Both Dr. Andersen and Dr. Kendall believe that a major challenge for physicians is knowing where to refer patients when screening indicates they may need follow-up for depression. “The ASCO guidelines specify that referral for further evaluation of appropriate treatment is needed to address specific symptom levels,” said Dr. Andersen. “The challenge is for providers to identify specific referral resources in their facility and their community.”
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April 2016Both recommend that physicians look carefully at the resources within their institutions, as well as in the community, and establish relationships, just as they do for any other referral pathway. “The longer-term issue is the need for more resources and more trained professionals, such as psychologists and social workers, within cancer programs,” said Dr. Kendall. “We’ve all been mandated to do distress screening, but there has been no money allocated to do that.”
To help otolaryngologists implement screening as well as develop referral pathways for assessment and treatment, Dr. Kendall also suggested seeking guidance from organizations that understand these issues. Recently, a joint task force comprising the American Psychosocial Oncology Society (APOS), the Association of Oncology Social Work (AOSW), and the Oncology Nursing Society (ONS) developed consensus-based recommendations based on six components of the CoC Standard 3.2 (Cancer. 2014;120:2946-2954), including:
- psychosocial representation on the cancer committee with a committee meeting that includes plans for screening;
- timing of screening;
- method and mode of screening;
- tools for screening;
- assessment and referral; and
- documentation.
Screening is just the first step to address potential depression in patients with cancer, but because referral for further assessment and treatment is needed for patients once they have been screened and identified with depression, clinics should put in place referral pathways prior to screening to ensure optimal treatment.
Prophylactic Treatment of Depression
Another approach that clinicians may think about is the use of prophylactic antidepressants to reduce the risk of cancer patients developing depression. This was suggested in a study by Lydiatt and colleagues, who found that prophylactically treating nondepressed patients undergoing treatment for head and neck cancer reduced the risk of depression by more than 50%, and that patients who were treated and were not depressed reported significantly better quality of life for three months after stopping the antidepressant (JAMA Otolaryngol Head Neck Surg. 2013;139:678-686).
William Lydiatt, MD, professor and vice chair of the department of otolaryngology and director of head and neck surgery at the University of Nebraska Medical Center in Omaha, said that both initial screening for depression and prophylactic antidepressants in nondepressed patients with head and neck cancer should be employed. “Initial screening should be done to determine if the patient is already depressed,” he said, noting that up to 15% of people are depressed at baseline and will have a worse prognosis.