Screening for depression proves beneficial for people with breast cancer

This new study of data from Kaiser Permanente Southern California compared the outcomes of behavioral health recommendations in breast cancer patients between those receiving a personalized intervention or an educational-only approach.

Following their pragmatic cluster-randomised clinical trial in patients with new primary breast cancer, researchers using data from Kaiser Permanente Southern California (KPSC) determined that there is a likely benefit to routine screening of depression in community oncology practices.

Their study compared outcomes for patients having oncology consultations between October 1, 2017 and September 30, 2018 (N=1436), across 6 Southern California medical centers. After 1:1 randomization to study group (received personalized intervention; n=744 patients at 3 sites) or control group (received education only; n=692 patients at 3 sites), all Participants were followed until death, insurance opt-out, or the study end date of May 31, 2019. The primary outcome was the percentage of eligible patients screened and given a health referral behavioral; secondary outcomes were outpatient health care utilization rates for behavioral health, primary care, oncology, urgent care, and emergency department (ED).

“Although the need for large-scale screening seems intuitive, screening programs incur costs and knowledge of key outcomes is insufficient,” the authors wrote. “And despite demonstrated efficacy, there is little evidence to support the effectiveness of depression screening programs under routine practice conditions.”

Screening was done via the 9-Item Patient Health Questionnaire (PHQ-9) and referral to behavioral health services was done using an algorithm-based scoring method that ranked patients (average [SD] age, 61.5 [12.9] year; 17 black; 18% Asian/Pacific Islander; 26% Hispanic; 37% white) based on a mild (0-9), moderate (10-19) or severe (20 or more) score.

The results were published in a recent issue of JAMA.

Investigator results indicate that significantly more patients in the study group received referrals for behavioral health compared to the education-only group: 7.9% versus 0.1%. Of these referrals, 75% and 100%, respectively, completed them.

Moreover, these results were observed despite the fact that participants receiving care at the intervention sites had significantly fewer overall outpatient medical oncology visits (adjusted rate ratio [aRR], 0.86; 95% CI, 0.86-0.89; P = 0.001). No significant differences were observed between cohorts for the secondary outcomes of primary care (aRR, 1.07; 95% CI, 0.93-1.24), emergency care (aRR, 0 .84; 95% CI, 0.51-1.38) and emergency department visits (aRR, 1.16; 95% CI, 0.84-1.62).

Most patients in both groups (87%, study group; 84%, control group) had stage 0-IIb breast cancer (early stage disease) and received low scores on their PHQ-9 (89% and 67%, respectively). Twenty-eight died during the study (19 from the intervention group and 9 from the control group).

Those in the study group who had a low PHQ-9 score received information about KPSC and community behavioral health resources; participants with moderate scores were referred to a licensed clinical social worker in oncology, depression care management, or both; and severe scores prompted direct referrals to behavioral health (psychiatry or psychology), immediate crisis telephone consultation, or both. In the tailored intervention group, 11% received moderate or high scores, and of this group, 94% also received an appropriate referral. The other participants in the group refused their referral or did not receive one. Overall, 75% had at least 1 visit with a behavioral health clinician.

However, regardless of PHQ-9 screening, 65% more patients in the personalized group received a referral for a behavioral health service compared to the education-only group: 18% versus 11%. In addition, more than twice as many people in personalized intervention clinics were referred by the oncology department: 59% versus 26%.

Follow-up times were almost equal across the groups, at 1.15 and 1.14 years, respectively.

“Given the heavy burden of depression in breast cancer patients, effective screening and referral programs are needed,” the authors noted. However, several challenges exist for their potential implementation, including the complexity of interventions, an unrealistic workload and lack of staff commitment.

Moreover, the finding of lower utilization of outpatient oncology in the intervention group may indicate the futility of a screening program that does not contribute to increased health care utilization. To confirm this, the authors suggest translating their study into other contexts.

Because mental health outcomes following behavioral health referrals were not measured, it remains unclear whether clinical outcomes actually improved in the referred group compared to the referral group. education only. A second limitation is that this study focused on patients with breast cancer, as the results cannot be generalized to other types of cancer.

“Further research is needed,” the authors concluded, “to understand the clinical benefits and cost-effectiveness of this program.”


Hahn EE, Munoz-Plaza CE, Pounds D, et al. Effect of a community-based medical oncology depression screening program on behavioral health referrals in breast cancer patients: a randomized clinical trial. JAMA. 2022;327(1):41-49. doi:10.1001/jama.2021.22596

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