Many Cancer Survivors Have Untreated Depression

Charles Bankhead

October 2016, Vol 7, No 9 - Survivorship


Nearly 20% of community-dwelling cancer survivors with depression received no treatment for their depression, according to an analysis of nationally representative data. Among patients whose records included International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes associated with depression, 81% received antidepressants, psychotherapy, or both, but the remaining 19% of patients received neither, according to a study presented at the 2016 International Society for Pharmacoeconomics and Outcomes Research annual meeting. Patients who received treatment for their depression were more likely to be women, Caucasian, insured, employed, and have a usual care provider. In addition, they had worse general health status, more pain, and multiple comorbidities compared with other cancer survivors. Cancer survivors who received combination therapy with antidepressants and psychotherapy were similar to those who received any treatment, but they were more likely to have poor mental health status, reported Hrishikesh Kale, MS, PharmD candidate at Virginia Commonwealth University School of Pharmacy, and colleagues. Previous studies have shown that 20% to nearly 50% of cancer survivors have depressive symptoms, and at least 10% of cancer survivors meet the diagnostic criteria for major depressive disorder, according to the Institute of Medicine’s report, From Cancer Patient to Cancer Survivor: Lost in Transition. Depression among cancer survivors is associated with an increased risk for suicide, poor quality of life, increased mortality risk, delayed return to work, and increased use of healthcare resources and associated costs. The use of antidepressants among cancer survivors has increased despite inconclusive evidence of their efficacy for treating depression in this patient population. Patterns of treatment for depression in cancer survivors have remained poorly understood. In an effort to inform decision-making, Mr Kale and colleagues analyzed data from the Medical Expenditure Panel Survey.

Factors Predicting Treatment for Depression

The analysis involved cancer survivors whose medical records included ICD-9-CM codes 296 or 311 between 2008 and 2012. The researchers included any form of treatment for depression that patients received, including psychotherapy and antidepressants. Of the 10,118 cancer survivors, 1551 (15.3%) had depression, and 81% of the cancer survivors with depression received treatment for their depression—66% of cancer survivors received antidepressants alone, 3% received psychotherapy alone, and 12% received a combination of antidepressants and psychotherapy; the remaining 19% of cancer survivors received no treatment for their depression. Among the patients who received antidepressants, the most frequently used agents included serotonin reuptake inhibitors (54%), serotonin and norepinephrine reuptake inhibitors (19.8%), phenylpiperazine (7%), tricyclic antidepressants (5.8%), and tetracyclic antidepressants (2.6%). Based on a multivariate analysis, the factors that significantly influenced the likelihood for receiving treatment for depression among cancer survivors were female sex (odds ratio [OR], 1.69), Hispanic ethnicity versus white (OR, 0.44), private health insurance versus uninsured (OR, 2.73), public health insurance versus uninsured (OR, 2.73), usual source of care versus no usual source of care (OR, 3.28), and high or extreme pain versus low pain (OR, 1.79). Multinomial analyses were done to identify factors that were significantly predictive of the type of depression therapy (antidepressants alone or combination of antidepressants and psychotherapy) that cancer survivors received, omitting the category of psychotherapy alone because of a small patient size. Female cancer survivors were significantly more likely than men to receive treatment for depression—either antidepressants or a combination of medication and psychotherapy. Hispanic ethnicity and unmarried status significantly reduced the likelihood of treatment with an antidepressant. In addition, older age (≥65 years) significantly reduced the odds of receiving treatment for depression with antidepressants or with combination therapy. Cancer survivors with private or public health insurance were significantly more likely than uninsured cancer survivors to receive anti-depressants or a combination of antidepressants and psychotherapy. In addition, cancer survivors with a usual source of care were more likely than cancer survivors without a usual source of care to receive antidepressants or antidepressants plus psychotherapy. Furthermore, cancer survivors with overall fair or poor mental health status were more likely than those with good health status to be treated for depression. High self-reported pain (vs moderate pain) increased the likelihood that a cancer survivor would receive an antidepressant.