Screening for Depression and Starting Antidepressants in Oncology Care

In this episode of CancerNetwork’s® Ask Me Anything, Erik Bengtsen, MD, an assistant attending psychiatrist and assistant director of the Consultation-Liaison Psychiatry Training Program at Memorial Sloan Kettering Cancer Center, answered questions about the psychiatric care of patients with cancer that were pulled from clinician forums and recurring themes in the psycho-oncology literature.

Bengtsen first discussed the single most useful screening question at an initial consultation. Beyond asking about sadness or despair, he recommended asking whether patients can still enjoy time with family and friends, a question that gets at anhedonia and reveals who and what matters most to the patient. He then addressed whether oncologists should start selective serotonin reuptake inhibitors (SSRI) or defer to psychiatry. Given wait times that can stretch to weeks or months, he noted that many oncologists start a low-dose antidepressant, often choosing agents with an added indication, such as duloxetine (Cymbalta) for depression and pain or venlafaxine (Effexor XR) for depression and hot flashes, before a psychiatrist adjusts the regimen.

Transcript:

CancerNetwork: What is the best single screening question during an initial patient consultation?¹

Bengtsen: We say you have to ask about mood, depression, and anxiety is whether there is some component of sadness or despair. Something that is often not asked, and that I would encourage people to add, is: ‘Are you still able to enjoy time with family and friends?’ That gets at the concept of anhedonia: Are we still able to experience some joy and connection? It also gets at what’s meaningful to the patient. They might bring up different family members that they rely on for support.

CancerNetwork: Should an oncologist start SSRI treatment or defer?²

Bengtsen: At plenty of cancer hospitals, and at community clinics as well, there might be a long wait time for a patient to be seen by a psychiatrist. It could be weeks or even months to get somebody established with a psychiatrist, so I’ve seen plenty of oncologists start a low-dose antidepressant. There are certain antidepressants that have indications for depression and pain, such as duloxetine, or for depression plus hot flashes, such as venlafaxine, which the oncologist might be more comfortable starting because of that extra indication. Then, once the psychiatrist meets the patient, they might increase the dose or change the medication if there’s not a good response or if there are side effects. I’d say it’s up to the oncologist’s level of comfort, but I’ve seen plenty of oncologists start a low-dose antidepressant.

References

1. Ahmed E. Antidepressants in Patients With Advanced Cancer: When They're Warranted and How to Choose Therapy. Oncology (Williston Park). 2019;33(2):62-68.

2. McFarland DC, Shen MJ, Polizzi H, et al. Preferences of patients with myeloproliferative neoplasms for accepting anxiety or depression treatment. Psychosomatics. 2017;58(1):56-63. doi:10.1016/j.psym.2016.08.006