Department of Orthopaedics, William Beaumont Army Medical Center, Fort Bliss, TX, USA.
Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Clin Orthop Relat Res. 2022 Nov 1;480(11):2148-2160. doi: 10.1097/CORR.0000000000002295. Epub 2022 Jun 30.
It is estimated that the 12-month prevalence of depression in the United States is 8.6%, and for anxiety it is 2.9%. Although prior studies have evaluated depression and anxiety in patients with carcinoma, few have specifically evaluated patients with sarcoma, who often have unique treatment considerations such as mobility changes after surgery.
QUESTIONS/PURPOSES: We evaluated patients with sarcoma seen in our orthopaedic oncology clinic to determine (1) the proportion of patients with depression symptoms, symptom severity, how many patients triggered a referral to mental health professionals based upon our prespecified cutoff scores on the nine-item Patient Health Questionnaire (PHQ-9), and if their symptoms varied by disease state; (2) the proportion of patients with anxiety symptoms, symptom severity, how many patients triggered a referral to mental health professionals based upon our prespecified cutoff scores on the seven-item Generalized Anxiety Disorder Scale (GAD-7), and if they symptoms varied by disease state; (3) whether other factors were associated with the proportion and severity of symptoms of anxiety or depression, such as tumor location in the body (axial skeleton, upper extremity, or lower extremity), general type of tumor (bone or soft tissue), specific diagnosis, use of chemotherapy, length of follow-up (less than 1 year or greater than 1 year), and gender; and (4) what proportion of patients accepted referrals to mental health professionals, when offered.
This study was a cross-sectional survey study performed at a single urban National Cancer Institute-designated Comprehensive Cancer Center from April 2021 until July 2021. All patients seen in the orthopaedic clinic 18 years of age and older with a diagnosis/presumed diagnosis of sarcoma were provided the PHQ-9 as well as the GAD-7 in our clinic. We did not track those who elected not to complete the surveys. Surveys were scored per survey protocol (each question was scored from 0 to 3 and summed). Specifically, PHQ-9 scores the symptoms of depression as 5 to 9 (mild), 10 to 14 (moderate), 15 to 19 (moderately severe), and 20 to 27 (severe). The GAD-7 scores symptoms of anxiety as 5 to 9 (mild), 10 to 14 (moderate), and 15 to 21 (severe). Patients with PHQ-9 or GAD-7 scores of 10 to 14 were referred to social work and those with scores 15 or higher were referred to psychiatry. Patients with thoughts of self-harm were referred regardless of score. Patients were divided based on disease state: patients during their initial management; patients with active, locally recurrent disease; patients with active metastatic disease; patients with prior recurrence or metastatic lesions who were subsequently treated and now have no evidence of disease (considered to be patients with discontinuous no evidence of disease); patients with no evidence of disease; and patients with an active, noncancerous complication but otherwise no evidence of disease. We additionally looked at the association of gender, chemotherapy administration, and tumor location on survey responses. Data are summarized using descriptive statistics. Differences across categories of disease state were tested for statistical significance using Kruskal-Wallis tests for continuous variables and Fisher exact tests for categorical variables as well as pairwise Wilcoxon rank sum tests.
Overall, symptoms of depression were seen in 35% (67 of 190) of patients, at varying levels of severity: 19% (37 of 190) had mild symptoms, 9% (17 of 190) had moderate symptoms, 6% (12 of 190) had moderately severe symptoms, and 1% (1 of 190) had severe symptoms. Depresssion symptoms severe enough to trigger a referral were seen in 17% (32 of 190) of patients overall. Patients scored higher on the PHQ-9 during their initial treatment or when they had recurrent or metastatic disease, and they were more likely to trigger a referral during those timepoints as well. The mean PHQ-9 was 5.7 ± 5.8 during initial treatment, 6.1 ± 4.9 with metastatic disease, and 7.4 ± 5.2 with recurrent disease as compared with 3.2 ± 4.2 if there was no evidence of disease (p = 0.001). Anxiety symptoms were seen in 33% (61 of 185) of patients: 17% (32 of 185) had mild symptoms, 8% (14 of 185) had moderate symptoms, and 8% (15 of 185) had severe symptoms. Anxiety symptoms severe enough to trigger a referral were seen in 16% (29 of 185) of patients overall. Patients scored higher on the GAD-7 during initial treatment and when they had recurrent disease or an active noncancerous complication. The mean GAD-7 was 6.3 ± 3.2 in patients with active noncancerous complications, 6.8 ± 5.8 in patients during initial treatment, and 8.4 ± 8.3 in patients with recurrent disease as compared with 3.1 ± 4.2 in patients with no evidence of disease (p = 0.002). Patients were more likely to trigger a referral during initial treatment (32% [9 of 28]) and with recurrent disease (43% [6 of 14]) compared with those with no evidence of disease (9% [9 of 97]) and those with discontinuous no evidence of disease (6% [1 of 16]; p = 0.004). There was an increase in both PHQ-9 and GAD-7 scores among patients who had chemotherapy. Other factors that were associated with higher PHQ-9 scores were location of tumor (upper extremity versus lower extremity or axial skeleton) and gender. Another factor that was associated with higher GAD-7 scores included general category of diagnosis (bone versus soft tissue sarcoma). Specific diagnosis and length of follow-up had no association with symptoms of depression or anxiety. Overall, 22% (41 of 190) of patients were offered referrals to mental health professionals; 73% (30 of 41) accepted the referral.
When treating patients with sarcoma, consideration should be given to potential concomitant psychiatric symptoms. Screening, especially at the highest-risk timepoints such as at the initial diagnosis and the time of recurrence, should be considered. Further work should be done to determine the effect of early psychiatric referral on patient-related outcomes and healthcare costs.
Level III, therapeutic study.
据估计，美国的抑郁症 12 个月患病率为 8.6%，焦虑症为 2.9%。尽管先前的研究已经评估了癌症患者的抑郁和焦虑症状，但很少有专门针对肉瘤患者的研究，肉瘤患者通常有独特的治疗考虑因素，例如手术后的移动能力变化。
问题/目的：我们评估了在我们骨科肿瘤门诊就诊的肉瘤患者，以确定（1）有抑郁症状的患者比例、症状严重程度、根据我们 PHQ-9 的九个项目中的预设截止分数，有多少患者需要转介给心理健康专业人员，以及他们的症状是否因疾病状态而异；（2）有焦虑症状的患者比例、症状严重程度、根据我们 GAD-7 的七个项目中的预设截止分数，有多少患者需要转介给心理健康专业人员，以及他们的症状是否因疾病状态而异；（3）是否有其他因素与焦虑或抑郁症状的比例和严重程度相关，例如肿瘤在身体中的位置（轴骨骼、上肢或下肢）、一般类型的肿瘤（骨或软组织）、特定诊断、使用化疗、随访时间（<1 年或>1 年）和性别；以及（4）当提供时，有多少患者接受了转介给心理健康专业人员。
本研究是在一家单一的城市国立癌症研究所指定的综合癌症中心进行的一项横断面调查研究，从 2021 年 4 月至 2021 年 7 月。所有在骨科诊所就诊的年龄在 18 岁及以上、诊断/疑似肉瘤的患者均在我们的诊所中接受 PHQ-9 和 GAD-7 调查。我们没有跟踪那些选择不完成调查的人。调查按照调查方案进行评分（每个问题的得分为 0 至 3 分，然后求和）。具体来说，PHQ-9 评分抑郁症状为 5 至 9（轻度）、10 至 14（中度）、15 至 19（中度严重）和 20 至 27（严重）。GAD-7 评分焦虑症状为 5 至 9（轻度）、10 至 14（中度）和 15 至 21（重度）。PHQ-9 或 GAD-7 评分在 10 至 14 分之间的患者被转介给社会工作者，评分在 15 分或更高的患者被转介给精神病医生。有自杀念头的患者无论得分如何都被转介。根据疾病状态将患者分为：初始管理期间的患者；有活动性、局部复发性疾病的患者；有活动性转移性疾病的患者；有先前复发或转移性病变且现已接受治疗且目前无疾病证据的患者（被认为是连续无疾病证据的患者）；无疾病证据的患者；以及有活动性、非癌症性并发症但无其他疾病证据的患者。我们还观察了性别、化疗管理和肿瘤位置对调查结果的影响。数据采用描述性统计进行总结。使用 Kruskal-Wallis 检验比较连续变量，使用 Fisher 确切检验比较分类变量，以及两两 Wilcoxon 秩和检验比较疾病状态类别之间的差异。
总体而言，35%（190 名患者中的 67 名）的患者有抑郁症状，症状严重程度不同：19%（190 名患者中的 37 名）有轻度症状，9%（190 名患者中的 17 名）有中度症状，6%（190 名患者中的 12 名）有中度严重症状，1%（190 名患者中的 1 名）有严重症状。17%（190 名患者中的 32 名）的患者出现了足够严重到需要转介的抑郁症状。总体而言，患者在初始治疗期间或有复发或转移疾病时在 PHQ-9 上的得分更高，并且在这些时间点更有可能触发转介。PHQ-9 的平均得分在初始治疗时为 5.7 ± 5.8，在转移性疾病时为 6.1 ± 4.9，在复发性疾病时为 7.4 ± 5.2，而在无疾病证据时为 3.2 ± 4.2（p=0.001）。焦虑症状见于 33%（185 名患者中的 61 名）：17%（185 名患者中的 32 名）有轻度症状，8%（185 名患者中的 14 名）有中度症状，8%（185 名患者中的 15 名）有严重症状。16%（185 名患者中的 29 名）的患者出现了足够严重到需要转介的焦虑症状。患者在初始治疗期间和有复发性疾病或活动性非癌症性并发症时在 GAD-7 上的得分更高。有活动性非癌症性并发症的患者的平均 GAD-7 得分为 6.3 ± 3.2，在初始治疗时为 6.8 ± 5.8，在复发性疾病时为 8.4 ± 8.3，而在无疾病证据时为 3.1 ± 4.2（p=0.002）。与无疾病证据的患者（9%[97 名患者中的 9 名]）和连续无疾病证据的患者（6%[16 名患者中的 1 名]）相比，患者在初始治疗（32%[28 名患者中的 9 名]）和复发性疾病（43%[14 名患者中的 6 名]）期间更有可能触发转介（p=0.004）。在接受化疗的患者中，PHQ-9 和 GAD-7 评分均升高。其他与 PHQ-9 评分升高相关的因素包括肿瘤部位（上肢与下肢或轴骨骼）和性别。与 GAD-7 评分升高相关的另一个因素包括一般诊断类别（骨与软组织肉瘤）。具体诊断和随访时间没有与抑郁或焦虑症状相关。总体而言，22%（190 名患者中的 41 名）的患者被转介给心理健康专业人员；30 名患者（41 名患者中的 73%）接受了转介。
在治疗肉瘤患者时，应考虑潜在的伴发精神症状。应考虑在风险最高的时间点（如最初诊断和复发时）进行筛查。应进一步研究早期精神病转诊对患者相关结局和医疗保健成本的影响。
III 级，治疗研究。
