PHQ-9 Screening vs.

Brief Screenings for Major Depression in Oncology Patients

Sheree Carlson was a masters-prepared diabetic nurse that worked for clinics in North

Dakota. She believed nursing was the closest practice to God’s work, as she loved all aspects of

care, even washing her patient’s feet. She commented about how alone she felt while

hospitalized, yearning for her care team to reach out to her and care for her on a deeper level.

Never was her psychological care addressed during her treatment and she talked about how

regretful she was towards nursing behavior she once had practiced and believed was

“professional” towards her patients. In 2004, Sheree passed away from kidney cancer without a

single assessment, screening, or conversation regarding her mental state. Oncology patients are

complicated patients to care for, systems are delicately intertwined as teams of healthcare

professionals work together to treat patients’ physiological being. As providers fight for the

physiological health, what happens to these patients’ psychological health? Patients face

immense stress, distress, and psychiatric trauma as well as physical trauma related to intense

treatment and often these feelings as cast aside due to the intensity of treatment. What if

someone had reached out to Sheree and inquired further about her mental health? Diagnoses such

as Major Depression can affect a patients outlook and in turn, their prognosis. More rigorous

screening is needed to identify patients that may maladapt or not develop appropriate coping

skills related to the stress of a cancer diagnosis and treatment.

Problem and Significance: Proper and adequate screenings are not being performed for

patients with cancer diagnoses and this affects their prognosis and affect towards treatment.

Through screenings, treatment needs assessments can be performed and patients can receive

relevant care that can increase their likelihood of treatment adherence and success. This affects

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nursing through the care they provide and the lack of holistic care. When family and friends

cannot relate, patients turn to their care team for support. Without the knowledge about a

patient’s mental state that can be provided through the PHQ-9, healthcare professionals cannot

address the holistic needs of both body and mind that these patients so desperately need.

Hospitalization causes distress in any population, with decreased access to regular coping

mechanisms and limited freedom. The World Health Organization is projecting the annual cases

of cancer will rise from 14.1 million in 2012 to 21.6 million in 2030 (WHO, 2017). A study

showed that 57.2% of cancer patients seen in the ER are admitted for diagnoses relating to their

cancer and had a median stay in the hospital of 3 days (Caterino et al, 2019). Depending on the

type of cancer, patients can experience decreases in “performance status and functional activity”

and difficulty performing activities of daily living, difficulty concentrating, and problems with

memory (Caruso et al, 2017). Additionally, a cancer diagnosis and subsequent treatment is not a

straight line. Uncertainty and concerns regarding mortality, fear, stress and changes in self-

esteem can all influence a patient’s emotional responses. The International Psycho-Oncology

Society (IPOS) which mandates standards related to oncology care, suggests measuring distress

as the sixth vital sign in oncology patients (Travado et al, 2017).

Research has suggested that diagnosed Major Depressive Disorder for oncology patients

is “four times greater than in the general population” (Ruicci & Wang, 2020). Patients with

psychological symptoms are shown to have “negative effects on adherence to treatment, health

behavior, and quality of life” (Caruso et al, 2017). Depressive symptoms specifically can lead to

increased length of stay and longer rehabilitation times (Cordova, Riba, & Spiegel, 2017). Most

importantly, “an increased risk of suicide has also been associated with psychological disorders

in cancer” (Anguiano et al, 2012).

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 The current standard of care for oncology screenings to detect psychological symptoms is

screenings such as the Hospital Distress Thermometer, as the thought is that oncology patients

are weak and cannot maintain a longer interview. Studies have indicated that only 40% of

oncology survivors had discussed with a provider how cancer has affected them emotionally

and/or their interrelationships (Forsythe, 2013). This number suggests that less than half of those

who survived cancer were asked about psychological symptoms and side effects, which still does

not indicate the entire population.

The Hospital Distress Thermometer is a graphic of a thermometer scaled 0-10 in which

the patient is to rate their distress. There are also questions with yes or no answers in different

“problems” such as practical, family, emotional, spiritual, and physical problems that clients are

to answer yes or no. While the distress thermometer is a clinical standard, it measures

meaningful distress, not depression (McFarland et al, 2020). Conversely, the PHQ-9 is a

questionnaire in which clients scale nine questions from 0-3, 0= none at all, 1= several days, 2=

more than half the days, 3= nearly all the days. The end total is an indication of depression

severity and has been shown to effectively screen cancer patients (McFarland et al, 2020). Past

studies have compared the Distress Thermometer with the PHQ-2 questionnaire, which is

comprised of two questions and found that for newly diagnosed patients (within 30 days of

receiving diagnosis). The Distress Thermometer had higher sensitivity rates for identifying

depression (Lazenby et al, 2014).

PICOT Question: The following PICOT question will be examined: In (P) patients

between the ages of 35-65 that are hospitalized for oncology related reasons, (I) how does a self-

administered screening for Major Depression through PHQ-9 assessed by a psychiatric nurse

practitioner(C) compared to brief screenings such as Hospital Distress Thermometer (O) differ in

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number of psychiatric interventions (continued treatment by PMHNP, medication prescriptions,

counseling, or therapy referrals) given to the patients (T) within 3 months of the screening being

performed?

Purpose Statement: The purpose of this paper is to answer the proposed evidence based

practice PICOT question and make recommendations for improvement of the standard of care in

clinical practice. A literature search was conducted using databases such as Cochrane Library,

PubMed, and CINHAL regarding the need for more rigorous screenings for Major Depression in

oncology patients. Depression can effect a patient’s affect, participation in care, and overall

outlook on treatment. The PHQ-9 screenings can better identify and therefore treat patients that

have concurrent depression and cancer diagnosis.

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