Psychcast/Blood & Cancer crossover episode: Using cognitive-behavioral therapy to help cancer patients cope with depression and anxiety in the COVID-19 era

David Henry, MD, host of the Blood & Cancer podcast, joins Psychcast host Lorenzo Norris, MD, to discuss steps clinicians can take to alleviate the distress associated with receiving a diagnosis of cancer.

Dr. Henry is clinical professor of medicine at the University of Pennsylvania, Philadelphia. He has no disclosures. Dr. Norris is director of consult liaison psychiatry at George Washington University, Washington. He has no disclosures.

Take-home points

• Cancer patients have always been susceptible to developing depression and anxiety after receiving their distressing diagnoses. During the COVID-19 pandemic, the risk for depression and anxiety are even greater because patients face separation from their oncology treatment teams and for some, delays in treatment.
• Major depressive disorder (MDD) occurs in up to one-third of cancer patients, and any depressive disorder can be seen in about half.
• Another concern is how to screen for depression in the context of cancer. Dr. Norris suggests using the Patient Health Questionnaire–2 (PHQ-2) screener, or the question: "Are you sad or depressed?" Answering those questions can give patients the opportunity to open up about their emotions.
• Signs of depression in cancer include nonadherence to treatment, changes in mood and anxiety affecting daily functioning at home or work, and demoralization, which is defined as helplessness, isolation, and despair in the face of overwhelming stressors.

Summary

• An emotional upset, such as disbelief, despair, or even denial, might occur immediately after receiving a cancer diagnosis. A depressive disorder, however, is a persistently depressed, sad mood with changes in functioning that affect the patient, his/her family, and even engagement with treatment.
• Findings of studies about the prevalence of depression in patients with cancer vary depending on the type of screening and/or diagnostic tool used. In general, the prevalence of MDD is up to 38%, and the prevalence of any depressive disorder is up to 58%. The prevalence of depression is even greater in patients with advanced cancer. In the general population, the 12-month prevalence of MDD is 6%, and the lifetime prevalence is 16%.
• It's useful to think about stress along a continuum of diagnoses ranging from a normal expected stress syndrome, an adjustment disorder, MDD triggered by the event, depression secondary to a general medical condition as can occur in central nervous system and pancreatic cancer, or even a substance-induced mood disorder from either prescribed medications or perhaps a form of coping that has turned maladaptive.
• Cognitive-behavioral therapy (CBT) can be explained as examining the way thoughts influence emotions and behavior. When using CBT with cancer patients, a good place to start is checking in on their understanding of their diagnosis, their prognosis, and current and future treatments. The goal is to see whether they have unnecessary cognitive distortions that may be affecting their emotions and behaviors. During periods of extreme stress, CBT can help patients by emphasizing the use of adaptive thoughts, and identifying maladaptive thoughts and behaviors as opportunities for intervention.
• To screen for depression, it may be enough to ask: "Are you depressed?" As a screening tool, the PHQ-2 asks only two questions: "Over the last 2 weeks, how often have you been bothered by the following problems: Little interest or pleasure in doing things, or been feeling down, depressed or hopeless? The PHQ-2 score ranges from 1 to 6, and even at the lowest score, it has a sensitivity and specificity of 90.6% and 65.4%, respectively, in detecting any depressive disorder.

References

Krebber AMH et al. Psycho-oncology. 2014 Feb;23(2)121-30.

Walker J et al. Ann Oncol. 2013 Apr 1;24(4):895-900.

Trinidad AC et al. Psychiatr Ann. 2011;4(9):439-42.

Daniels S. J Adv Pract Oncol. 2015 Jan-Feb;6(1):54-6.

Other resources

PHQ-2: https://www.hiv.uw.edu/page/mental-health-screening/phq-2

National Cancer Institute: Depression–Health Professional Version: https://www.cancer.gov/about-cancer/coping/feelings/depression-hp-pdq