Depression Screening Shown to Benefit Persons Living With Breast Cancer

This new study of data from Kaiser Permanente Southern California compared outcomes for behavioral health referrals among patients with breast cancer between those receiving a tailored intervention or an education-only approach.

Following their pragmatic cluster randomized clinical trial conducted among patients with new primary breast cancer, investigators utilizing data from Kaiser Permanente Southern California (KPSC) determined there is a likely benefit to routine depression screening within community-based oncology practices.

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

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

Screening was carried out via the 9-item Patient Health Questionnaire (PHQ-9), and referral for behavioral health services made using an algorithm-based scoring method that classified patients (mean [SD] age, 61.5 [12.9] years; 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.

Results were published in a recent issue of JAMA.

The investigators’ findings indicate that a significantly greater number of patients from the study group received referrals for behavioral health vs the education-only group: 7.9% vs 0.1%. Of these referrals, 75% and 100%, respectively, completed them.

In addition, these results were seen despite the participants receiving care at the intervention sites having significantly fewer overall outpatient medical oncology visits (adjusted rate ratio [aRR], 0.86; 95% CI, 0.86-0.89; P = .001). Significant differences were not seen between the cohorts for the secondary outcomes of primary care (aRR, 1.07; 95% CI, 0.93-1.24), urgent care (aRR, 0.84; 95% CI, 0.51-1.38), and ED visits (aRR, 1.16; 95% CI, 0.84 to 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 over the course of the study (19 from the intervention group and 9 from the control group).

Those in the study group who had a mild score on the PHQ-9 received information about KPSC and community behavioral health resources; participants with moderate scores received referrals for a oncology licensed clinical social worker, depression care management, or both; and severe scores prompted direct referrals to behavioral health (psychiatry or psychology), an immediate telephone crisis 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 remaining group participants declined their referral or were not offered one. Overall, 75% completed at least 1 visit with a behavioral health clinician.

However, regardless of PHQ-9 screening, 65% more patients in the tailored group received a referral for any behavioral health service vs the education-only group: 18% vs 11%. In addition, more than twice as many persons at the tailored-intervention clinics received their referrals through the Oncology Department: 59% vs 26%.

Follow-up times were close to equal in the groups, at 1.15 and 1.14 years, respectively.

“Given the high burden of depression in patients with breast cancer, effective screening and referral programs are needed,” the authors noted. However, several challenges exist to their potential implementation, including intervention complexity, unrealistic workload, and lack of staff engagement.

In addition, the finding on less outpatient oncology utilization in the intervention group may indicate the futility of a screening program that does not help to increase health care utilization. To confirm this, the authors suggest translating their study in other settings.

Because mental health outcomes following the behavioral health referrals were not measured, it remains unknown if clinical outcomes were actually improved in the referred group over the education-only group. A second limitation is because this study focused on patients with breast cancer, the findings many not be generalizable to other cancer types.

“Further research is needed,” the authors concluded, “to understand the clinical benefit 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 among patients with breast cancer: A randomized clinical trial. JAMA. 2022;327(1):41-49. doi:10.1001/jama.2021.22596

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