: Would Women With Breast Cancer Prefer to Receive an Antidepressant for Anxiety or Depression From Their Oncologist?

Abstract

QUESTIONS ASKED: Preferences of patients with breast cancer for provider-specific pharmacologic management of anxiety and depression are unknown. Use of patient-guided treatment preferences for the treatment of depression and anxiety are known to improve adherence and treatment outcomes in primary care settings, but these preferences are not known in women with breast cancer. This may be especially true shortly after the patient receives a diagnosis of cancer and is most psychologically symptomatic, yet committed to following through with her oncologic care. Do breast cancer patients have preferences regarding having their anxiety and depression assessed and treated by their oncologists versus being cared for by a psychiatrist or mental health provider? SUMMARY ANSWER: The majority of patients accepted antidepressant prescribing by their oncologist; only a minority preferred treatment by a mental health professional. These findings are consistent with previous data from medically ill patients that demonstrated a preference for medical providers to address and treat their depression or anxiety. Twenty percent of participants would not want any treatment. Patients who met depression criteria were less likely to prefer a mental health referral. Patients who were already taking an antidepressant or demonstrated higher levels of chronic stress were more likely to prefer a mental health referral. METHODS: Patients with breast cancer (stages 0-IV) were asked two questions: (1) “Would you be willing to have your oncologist treat your depression or anxiety with an antidepressant medication if you were to become depressed or anxious at any point during your treatment?” and (2) “Would you prefer to be treated by a psychiatrist or mental health professional for problems with either anxiety or depression?” In addition, the Distress Thermometer and Problem List, Hospital Anxiety and Depression Scale, Risky Families Questionnaire, and demographic information were assessed. BIAS, CONFOUNDING FACTORS, DRAWBACKS: This was a survey of only women who were asked to self-report hypothetical preferences. Although minimal differences were noted for the 16.8% of participants who were already taking an antidepressant medication, it is not clear how they might have interpreted the questions in a more realistic setting. REAL-LIFE IMPLICATIONS: These findings suggest a benefit for promoting education of oncologists to assess psychological symptoms and manage anxiety and depression as a routine part of an outpatient visit. It highlights a fertile opportunity for oncologists to integrate mental health treatment for their patients by beginning pharmacologic treatment, discussing their anxiety or depressive symptoms, and initiating or comanaging pharmacologic treatment of anxiety or depression. Early recognition and management of distress, anxiety, and depression would limit the delay in obtaining appropriate treatment, especially during the first year after a cancer diagnosis when patients are most symptomatic and have many difficult treatment decisions to make. The oncologist’s use of antidepressant medications to treat anxiety and depression may benefit patients most by following guidelines. A collaborative care model offers one potential solution that could establish ownership, expand resources, disseminate knowledge, and provide a system of integration for mental health and oncology providers. [Table: see text]

Screening for Depression in Younger Breast Cancer Survivors: Outcomes From Use of the 9-item Patient Health Questionnaire

“…Recommendations of the Institute of Medicine ( 47 ), the American Society of Clinical Oncology ( 1 ), the Commission on Cancer ( 3 ), and Center for Medicare and Medicaid Services Oncology Care Model ( 48 ) all include screening for depression as a quality metric in cancer patients and survivors. Depression is often treatable with pharmacologic and nonpharmacologic interventions, and screening for depression is designed to help reduce suffering and improve well-being among those living beyond cancer ( 49 ). Adverse mental health outcomes, such as anxiety, depression, and suicide, are increased in YBCS compared with women without a cancer history, emphasizing the need for screening, prevention, and management strategies ( 50 ).…”

The Oncologist as Therapist

“…Oncologists play a major role in ameliorating distress because patients prefer to rely on the oncologic team and may resist mental health referrals. [5][6][7] Although we need not always play therapist, understanding when and how to think psychologically about the patient's situation is beneficial. Disregarding mental health undermines patient care.…”

“…In fact, problem-solving therapy focuses on improving an individual's working attitude and ability to actively approach problems effectively and cope with stressful life experiences. 6,7 It centers on the process of finding solutions and guides the patient in being his or her own problem solver. 9,28 Indeed, practical problems exist that must be addressed directly in the cancer context.…”

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“…The intervention can be a health policy, such as the Affordable Care Act; continual revision of guidelines, such as the US cholesterol treatment guidelines; or a new diagnostic tool, such as the test for Coronavirus. 1 , 2 Randomized controlled trials (RCTs) are commonly considered the ideal approach for assessing intervention effects, however, it is not always feasible or appropriate to conduct an RCT due to ethical or financial reasons. Quasi-experimental studies are frequently used in place of RCTs when they are not feasible.…”