Psychosomatics 40:64-69, February 1999
© 1999 The Academy of Psychosomatic Medine
Screening for Anxiety and Depression in Women With Breast Cancer
Psychiatry and Medical Oncology Gear Up for Managed Care
David K. Payne, Ph.D.,
Rosalind G. Hoffman, M.D.,
Maria Theodoulou, M.D.,
Michael Dosik, M.D., and
Mary Jane Massie, M.D.
Received November 12, 1997; revised March 31, 1998; accepted April 9, 1998. At the time of this study, Dr. Payne was the Barbara White Fishman Psychology Fellow, Department of Psychiatry and Behavioral Sciences. Currently, he is a Clinical Instructor, Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York. At the time of this study, Dr. Hoffman was a resident in psychiatry at New York Hospital, Cornell University Medical College-Westchester Division, White Plains, New York. She is now a Fellow, Department of Psychiatry, Long Island Jewish Medical Center, New Hyde Park, New York. Dr. Theodoulou is Assistant Attending Physician, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York. Dr. Dosik is at North Shore Hematology and Oncology Associates, East Setauket, New York. Dr. Massie is Attending Psychiatrist and Director, Barbara White Fishman Center for Psychological Counseling; and in the Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York. Address correspondence and reprint requests to Dr. Payne, Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021.
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ABSTRACT
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In this study, 275 women with breast cancer attending ambulatory breast cancer clinics in two sites were evaluated for psychological distress by using three self-report instruments: a visual analogue scale for psychological distress, the Hospital Anxiety and Depression Scale, and the Brief Symptom Inventory. Results suggest that significant psychological distress exists in ambulatory women with breast cancer; all three instruments effectively measured that level of distress. Implications for the use of these instruments in educating oncological staff members, documenting need for psychiatric services in a period of capitation, and providing quality assurance evaluations of psychiatric services are discussed.
Key Words: Anxiety • Depression • Cancer
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INTRODUCTION
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As managed care captured more of the health care market in the Northeast, the cost of medical services came under increased scrutiny. To remain competitive in this changing market and to prepare for the negotiation of managed care contracts, Memorial Sloan-Kettering Cancer Center (MSKCC), a cancer research hospital, formed disease-management teams to streamline, standardize, and "cost out" cancer care services. In anticipation of these managed care contracts, which would result in the influx of 4,000 to 6,000 additional women with breast cancer, the psychiatric consultants at the MSKCC breast cancer center began to prepare themselves for this increase in patients. This expansion provided an opportunity for the psychiatric consultants to strengthen their positions as members of the disease-management team by educating oncologists about the prevalence of psychiatric distress in ambulatory women with breast cancer, evaluating simple and effective methods of identifying psychological distress, and developing interventions.
Although significant psychological distress exists in women with early-stage breast cancer and increases with disease progression, anxiety and depression may not be identified. Patients may be reluctant to spontaneously disclose their distress to their oncologists and, in the constraints of a busy clinic schedule, oncology staff members may not have the time to ask.1–3 To address this deficit, inexpensive and convenient paper-and-pencil screening devices have been used to identify patients who have psychosocial distress.4,5
As clinicians we recognized the psychiatric vulnerability of cancer patients and the need to evaluate this distress and to provide psychiatric intervention.3,6 In the era of managed care, however, we wanted to teach our oncological colleagues that identifying and treating psychiatric distress results in improved medical outcomes, reduced health care costs, and increased quality of life.7,8 This quality assurance study was another step in the process of strengthening our relationship with the breast cancer disease-management team members and teaching them the important role that the psychiatric consultant can play.
Criticism frequently leveled at psychosocial research conducted in institutions such as ours is that patients who seek treatment in research hospitals are not comparable to patients in community settings; therefore, research findings are not applicable to other settings. Consequently, we invited the oncologists at North Shore Hematology and Oncology Associates (NSHOA), a Long Island, New York, community (Smithtown) to collaborate with us. In contrast to the primarily urban, professionally employed patients treated at MSKCC, the Smithtown oncologist-consultant member of our disease-management team treated primarily suburban homemakers.
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METHODS
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Two hundred seventy-nine women with breast cancer attending the outpatient medical oncology breast cancer clinic at MSKCC (n=174) or at NSHOA in Smithtown, Long Island, (n=105) for either an initial or follow-up visit participated in the study, which was conducted in 1996. The steering committees of both sites approved this project as a quality assurance study and did not require patients to participate in an informed-consent process. On the days we attended the clinics, we recruited consecutive patients as they registered to see their oncologist. Since the patient populations in these oncologists' clinics were heterogeneous in both disease status and treatment, we felt certain that we obtained a representative sample of the oncologists' practice. Members of the psychiatry staff (MSKCC) and nursing staff (NSHOA) approached patients while they waited for their visit with the oncologist and asked patients to participate in a quality assurance project designed to help determine if we were attending to both the psychological and physical needs of patients. Patients then completed the Hospital Anxiety and Depression Scale, the Brief Symptom Inventory, a visual analogue scale measuring psychological distress, and a 15-item demographic questionnaire. It took an average of 15 minutes to complete these 4 measures. As a means of validating the self-report instruments, a senior postgraduate year (PGY)-4 psychiatry resident trained in the research and clinical use of the Structured Clinical Interview for DSM-III-R interviewed 31 women (MSKCC site) with a modified version of this instrument. We obtained this convenience sample by asking consecutive women over the span of several clinic days to participate in this 45-minute interview.
Hospital Anxiety and Depression Scale (HADS)
The HADS is a 14-item self-report scale that includes 7 items that measure depression and 7 that assess anxiety. Each item is rated on a scale from 0 ("not at all") to 3 ("very much"). Separate anxiety and depression scores as well as a global measure were obtained. Developed for use with medically ill patients,9 the HADS contains only the cognitive symptoms of anxiety and depression, thus eliminating the somatic symptoms that are poor indicators of psychiatric distress in the medically ill. In a study of outpatients with lymphoma, Razavi et al.10 suggested a cutoff score of 10, which was associated with a 44% positive-predictive value when screening for adjustment disorders, major depressive, or anxiety disorders; a higher score of 13 was associated with a 75% positive-predictive value.
Brief Symptom Inventory (BSI)
The BSI is a 53-item instrument that measures a wide range of psychiatric symptomatology. Patients rate the severity of 53 symptoms on a scale from 0 (not at all) to 4 (very much). Each of the 53 items loads onto 9-symptom dimensions: somatization, obsessive-compulsive ideation, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. There are three global scales that measure, among other factors, average psychological distress. The BSI has been used extensively with medically ill patients.5,11
Visual Analogue Scale (VAS)
A VAS rating of mood is one subscale of the Memorial Pain Assessment Card (MPAC).12 The MPAC consists of three scales measuring pain intensity, pain relief, and psychological distress. The psychological distress subscale asks patients to rate their psychological distress on a 10-centimeter line with anchors of "worst mood" and "best mood." Significant correlations exist between the VAS mood and other measures of psychological distress, including the Zung Anxiety Inventory (r=-0.41, P<0.005) and Hamilton Depression Rating Scale (r=-0.44, P<0.001). The patients rated their psychological state over the past week, including the day of the evaluation, by placing a mark on the line that corresponded to their level of distress. The anchors we used were 0="worst I ever felt emotionally" and 100="best I ever felt emotionally," a slight modification made for the sake of clarity from the "worst mood" and "best mood" used in the original MPAC. In addition, the oncologists and nurses completed the VAS based upon their perceptions of the patient's psychological distress following their visit with the patient, unaware of the patient's self-rating on the VAS.
Structured Clinical Interview for DSM-III-R (SCID)
The SCID13 is a structured method for assessing psychiatric symptomatology that corresponds to DSM diagnostic categories. We modified the SCID to assess only those psychiatric disorders most prevalent in ambulatory breast cancer patients, including major depressive disorders, adjustment disorders, panic disorders with and without agoraphobia, obsessive-compulsive disorders, eating disorders, and substance abuse disorders. Psychotic disorders and other categories, although noted if present, were not included in this modification of the SCID, since they represented low base-rate phenomena in this population.
Demographic and Referral Information
Disease-related information was gathered by chart review. The members of the Department of Psychiatry and Behavioral Sciences at the breast cancer center keep accurate information about referrals to psychiatry. During the time of this study, the MSKCC oncologist did not refer patients to social work for psychotherapy. There are no psychiatric or social work services available at the NSHOA site.
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RESULTS
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Of the 279 patients asked to complete the questionnaires (174 at MSKCC and 105 at NSHOA), 275 agreed to participate. One patient refused, and three patients were excluded because of language barriers or mental retardation. The mean age of the sample was 58 years (range: 30–90). The sample was primarily Caucasian (86%), with 6% African American, 2% Latina, 2% Asian, and 4% other. Forty-three percent of the patients had no evidence of cancer, were receiving no active treatment, and attended the clinics for routine follow-up visits. Of the patients receiving chemotherapy or hormonal therapy, 11% had Stage I, 31% had Stage II, 7% had Stage III, and 51% had Stage IV breast cancer.
The combined sample mean ± standard deviation (SD) for the patient VAS was 62.3 ±2 7.3 (Table 1). The NSHOA sample reported significantly elevated mood (67.8 ± 22.5), compared with the MSKCC sample (59.4 ± 23.2, P<0.001). The sample mean ± SD for the oncologist VAS was 59 ± 27.8, and the sample mean ± SD for the nurse VAS was 58.4 ± 19.2. There were no intersite differences for the oncologist or nurse ratings of the patient's mood. Correlations among the patient and oncologist (r=0.45,P<0.001), patient and nurse (r=0.42 P<0.001), and oncologist and nurse (r=0.58, P<0.001) were significant.
The mean ± SD sample score on the total HADS was 9.6 ± 6.4. On the anxiety subscale, the mean ± SD sample score was 6.2 ± 4.1, and the mean ± SD depression score was 3.4 ± 3.2. Although there were no differences between the sites on total HADS scores and the anxiety scores, MSKCC patients reported higher depression scores (Table 1).
On the BSI, the sample mean ± SD T-score for the Global Severity Index was 55 ± 24.6; both sites had the identical Global Severity Index score. No significant differences between the two sites emerged on any of the subscales of the BSI (Table 2).
Although the correlations among the HADS, BSI, and VAS were all significant (Table 3), we explored the concordance among the three measures. For this evaluation with the HADS, we used a more stringent cutoff of 13 that has a positive predictive value of 75%, compared with the 44% for a score of 10.10 For the BSI Global Severity Index, we used the T-score of 60 (1 standard deviation above the mean) as a cutoff for significant distress. On the VAS, we used a cutoff of 75, which gave us the highest concordance with our other measures. We found a 57% concordance between the BSI and VAS, a 51% concordance between the VAS and the HADS, and a 84% concordance between the HADS and the BSI.
Of the 31 patients who completed a SCID interview, 13 (42%) did not meet criteria for a DSM diagnosis. Of the remaining 18, adjustment disorder, depressed and anxious mood, and major depression (past) represented the greatest percentage of diagnoses (Table 4). Six (19%) of the 31 patients who participated in the SCID had previously been referred to psychiatry by the medical oncologist. A comparison of the treating psychiatric clinician's diagnosis with that of the SCID revealed that in 50% of the cases (n=3), there was 100% concordance between clinician and SCID diagnosis. In the remaining three, significant symptom overlap existed between clinician and SCID diagnoses (Table 5).
A comparison among the VAS, HADS, and BSI scores of those patients who received a SCID diagnosis with those who did not revealed that the HADS and the BSI consistently distinguished between the patients with significant psychological distress (Table 6). For the purposes of this analysis, the patients who met criteria for a major depression (past) were included with the "no diagnosis" group. Although the VAS did not distinguish between the two groups, there was a trend toward this significance (P=0.075). The HADS and all but two subscales (interpersonal sensitivity and paranoid ideation) of the BSI were significantly higher in the patients who had a current DSM diagnosis.
At the time of this study, 24% of the patients in the MSKCC's oncologist's clinic were referred for psychiatric evaluation. To further evaluate referral patterns of patients to psychiatry, we divided study patients at MSKCC into two groups: those scoring above or below 10 on the total HADS, Razavi's10 suggested cutoff for outpatients with cancer. Of those 74 patients scoring at or above 10, 36% had either been referred or were being followed by psychiatry; only 15% of the 100 remaining patients scoring below 10 were being followed by psychiatry. By using the more conservative cutoff of 13 on the total HADS, 44% of the 55 patients scoring at or above 13 had been referred, and only 7% of those scoring below 13 were referred to psychiatry.
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DISCUSSION
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In the era of managed care, the necessity and feasibility of psychiatric interventions are under increasing scrutiny. To document the need for and utility of these services, screening instruments provide a method of efficiently evaluating a large number of patients, and identifying those whose psychiatric difficulty may result in better utilization of health care resources. This study explored the utility of three screening measures that differed in complexity and in the time demands for the patient and for staff members. We used these instruments to educate our oncological colleagues about the level of psychiatric distress in their patients, to provide our colleagues with a method for evaluating patients' distress, and to provide a checkpoint on the medical oncology staff members' abilities to identify the patients most in need of psychiatric intervention.
Although the VAS was the most time-efficient, many patients had difficulty understanding the concept of the VAS. We asked patients to focus on emotional distress when completing the VAS. Anecdotally, the patients in our study reported difficulty differentiating physical symptoms from psychological distress. The relatively low concordance between the VAS and both the HADS and the BSI also suggests that the VAS may be measuring other symptoms than just psychiatric distress. By increasing the cutoff on the VAS to 90, we still found a relatively low 68% concordance between the BSI and VAS and a 64% concordance between the VAS and the HADS. Consequently, high scores on the VAS may reflect unmanaged physical symptoms as well as psychiatric symptoms. A psychiatric instrument that primarily identifies unmanaged physical rather than psychiatric symptoms misuses the psychiatric consultant's time and resources. Although the VAS may not be the cleanest measure of psychiatric distress, the correlations among the oncologists', nurses', and patients' VAS provided reassurance to the staff of their ability to detect distress in their patients as well as alerted them to consider their patients' psychological needs.
Of all the self-report measures used, the BSI measures the psychiatric symptomatology present in the population most completely. Its lengthier administration and scoring time, however, argue against its use in our medical setting. Finally, the inclusion of multiple scales may confuse busy oncologists who want a brief measure of the severity of psychiatric distress for their patients.
Patients reported ease in answering the items on the HADS. It also correlates well with a more complex measure of psychiatric symptomatology, the BSI. Consequently, we selected the HADS as the instrument we will continue to use for psychiatric screening in our setting. The clinical utility of the HADS depends upon the cutoff score used. With the cutoff of 10 or more suggested for outpatients,10 we would identify 33% of our population for psychiatric evaluation, thus justifying the continuing need for comprehensive psychiatric services at our center. With the more stringent cutoff of 13, we would identify 27% of our patients for further psychiatric intervention. Because of this project, we have been able to justify the need for a third psychiatric consultant on our team. For those consultants interested in replicating aspects of this project, the cutoff selected is ultimately dependent upon available resources. In those settings where the addition of psychiatric staff members is impossible, the clinician may use a higher cutoff to ensure that the patients most in need of attention are being identified.
The similarities between the distress noted at MSKCC and NSHOA indicate that comparable levels of distress exist in both populations despite demographic differences. The patients at NSHOA reported better mood and less depression than the patients at MSKCC. This represents an interesting finding, possibly attributable to differences in the availability of social support. We will explore this in future research. The similarities of our results at MSKCC and NSHOA support the need for psychosocial interventions in community as well as research hospital settings.
In our setting, this project has helped us to identify and quantify the level of psychiatric distress in our population and to further our exploration of the means by which we can best treat large numbers of women with breast cancer. We presented these results to our oncologists, both educating them about underdiagnosed psychiatric distress in their populations and providing them with an acceptable and efficient evaluation tool. Our exploration of referral patterns reassured both the oncological and psychiatric staff that we were already focusing our attention on many of the patients most in need and encouraged us that with continued use of the HADS we would increase the likelihood of identifying those patients who have significant psychological distress.
In preparation for the increased integration among psychiatry, oncology, and managed care, we reacquainted ourselves with the research demonstrating that short-term, focused interventions lead to reduced health care costs when compared with more traditional forms of psychiatric service delivery.14 Consequently, we developed a brief cognitive–behavioral group intervention focused on techniques for coping with breast cancer. The use of the HADS will allow us to select appropriate patients and monitor the efficacy of the intervention.
The reorganization of health care delivery systems requires a reexamination of treatments such as psychiatric interventions. This reevaluation provides a new opportunity for psychiatric consultants to integrate themselves into the oncology setting by providing consultation, screening, and treatment. The use and integration of psychiatric scales in patient evaluation and diagnosis is an initial step toward achieving this goal.
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FOOTNOTES
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The authors thank Abaigeal Darby Langtry, R.N., Claire DeAngelis, B.S., Christine Martine, Jean Chieppa, R.N., Helen Henry, R.N., Susan Havel, R.N., and Alex Pisani for their assistance in this project.
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ABSTRACT
INTRODUCTION
