Among the many challenges facing patients with head and neck cancer, depression can be an added stressor that, if unrecognized and untreated, contributes to decreased quality of life and early mortality.
This information is not new. Evidence has long shown that depression rates in cancer patients are among the highest in those with head and neck cancers, occurring in approximately 15% to 50% of these patients. Some of these patients will present with or have a prior history of depression, while others will develop depression in the year following diagnosis. For patients who do develop depression, symptoms typically peak two to three months after diagnosis (Cancer Epidemiol. 2016;43:42-48; Clin Adv Hematol Oncol. 2009;7:397-403).
Recognizing the increased risk for and prevalence of depression in head and neck patients is the first critical step in addressing the problem. Diagnosis can be tricky, however, because many of the symptoms of depression are similar to side effects of cancer treatment. Additionally, treatment may be unfamiliar territory for clinicians who don’t typically address behavioral health issues.
Although diagnosing and treating depression may not be considered a part of standard otolaryngologic care, the high rates of depression in head and neck patients and associated decrease in quality of life and survival make it imperative that physicians address this issue more effectively.
“Looking at historical norms, we don’t do a very good job of addressing depression in our patients,” said William M. Lydiatt, MD, chair in the department of surgery at Nebraska Methodist Hospital and clinical professor of surgery at Creighton University in Omaha, who has written extensively on the issue. This lack in addressing depression occurs not only because otolaryngologists and other members of a typical treatment team (i.e., radiation oncologists and medical oncologists) lack the training and facility to diagnose it, said Dr. Lydiatt, but also because it is an issue that patients themselves don’t want to address. “Many patients just don’t want to address one more thing,” he said.
One way to better address this issue is to include a behavioral therapist in the treatment team to ensure that depression is identified early and treated appropriately. Another strategy suggested by recent data is the prophylactic use of antidepressants as part of the treatment protocol for all head and neck patients, particularly for those at high risk of depression.
Although there is currently no standard approach to address depression in these patients, what is clear is the need to do so and to address it with more success. “Depression is common and impacts quality of life and survival,” said Dr. Lydiatt. “It can be treated or prevented in many cases.”
Need to Address All Depression, Even Mild Cases
The substantial effect depression can have on these patients is underscored by ongoing data showing their reduced survival rates due to the depression. A study published in 2018 confirmed this evidence, showing that depressive symptoms predicted shortened survival among patients with head and neck cancer (Cancer. 2018;124:1053-1060).
The study, which included 134 patients with head and neck cancers who presented with depressive symptoms during treatment planning, followed these patients for two years. Clinical data at two years showed shorter survival in the patients with greater depressive symptoms. In addition, these patients also had higher rates of chemoradiation interruption and poorer treatment response.
Importantly, the study showed that depression predicted survival independent of other commonly used variables associated with prognosis, such as patient age, tumor stage, or extent of smoking history. According to the investigators, this suggests that depressive symptoms may be an important predictor of survival and a prognostic indicator as powerful as traditional clinical features to determine the prognosis of these patients.
Another important study finding was that the adverse effects of depression on survival and other measures cited above were seen even in patients with mild depression.
“The majority of patients in our study did not meet criteria for diagnosis of major depressive disorder,” said senior author of the study Liz Cash, PhD, clinical health psychologist, director of research, and assistant professor in the department of otolaryngology-HNS and communicative disorders at the University of Louisville School of Medicine in Louisville, Ky. “This means that even mild symptoms of depression may interfere with head and neck cancer treatment outcomes.”
Dr. Cash noted that signs of depression are different for everyone. Instead of looking for a “hallmark” sign of depression for all patients, she encourages otolaryngologists to look for two common signs that indicate depression in most patients: depressed mood and losing interest in activities for most of the day, every day, for two weeks or more.
Given the prevalence of depression in head and neck patients and its impact on survival even in patients with only minor depressive symptoms, Dr. Cash emphasizes the need for screening for all patients. “We feel this underscores the importance of screening even for depressive symptoms in patients with head and neck cancer, particularly during the medical treatment planning phase,” she said.
Amy Williams, PhD, senior staff psychologist in the department of otolaryngology–head and neck surgery at the Henry Ford Health System in Detroit, Mich., pointed out that the American College of Surgeons Commission on Cancer (ACS CoC) recommends regular screening of all cancer patients throughout their treatment for distress, including depression. “The use of regular distress screening mandated by the ACS CoC can help identify those patients who are struggling and help identify those patients who warrant further questioning,” she said.
Christine G. Gourin, MD, professor in the department of otolaryngology–head and neck surgery and head and neck surgical oncology at Johns Hopkins University in Baltimore, Md., agreed that otolaryngologists need to be more aware of and look for depression in patients with head and neck cancer. She cited simple tests that can be used to screen for depression. Along with asking the patient about their mood or interest in daily activities, she also suggested using standardized assessment tools such as the Beck Depression Inventory or the Hospital Anxiety and Depression Scale.
In addition, new information on risk factors associated with the development of depression in these patients is shedding light on the possibility that most patients treated for head and neck cancer are at increased risk of developing depression and therefore should be treated prophylactically for depression as a part of their treatment planning.
We have randomized evidence that if we start an antidepressant prior to radiation therapy, we can reduce depression. This is one strategy that could be considered in our attempts to reduce the burden of depression among our head and neck cancer patients. —William M. Lydiatt, MD
Radiation as a Risk Factor, Prevention as Strategy
New research shows that radiation is a significant risk factor for the development of depression in head and neck patients. A recent study by Dr. Lydiatt and colleagues that looked at the efficacy of preventing depression by prophylactically treating patients with an anti-depressant within weeks of diagnosis and treatment initiation found that patients who received radiation therapy as initial treatment had significantly higher rates of depression than those who received surgery as initial therapy (38% vs. 12%, respectively) (JAMA Otolaryngol Head Neck Surg. 2013;139:678–686).
“I think one of the misconceptions is that surgery is this disfiguring thing that makes people depressed,” said Dr. Lydiatt. “The reality is that there is something in radiation that increases the risk of depression and suicide in these patients.”
Dr. Lydiatt speculated that this effect of radiation could result from a number of things: the length of a course of radiation therapy; post-traumatic stress-type disorder, in which patients have episodes of anxiety due to airway compromise; requiring a mask to hold the patient in place as they undergo radiation, which may create a sense of claustrophobia; and also some kind of cytokine produced by the radiation. “All of these factors [likely] contribute to the higher depression rates with radiation,” he said.
A key difficulty in recognizing and diagnosing depression in head and neck patients results from the fact that the side effects of radiation, such as fatigue and sleep disturbance, are also some of the symptoms of depression, said Dr. Lydiatt.
Dr. Lydiatt suggested that even for most patients who do not have a diagnosis of depression at baseline, adding prophylactic treatment of depression into the treatment planning could be considered. Results of the recent prevention study showed that patients who received prophylactic antidepressant medication had an overall 50% reduction in depression compared to patients who did not receive such treatment.
“We have randomized evidence that if we start an antidepressant prior to radiation therapy, we can reduce depression,” he said. “This is one strategy that could be considered in our attempts to reduce the burden of depression among our head and neck cancer patients.”
Dr. Williams, on the other hand, questioned whether the benefits of giving an antidepressant to all patients outweigh the risks of antidepressants. She noted that many antidepressants can interact with chemotherapeutics and with antinauseants, such as Zofran and Compazine, and can carry the risk of hyponatremia. “I would argue that antidepressants are not without risk, while the regular, appropriate screening for distress and referral to a behavioral health specialist for evaluation and recommendations would better serve this patient population,” she said.
Expanding Multidisciplinary Team: Role of a Behavioral Health Specialist
Incorporating a behavioral health specialist into the multidisciplinary team providing care, or referring patients to a behavioral specialist, is another strategy that otolaryngologists may want to adopt. “If the treating provider believes that the patient is struggling and/or is nonadherent to treatment and/or the patient is reporting distress, a referral to a behavioral health specialist would be appropriate,” said Dr. Williams, “similar to how the ENT doc/team would refer to a nephrologist for renal issues or endocrinology for identified endocrine issues that are out of the scope of practice for an ENT provider.”
Along with antidepressant therapies, she underscored the importance of psychotherapy for some patients as a treatment option that has longer-lasting effects than medication and that doesn’t interfere with medical treatment. Dr. Williams said that such a specialist can provide psychotherapy assistance during the medical treatments, such as chemotherapy infusions, or following their radiation therapy sessions.
Overall, she emphasized that “the behavioral health specialist works with the patient to manage distress that can interfere in treatment and prevent the longer clinic visits with the ENT provider when the patient is distressed.”
Dr. Gourin agreed that otolaryngologists need to treat depression in their patients in ways similar to those they use to treat other comorbid conditions. “We treat hypothyroidism in our patients; we should approach depression the same way,” she said.
She also emphasized the fact that otolaryngologists are increasingly on the front lines of care and need to coordinate multidisciplinary care for patients. “It really is incumbent upon us to recognize and look for depression in high risk patients, which includes patients with head and neck cancer,” she said.
Mary Beth Nierengarten is a freelance medical writer in Minnesota.