Distress, psychiatric morbidity, and prescriptions for psychotropic medication in a breast cancer waiting room sample

General Hospital Psychiatry 26 (2004) 121–128

Distress, psychiatric morbidity, and prescriptions for psychotropic medication in a breast cancer waiting room sample James C. Coyne, Ph.D.*, Steven C. Palmer, Ph.D., Pamela J. Shapiro, Ph.D., Richard Thompson, Ph.D., Angela DeMichele, M.D. Departments of Psychiatry and Hematology/Oncology, Abramson Cancer Center of the University of Pennsylvania and the University of Pennsylvania School of Medicine, Philadelphia, PA, 19104, USA Received 22 August 2002; accepted 20 August 2003

Abstract We examined relationships among psychiatric screening, the prevalence of psychiatric morbidity, and prescription rates for psychotropic medication in a waiting room sample of breast cancer patients (N⫽113). Rates of distress (29%), major depressive disorder (MDD; 9%), and generalized anxiety disorder (GAD; 6%) were low and similar to those found in primary care settings. A substantial proportion of patients (52%) had received psychotropic medication during treatment, including almost half (48%) of those without a current psychiatric diagnosis. Most individuals with MDD received pharmacotherapy during cancer treatment (80%), although only half of those with GAD were treated. Overall high rates psychotropic medication negatively impacted the efficiency of screening, and individuals with elevated distress were about 6 times less likely to represent a case of untreated psychiatric morbidity than to be a new case. We conclude that the risk of psychiatric morbidity attributable to breast cancer may be lower and treatment rates for psychiatric morbidity higher than previously believed and that screening is unlikely to provide efficient identification of untreated psychiatric morbidity. Adequacy of follow-up care is unclear and medication may be prescribed nonspecifically. The low rate of untreated psychiatric morbidity may signal a need for multisite collaborations to generate adequate numbers of participants in clinical trials. © 2004 Elsevier Inc. All rights reserved. Keywords: Cancer; Depression; Distress; Screening instruments

1. Introduction Although rates of psychiatric morbidity are assumed to be elevated among cancer patients [1,2], morbidity is believed to go largely undetected and untreated. Routine use of brief screening instruments has been proposed as a solution to this problem [3–5]. The relevant literature, however, is limited and may be outdated, given recent increases in the rate of psychotropic medication prescribed in both the community and medical settings [6,7]. Breast cancer has the greatest 1-year incidence of any cancer among women, and breast cancer survivors constitute the largest group of female cancer survivors at 5 years and beyond [8]. Although early in the 20th century the life-expectancy after diagnosis was about 3 years, [9] detection of breast cancer is now more likely to initiate a * Corresponding author. Tel.: ⫹1-215-662-6553; fax: ⫹1-215-3495067. E-mail address: [email protected] (J.C. Coyne). 0163-8343/04/$ – see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2003.08.012

long-term stress process than an acute health crisis ending in early death, and the 5-year relative survival rate is 86% [10]. Yet, as the second leading cause of cancer-related death among women, breast cancer remains a life-threatening and life-altering experience that can be associated with significant psychological distress [11]. The performance of psychiatric screening instruments has been well studied in general medical populations, primarily with respect to depression, and the general consensus is that with appropriate cutpoints most instruments perform comparably [12,13]. Routine screening alone, however, is not sufficient to improve the outcome of psychiatric morbidity, although it may be a crucial component of more extensive practice modifications to improve care for psychiatric comorbidity among general medical patients [14 –16]. It is unclear how such screening instruments perform in routine cancer care. Unpublished data (Maunsell, 1999, personal communication) suggest that more than half of breast cancer patients present with elevated distress at some point during treatment, which is a lower estimate than others

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[17]. The degree to which such distress indicates a need for intervention is unclear, as two thirds of distressed patients may be expected to improve in the absence of formal intervention [18]. There may be a typical trajectory such that most patients experience a reduction in distress within weeks of diagnosis and considerable improvement within 3 to 4 months [19 –22]. On the other hand, there is a consensus that not all distress among breast cancer patients resolves so readily [23]. Estimates of the prevalence of major depression among breast cancer patients range from 2 to 48% [11], while estimates of anxiety disorders among cancer patients range from less than 1 to 49% [24]. Higher estimates variously reflect use of symptom rather than syndrome definitions of disorder, self-report questionnaires, and reliance on psychiatric referrals or oversampling of the most ill or dying patients. Estimates relying on semistructured interviews tend to suggest that 9 to 24% of breast cancer patients meet criteria for major depression during cancer care [25–28] and 10 to 30% of cancer patients meet criteria for anxiety disorder [24]. Primary care physicians fail to diagnose much of the psychiatric disorder presented to them [29 –32], and there is reason to assume that oncologists would perform even more poorly because of competing demands and less training in mental health issues [33–37]. Although the literature is limited, one study found that oncologists missed 60% of the depression in a sample of cancer patients [38]. Similarly, Fallowfield and colleagues [39] found that oncologists failed to detect elevated distress 71% of the time, while Passik and colleagues [40] found that physicians misclassified cancer patients reporting moderate-to-severe depression on the Zung Self-rating Depression Scale [41] 87% of the time. Indeed, 49% of those reporting moderate-to-severe depressive symptoms in the Passik [40] study were rated by their oncologists as having essentially no symptoms of depression. However, the bulk of such studies use self-reported distress as the criterion for evaluating clinician performance and the extent to which distress warrants intervention remains unclear. Nondetection of distress in the absence of demonstrated clinical need or effective treatment options does not necessarily indicate poor care. Yet, evidence exists that a substantial number of cancer patients are incorrectly identified with major depression, and that patients identified with major depression receive inadequate treatment [35,40]. There is a need to update statements about the detection and treatment of psychiatric morbidity in medical settings, as much of the extant data were gathered before the mid1990s and may not reflect increases in the rate of antidepressant prescriptions over the past decade. From 1991 to 1997, the annual number of antidepressant prescriptions written in the United States by primary providers increased from 25 million to 50 million, and there was an increase from 15 million to 33 million for prescriptions by psychiatrists [42]. In some segments of the population, the propor-

tion of individuals who have received an antidepressant may exceed the prevalence of depression [43,44]. Data concerning cancer patients are limited, but one recent study found that the prevalence of major depression in hospice care was 17%, although 40% of all patients had an antidepressant prescription [45]. We examined psychiatric morbidity and prescription of psychotropic medication in a sample of women being treated for breast cancer in a comprehensive cancer center. Our aims were 3-fold: 1) to assess the yield of routine screening in the waiting room of a specialty breast cancer clinic; 2) to establish the prevalence of major depression, generalized anxiety disorder, and research diagnosis of minor depression in this sample, 3) to assess rates of prescription for psychotropic medication and their relationship to diagnoses.

2. Methods 2.1. Participants Participants were a waiting room sample of 113 women undergoing treatment at a tertiary care facility specializing in breast cancer. In total, 153 women were approached, 98% (n⫽150) gave consent and contributed partial data, and 75% completed diagnostic interviews. Individuals completing diagnostic interviews did not differ from those who did not in years since cancer diagnosis, or, when applicable, years since metastases or relapse, all ts ⬍.90, ns. Similarly, there was no difference between these groups in stage of cancer at diagnosis, ␹2 (3)⬍2.64, ns. Women who were unavailable for interview were younger (M⫽50.0 years) than women who completed interviews (M⫽55.6 years), t(136)⫽2.09, P⬍.05. 2.2. Measures 2.2.1. Structured clinical interview for DSM-IV (SCID) Research diagnoses were made using SCID [46] modules for current and past Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD) administered via telephone by trained, doctoral-level clinical psychologists. Research criteria for Minor Depressive Disorder (MinD) were derived from responses to the MDD module. As in previous studies [47], diagnosis of MinD was made without regard to history of MDD. Similarly, diagnosis of MDD and GAD were made without reference to impairment criteria, as has been sometimes recommended [48,49], and, as such, provide a liberal estimate of prevalence. Training and supervision for SCID interviewers followed recommended procedures [50]. As part of training, interviewers reviewed the SCID user’s guide, viewed SCID training videotapes, rated videotaped expert interviewers, and received feedback on role-played interviews. A sample of 13% of the interviews was audiotaped and scored by second raters for reliability analysis in the current study. Agreement on the presence of symptoms between initial and

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secondary raters was high (95%) and inter-rater reliability was adequate (␬⫽.81). Previous studies have shown the concordance of telephone-administered diagnostic interviews with face-to-face interviews for assessment of depression [51–53]. 2.2.2. Hopkins symptom checklist (HSCL-25) The 25-item version [54] of the Hopkins Symptom Checklist (HSCL) [55] was used to assess psychological distress. HCSL-25 items appear on the Symptom Checklist-90 with inconsequential differences in wording [55] and the measure is highly correlated with the 58-item version HSCL [56]. The HSCL-25 and the closely related Brief Symptom Inventory [57] are widely used as screening instruments among cancer patients. Using a cutoff of 44 and above for caseness, Hough and colleagues [54] found that the HSCL-25 was comparable or superior to the Center for Epidemiological Studies–Depression Scale [58] in detecting psychiatric disorder. The HSCL-25 has demonstrated reliability and validity across a variety of general and medical populations [59 – 61]. The HSCL-25 demonstrated adequate internal consistency (Cronbach’s ␣⫽.92) with the current sample. 2.2.3. Chart abstraction/psychotropic medication Information regarding demographics, staging of cancer and date of diagnosis, occurrence and date of detected metastases and recurrences, and medication prescription across the course of treatment was abstracted from clinic charts by a trained, predoctoral research assistant. Chart abstraction information was then coded for presence of antidepressant and anxiolytic medication prescription by a member of the investigator team. Medication type and categorization was made with reference to the Physician’s Desk Reference [62]. Given that charts were often lacking information regarding the conditions for which prescriptions were made, dosage, time-frame during which prescriptions were active, or whether prescriptions were filled or refilled, it was not possible to distinguish between current and discontinued prescriptions, and only presence in the chart of an antidepressant or anxiolytic medication was recorded. To address possible prescription of anxiolytic or antidepressant medications by physicians not associated with the cancer center, SCID interview data concerning reports of current medications were also examined for presence of anxiolytic or antidepressant treatment. 2.3. Procedure Participants were recruited after approval was granted by the University of Pennsylvania Institutional Review Board. Women arriving for an appointment for breast cancer at a tertiary care facility were approached by a research assistant and asked to participate in a study of the impact of breast cancer on emotional and social well-being. Research assistants approached consecutive patients arriving during the

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4-h blocks of time from which the waiting room was sampled. Exclusion criteria consisted of inability to speak and understand English well enough to allow for informed consent and completion of instruments and diagnostic interview. After providing informed consent, participants were provided with a brief screening instrument to be completed on site, a packet of questionnaires to be completed at home and mailed back to the investigators within 1 week, and were scheduled for a telephone SCID interview to take place within 2 weeks. If questionnaire materials were not received before the scheduled interview, participants were phoned with a reminder and rescheduled for interview.

3. Results 3.1. Demographics Participants were primarily middle aged (M⫽55.8 years; R⫽34 – 89 years), European American (80%), married or living in a marriage-like situation (72%), parents (90%), and about equally likely to be employed (54%) as not. This was a well-educated group, with 60% having received at least a 2-year college degree and 24% having completed a graduate degree. Time since diagnosis of cancer varied, with 31% being initially diagnosed more than 5 years previously, 35% between 2 and 5 years, 14% between 1 and 2 years, and 19% within 1 year. Seventy-two percent of those women who were more than 5 years from initial diagnosis had either metastases or cancer recurrence 2.4 years, on average, before entrance into the study. At cancer diagnosis, 22% were diagnosed with Stage 1, 28% with Stage 2a, 24% with Stage 2b, 10% with Stage 3a, 6% with Stage 3b, and 10% with Stage 4 disease. Given the low prevalence rates within some TNM stages, analyses using staging of cancer were collapsed across subcategories within Stages 2 and 3. 3.2. Psychiatric distress and morbidity 3.2.1. Psychiatric distress Overall, distress was moderate, with a mean score on the HSCL-25 of 40.5 (SD⫽11.26), significantly below the established cutpoint of 44 (t(112)⫽3.32, P⬍.001). The proportion of the sample exceeding the established cutpoint was 29.2%. Similar to previous studies [63– 65], women who were older tended to be less distressed (r⫽⫺.20, P⬍.05). Level of distress was unrelated to educational attainment, staging of cancer at diagnosis, time since diagnosis, or time since last recurrence or metastasis (all P⬎.50). 3.2.2. Depression and anxiety Results of the SCID interview indicated that 9% (CI⫽5– 16%) of the sample met criteria for MDD, 6% met criteria for GAD (CI⫽3–12%), and an additional 7% (CI⫽4 –13%) met research criteria for MinD. Individuals without a college degree were more likely to receive a diagnosis of MDD

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Table 1 Prescription rates by diagnostic category Diagnostic category

Any psychotropic

Antidepressant

Anxiolytic

Major depressive disorder Minor depressive disorder Past major depressive disorder without current depressive disorder Generalized Anxiety Disorder

80% 50% 68.8% 50%

70% 37.5% 66.7% 33%

30% 25% 31.3% 17%

than individuals with such a degree, ␹2(1)⫽4.75, ⬍.05, although educational attainment was unrelated to other diagnostic categories (all P⬎.10). Diagnosis of MDD, GAD, or MinD classified as individual psychiatric disorders, depressive cluster disorders, or presence of any disorder, was unrelated to stage of cancer (all ␹2(3ⱕ4.71, ns), or age, time since diagnosis, time since last recurrence or metastasis (all P⬎.25). 3.2.3. History of depression Prevalence of SCID-assessed history of MDD was 30% (CI⫽22–39%) overall, and 60% with current MDD, 57% of those with GAD, and 38% of those with MinD reported such a history. The relative risk of an MDD diagnosis being associated with a past history of MDD was 3.49 and for GAD the relative risk was 3.47. History of MDD was unrelated to stage of cancer at diagnosis, age, time since diagnosis, or time since last recurrence or metastasis (all P⬎.10). 3.2.4. Psychiatric distress and disorder1 The HSCL-25 was a significant predictor of MDD, ␹2(1)⫽8.83, P⬍.05. However, almost one-third (30%) of those with MDD were missed, while 25% of those without MDD screened positive. The probability that an individual with an elevated HSCL-25 score received a diagnosis of MDD was 21%, suggesting that approximately four times as many individuals screening positive did not meet criteria for MDD as did. The HSCL-25 correctly identified 65% of those with either MDD or MinD, misidentifying 22% of those without a depression cluster disorder, and 34% of the individuals with a positive screen was diagnosed with one of these disorders. The HSCL-25 was not a significant predictor of GAD, ␹2(1)⫽.67, ns, correctly identifying only 43% of the individuals with a GAD diagnosis while mislabeling 28% of those individuals without such a diagnosis as potential cases. The probability that an individual with an elevated HSCL-25 score would be found to have GAD was 9%. When used as a screen for the presence of any of the above disorders, the HSCL-25 missed 40% of cases and incorrectly identified 20% of those without disorder as potential cases. The probability that an elevated HSCL-25 score was related to any disorder was 46%. 3.2.5. Prescription of psychotropic medication Across the course of treatment, 52% of the sample had received a prescription for anxiolytic or antidepressant medication. Anxiolytics were prescribed to 33% of the sample,

antidepressants were prescribed to 34%, and 12% of the sample received both. Neither prescription rates for anxiolytics or antidepressants, nor rates for psychotropics overall were related to age, educational attainment, stage of cancer at diagnosis, time since diagnosis, or time since last recurrence or metastasis (all P⬎.27). 3.2.6. Prescription and psychiatric morbidity As can be seen in Table 1, more than two-thirds of the cases of current MDD had received an antidepressant during breast cancer treatment. Overall, more than half of those patients experiencing MDD or MinD received psychotropic medication during treatment, and similar results were found for individuals with a history of MDD but no current disorder. Combining those women with MDD and those with MinD, 65% received some form of psychotropic medication; 53% an antidepressant and 29% an anxiolytic. Half of the women with GAD received psychotropic medication, with one-third receiving an anxiolytic and one-sixth receiving antidepressant therapy during treatment for breast cancer. Prescriptions were not limited to those with identified psychiatric morbidity, and 48% of those without current disorder received psychotropic medication; 31% an anxiolytic and 27% an antidepressant. To ascertain if the prescription rate among individuals without current diagnosis was a result of treatment of past psychiatric morbidity, an analysis limited to individuals without past MDD was conducted. Results indicated that 44% of those individuals with no prior history of depression and neither current nor past MDD, nor current GAD or MinD received psychotropic medication over the course of treatment for cancer, 30% an anxiolytic and 22% an antidepressant. 3.2.7. Screening for untreated psychiatric morbidity Screening is most often suggested as a means of identifying patients with psychiatric morbidity that would otherwise be unidentified or untreated. We reanalyzed our data, excluding patients with MDD receiving antidepressant medication and patients with GAD receiving either antidepressant or anxiolytic medication, to determine the efficiency of screening in the identification of individuals with psychiatric morbidity who would otherwise be unidentified, using prescription of psychotropic medication as a proxy for identification. In this subset of patients, the HSCL-25 was unrelated to identification of undetected MDD, ␹2(1)⫽2.57,

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ns. The HSCL-25 continued to miss one-third (33%) of those with MDD and misclassify 25% of those without MDD. Most strikingly, the probability that a breast cancer patient screening positive for distress would not be diagnosed with untreated MDD (93%) was now more than 13 times the probability that she would (7%). Similar results were found for detection of untreated GAD. The HSCL-25 was unrelated to identification of undetected GAD, ␹2(1)⫽.88, ns, missed one-half (50%) of those with untreated GAD and misclassified 28% of those without GAD. As with MDD, the probability that a breast cancer patient screening positive for distress would not be diagnosed with untreated GAD (94%) was now more than 13 times the probability that she would be diagnosed with GAD (6%). We next calculated the utility of distress as a screen for any undetected DSM-IV disorder by excluding patients with either MDD and an antidepressant prescription, or GAD and an antidepressant or anxiolytic prescription. The HSCL-25 continued to miss 43% of those with a disorder and misclassify 24% of those without a disorder as having one. A slight improvement in positive predictive value was found (15%); however, women remained almost 6 times more likely to be incorrectly identified as having either untreated MDD or GAD as they were to be correctly identified.

4. Discussion Screening of a breast cancer waiting room sample found that 29% of patients were in the distressed range. Follow-up interviews found that approximately 9% met criteria for major depression, 7% met research criteria for minor depression, and 6% met criteria for GAD. Consistent with research in other populations, the HSCL-25 functioned moderately well as a screening instrument. However, as a clinical tool, it would have missed about one-third of patients with MDD, more than one-half of those with GAD, and most patients with a positive screen would not have a diagnosable disorder. The most striking findings concerned rates of psychotropic medication prescription. Over half of the women received psychotropic medication after diagnosis of breast cancer. Although over two-thirds of the women with current MDD received an antidepressant and half of those with GAD received either an antidepressant or anxiolytic, almost half of all women without a current diagnosis received a prescription. Partly because of this high rate of already initiated treatment, screening was inefficient in its ability to detect women with psychiatric morbidity who were not already receiving pharmacotherapy. Interpretation of these results should take into account features of the study that may limit their generalizability. The study was intended to simulate the impact of routine psychiatric screening in a breast cancer treatment center. Similar to studies of general medical patients, we screened and interviewed all patients in the waiting room during

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recruitment periods. Although this allowed us to address questions about the efficiency of screening, it cannot be assumed to produce estimates of the prevalence of distress and psychiatric morbidity associated with breast cancer. The sample was heterogeneous in terms of staging of cancer, time since diagnosis, and recurrence status. It is possible that focusing on recently diagnosed patients would have increased estimates of distress and led to a higher prevalence of psychiatric morbidity. However, time since diagnosis was unrelated to either distress or psychiatric morbidity in this sample. The sample was also limited to the waiting room of a single breast cancer program at a university-based cancer center and we cannot evaluate the generalizability of results to other settings. The precision of prevalence estimates is further limited by the small sample size. It is important to note, however, that this sample was similar in size or larger than that found in many recent studies examining distress and depression among cancer patients (e.g. [66 – 69]) and that our presentation of confidence intervals takes sample size into account. Although research diagnoses were by telephone administered SCID, rather than face-to-face, the validity of telephone-based psychiatric interviews are well established [51–53] and there was probably an advantage in terms of ensuring a greater retention of screened patients for an interview. A recent effort to provide psychiatric interviews to cancer patients during index visits encountered substantial logistical problems and a high rate of rejection by patients [70], which we avoided. Ascertainment of prescriptions of psychotropic medication was by chart review and self-report during interviews. Although the limitations of chart reviews are well noted in the literature, it is our sense that oncology clinicians in this setting routinely inquired about medications prescribed to patients. Nonetheless, we lacked systematic data about timing, indications, and sources of prescriptions, as well as adherence to medication. It is certainly possible that some of those whom we classified as previously identified patients were receiving medications for off-label purposes, such as pain or hot flashes. Were this the case, the HSCL-25 would perform somewhat better as a screening instrument. However, our chart review revealed only a few notes regarding prescription of antidepressants accompanied by reference to hot flashes and none among the individuals identified with MDD or GAD. This lack of information regarding reason for prescription, however, is a crucial limitation that should be addressed in subsequent work. Statements about rates of distress and morbidity need to be made with reference to appropriate comparison groups if we are to understand the impact of cancer on well-being. The rate of distress we found is consistent with recent findings that, as a group, cancer patients are not more distressed than general medical outpatients [19,71], and rates of MDD and distress are remarkably similar to what is found in primary care samples [14,72]. Although prevalence estimates for MDD and GAD vary widely across studies, findings of a modest rate are consistent with more recent

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studies and those using semistructured interviews. Notably different in the present study was the high rate of receipt of prescriptions for psychotropic medication. We know of no comparable data concerning cancer patients, other than the previously noted study of patients in hospice care for which rates were similar [45]. However, the rate of prescription in our sample is consistent with recent findings across medical settings that the highest rates of antidepressant prescriptions are to middle aged and older White women [73]. Interpretations of the prevalence of psychiatric morbidity and the performance of the screening instruments depend on how we understand the rate of psychotropic medication found in this sample. One interpretation is that antidepressants are being used effectively, which is reflected in a markedly reduced prevalence of distress and psychiatric morbidity. A number of factors caution against prematurely accepting such an optimistic assessment. First, the bulk of prescriptions were to women with neither current morbidity nor past MDD. Second, although there is evidence of undetected and under treated psychiatric morbidity among cancer patients, there is also evidence that oncology clinicians are nonspecific in their judgments about such morbidity. It may be that the prescription rate reflects nonspecificity in identifying transiently distressed patients as suitable for pharmacotherapy. Third, the interpretation that psychotropic medications are being used effectively requires that oncologists be considerably more successful than primary care physicians in detecting and managing psychiatric morbidity. A considerable body of literature establishes that under conditions of routine care, primary care physicians’ detection and initiation of treatment does not reliably lead to improved outcomes [12]. Indeed, there is evidence that the effectiveness of antidepressants administered in routine primary care is comparable to the performance of placebos in the context of clinical trials [74]. Results suggest the value of including inquiries about current treatment in any screening of cancer patients for psychiatric morbidity, and the rate of prescribing suggests the need to determine whether such prescriptions are appropriate and effective. As has been suggested in recent literature [75,76], greater benefit may be had on a population basis by improving the care provided to those who have received a prescription than by pursuing the proportionately fewer depressed patients who have not been offered treatment. There are numerous explanations, apart from high rates of prescribing, as to why the prevalence of distress and psychiatric morbidity are lower than what has been found in some studies. It may be that the trajectory for distress following diagnosis of breast cancer is such that distress had peaked and declined well before the point of assessment for the bulk of our participants. On the other hand, there are data suggesting that distress among cancer patients is not, on the whole, substantially elevated compared to groups such as college students [77] and control subjects drawn from the general population [78], although both sets of authors interpreted their results in terms of the inappropri-

ateness of such comparisons. The most ambitious study of distress among cancer patients to date involved over 9000 patients and found that 35% of cancer patients scored in the distressed range, with no variation a result of prognosis or illness burden [19]. Although somewhat higher than what was found in the present study it is still in a range consistent with what is found in the waiting rooms of primary care physicians. Past studies of psychiatric morbidity in cancer care which produced higher estimates of rates of depression were marked by reliance on self-report and intervieweradministered symptom scales, rather than research diagnostic instruments, and often involved biased recruitment strategies relying on referred, inpatient or advanced stage and dying patients. It is also possible that profound historical changes in the social and clinical context of cancer care have altered the experience of cancer patients [79,80]. The rate of minor depression approximated the rate of MDD in this sample, although its clinical significance remains ambiguous. Minor depression is associated with impaired functioning and quality of life [81– 83], but significant debate exists over how well it resolves with treatment [28,43]. Minor depression is undoubtedly heterogeneous, but it is noteworthy that only about a third of patients with minor depression in the present sample had a history of MDD. Before dismissing the appropriateness of treating minor depression, past history of depression should be investigated as an effect modifier, with particular focus on whether patients with current minor depression and a history of depression are responsive to treatment [84]. If replicated, findings that the prevalence of distress and psychiatric morbidity approximate what is found in a primary care setting have important implications, raising questions about the degree to which these difficulties are attributable to breast cancer diagnosis and treatment. An immediate implication is that the substantial literature concerning the improvement of care for depression in primary care settings becomes relevant to the specialty cancer setting. Currently, enthusiasm for frontloading strategies of screening, detection and treatment of even subsyndromal conditions holds sway within the cancer literature, with much less attention being paid to patient follow-up. There are, naturally, more complex issues in cancer care concerning competing demands and difficulties in ensuring continuity of mental health care at the end of acute cancer treatment. Yet, there is much to learn from studies conducted in primary care about the difficulty of improving the outcome of depression and how simple efforts, such as screening and clinician and patient education, prove insufficient.

5. Conclusions Our findings have implications for the conduct of clinical research concerning psychiatric morbidity among breast cancer patients. Given the rates of disorder, such trials may require larger pools of patients than anticipated to ensure adequate sample sizes, making multi-site trials a necessity.

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This problem may be compounded by the relatively large proportion of patients already identified and receiving psychotropic medication.

Note 1

For analyses examining false positive classification errors using the HSCL-25 as a screen for psychiatric morbidity, only individuals without a diagnosable condition (MDD, MinD, or GAD) are included.

Acknowledgments This study was supported by NIMH Center Grant, MH 52129-06.

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