Should ultrashort mental health screening tools be used across oncology practices?

Yes.

Evidence consistently reveals that patients with cancer are at heightened risk for distress, which can adversely impact their health-related quality of life and plays a role in overall patient survival. However, despite this evidence, psychosocial distress remains underrecognized by oncology clinicians who lack time and desire brief psychosocial assessments rather than lengthy clinical assessment interviews.

Therefore, the use of ultrashort screening tools may be considered by busy oncology practices and clinicians as an easy, inexpensive systematic screening approach for routine distress assessment.

Several ultrashort screening measures have been introduced, validated and implemented by the cancer community. For example, the Distress Thermometer (DT) is the most widely utilized and investigated single-item psychological screening measure developed specifically for patients with cancer and survivors. The PHQ-2, a two-item depression screen utilized in the primary care setting, also has been used among cancer populations.

Introduced more recently, the Patient-Reported Outcomes Measurement Information System (PROMIS) measures priority symptom burdens and outcomes in individuals with various chronic health conditions, including cancer, using existing self-report measures and online computer-adaptive testing.

However, the diagnostic accuracy of ultrashort screening tools to detect distress for patients most in need of psychosocial support at different points across the cancer trajectory remains unclear. Also, few studies have compared the accuracy of these measures with the standard well-accepted diagnostic interview utilized routinely in psychiatric assessment research. This form of investigation is crucial because without such a comparison, it can be challenging to determine the degree of accuracy of the ultrashort tools.

For example, Mitchell and colleagues conducted a rigorous systematic literature search and identified 38 analyses, 19 of which evaluated the DT, to examine the diagnostic validity of ultrashort screening in cancer settings. The pooled analysis revealed ultrashort methods were sensitive at excluding possible cases of depression but inadequately confirmed a suspected diagnosis. This review was the first to confirm that ultrashort screening measures should not be utilized alone to diagnose depression, anxiety or distress in patients with cancer but, rather, should be considered as a preliminary screener.

Low and colleagues evaluated the two-question depression screen, reporting a sensitivity between 84% and 94% and specificity between 72% and 73% compared with two criterion measures, supporting its usefulness as a screening tool for psychological distress in busy clinical U.K. cancer settings. Yet, the low positive predictive values revealed that high test scores require psychological referral for a comprehensive assessment.

In another study, Recklitis and colleagues compared the PROMIS Depression Short-Form (PROMIS-D-SF) with the structured diagnostic interview (SCID) among young adult cancer survivors. PROMIS-D-SF demonstrated moderately strong concordance with depressive diagnoses and symptoms measured by the SCID; however, the cutoff scores did not meet criteria for clinical screening. The authors concluded PROMIS-D-SF may be useful for assessing depression, but that it has limited utility as a single screening instrument.

In summary, ultrashort, high-quality mental health questionnaires should be used only as a screen to detect distress, depression and anxiety early on in the diagnosis and treatment phase, with repeated administration across the cancer trajectory. Ultrashort tools can serve as a preliminary “red flag” to prompt referral for additional, comprehensive psychological assessment, but they should never serve as a replacement or substitute for the comprehensive standard criterion mental health diagnostic clinical interview.

It remains critical that the cancer organization and clinicians collaborate to implement routine distress screening and management tailored for their clinical environment to provide equitable quality care. It is also vital that oncology clinicians undergo rigorous training in use of these tools for proper symptom detection to ensure that any patient distress detected is appropriately addressed.

References:

Arroll B, et al. BMJ. 2003;doi:10.1136/bmj.327.7424.1144.

Batty GD, et al. BMJ. 2017;doi:10.1136/bmj.j108.

Carlson LE, et al. J Clin Oncol. 2012;doi:10.1200/JCO.2011.39.5509.

Donovan KA, et al. Psychooncology. 2014;doi:10.1002/pon.3430.

Jacobsen PB. J Clin Oncol. 2007;doi:10.1200/JCO.2007.13.1367.

Low J, et al. J Pain Symptom Manage. 2009;doi:10.1016/j.jpainsymman.2008.08.006.

Mitchell AJ. J Clin Oncol. 2007;doi:10.1200/JCO.2006.10.0438.

Pirl WF, et al. Supp Onc. 2007;5:499-504.

Recklitis CJ, et al. Cancer. 2020;doi:10.1002/cncr.32689.

Riley WT, et al. J Ment Health Policy Econ. 2011;14(4):201–208.

Skarstein J, et al. J Psychosom Res. 2000;doi:10.1016/s0022-3999(00)00080-5.

Vodermaier A, et al. J Natl Cancer Inst. 2009;doi:10.1093/jnci/djp336.

Fay Hlubocky, PhD, MA, is a clinical health psychologist and research ethicist at University of Chicago Medicine. She can be reached at fhlubock@medicine.bsd.uchicago.edu.

No.

Ultrashort screening methods have a function, but the tools are extremely limited and need to be supplemented.

This form of screening may tell us that a patient is anxious or depressed, which are psychological problems, but they do not suggest interventions or offer solutions. Moreover, some people naturally have anxious personalities, whereas others tend to have lower moods. But, these personality traits are almost never the primary issue that a patient with cancer needs to have addressed.

The low uptake of ultrashort screening likely is due to its limited function. For example, it can identify patients who are stressed, who may be anxious or who may be depressed. But, these emotional states are such a small part of the overall patient story. The bigger story is how patients are coping with these feelings and if they need help.

The question is not: What is the matter with the patient or their family members? Rather, the real question should be: What matters to the patient and their family members? The latter is where the focus should reside and where energy should be spent. Personality traits are much harder to influence; it is more effective to teach coping skills.

If we are using an ultrashort method, then we are very unlikely to get a true sense of the social situation of the patient, which is where most of the stress originates. Anxiety and depression truly matter, but using ultrashort methods is like putting a flag on the moon and then leaving. If we have a screening instrument that does not motivate, educate or help patients identify what matters to them and barriers to their care, what are we really doing? Screening alone does not do anything. We do not need faster screening; patients need deeper screening to get to the root of the problem. We need to connect, motivate, educate and help orient patients and their families.

When we ask about depression, anxiety, financial concerns, fatigue or pain, we need to ask questions in a way that enables patients to understand the context and to know that help is available to them. It is hard to make the ethical argument to ask questions but do nothing to help address the difficulties patients face.

In summary, the screening process should be a therapeutic process. Ultrashort instruments cannot do this. More advanced and comprehensive screening tools ask more questions, and they gather more useful information in a way that promotes action and instills hope.

Matthew Loscalzo, LCSW, is executive director of the department of supportive care medicine at City of Hope. He can be reached at mloscalzo@coh.org.