Depression and Anxiety Management

Screening and Assessment

The American College of Oncology recommends screening all patients for depressive symptoms at initial visits, at appropriate intervals, and when clinically indicated, using validated tools such as the PHQ-9 with a clinical cutoff score of 8 1
Initial screening can use the first two items of PHQ-9, and for positive initial screens, complete the full PHQ-9 assessment 1
Other validated tools include the Center for Epidemiological Studies-Depression Scale (CES-D) with scores ≥16 suggesting moderate to severe symptoms, and the Geriatric Depression Scale (GDS) for older adults 1
Directly interview both patients and families/caregivers, assess for functional impairment across domains, and evaluate for comorbid psychiatric conditions 2
Always assess for risk of self-harm and suicidal ideation 1
The Generalized Anxiety Disorder 7-item scale (GAD-7) is a recommended tool for assessing anxiety severity in clinical practice, with a scoring interpretation of 0-4: Minimal anxiety, 5-9: Mild anxiety, 10-14: Moderate anxiety, and 15-21: Severe anxiety, as recommended by the American College of Oncology 1

The following table summarizes the interpretation of PHQ-9 and GAD-7 scores:

Consider medical causes that may present with or exacerbate depressive symptoms, such as thyroid disorders, medication side effects, metabolic disturbances, and neurological conditions 4
For patients with diabetes, consider annual screening for depressive symptoms 4
Cognitive Behavioral Therapy (CBT) or Interpersonal Therapy are first-line treatments, and consider referral to mental health providers with experience in evidence-based approaches 4
Collaborative care between mental health providers and the patient's medical team improves outcomes 4
Severe depression with suicidal ideation requires immediate psychiatric referral 1
Selective Serotonin Reuptake Inhibitors (SSRIs) are first-line pharmacotherapy for depression and anxiety, but may require higher doses for anxiety disorders, as recommended by the National Institute for Health and Care Excellence 1
Benzodiazepines should be used with caution and for a limited time due to the risk of dependence, as advised by the American Medical Association 1
Individual psychological therapy using manualized, evidence-based approaches, such as cognitive behavioral therapy (CBT), is a first-line treatment for depression and anxiety, according to the American Psychiatric Association 3

Continue monitoring at regular intervals during treatment, and reassess at 4 and 8 weeks after initiating treatment, and at 3, 6, and 12 months after treatment 1
Additional assessment is needed during personal transitions or crises 1
Consider changing the therapeutic regimen if depression worsens or if suicidality emerges, and if discontinuing medication, taper gradually to avoid discontinuation symptoms 1
Regular reassessment of treatment response is necessary at 4 and 8 weeks after initiating treatment, as suggested by the American Academy of Family Physicians 1
Maintenance treatment is often needed to prevent relapse, and discontinuing treatment too early can lead to poor outcomes, as recommended by the American College of Physicians 1
Patients should be reassessed at initial diagnosis, start of treatment, regular intervals during treatment, 3, 6, and 12 months after treatment, at diagnosis of recurrence or progression, when approaching end-of-life care, and during personal transitions or crises, as recommended by various guideline societies 1, 3

A comprehensive metabolic panel, which includes glucose, electrolytes, kidney and liver function, should be performed to evaluate for metabolic abnormalities that can present with anxiety symptoms 5
Thyroid function tests, including TSH, free T3, and free T4, should be included in a targeted laboratory workup to rule out medical causes that could be contributing to anxiety symptoms, such as thyroid dysfunction, which can mimic or exacerbate anxiety symptoms 5
The approach to laboratory testing should be selective rather than routine for all patients, as multiple studies have shown that routine extensive laboratory testing has low yield and high rates of false positives, with false positives being 8 times more frequent than true positives 6
Medical causes of symptoms, such as thyroid disorders, caffeine excess, hypoglycemia, cardiac conditions, and medication side effects, should be ruled out, as recommended by various guideline societies 1, 7
Patients with new-onset anxiety without prior psychiatric history, atypical presentation or sudden change in symptoms, presence of medical complaints or abnormal vital signs, elderly patients, patients with substance abuse history, and lower socioeconomic status patients should undergo targeted laboratory testing 6