In a study reported in JAMA, Hahn et al found that a depression screening and intervention program resulted in a higher rate of referral to behavioral health services vs education alone among patients with newly diagnosed breast cancer at community oncology centers located in Southern California.

Study Details

The trial drew from six Kaiser Permanente Southern California centers with 1,436 patients diagnosed with breast cancer who had a consultation with medical oncology between October 2017 and September 2018. Patients were randomly assigned to a tailored implementation program (three centers, n = 744) or education only (three centers, n = 692). The tailored program included depression screening with the Patient Health Questionnaire (PHQ-9) at consultation. Patients with moderate scores were referred to either an oncology licensed clinical social worker (LCSW), depression care management (staffed with LCSWs and nurse practitioners), or both; those with severe scores were directly referred to behavioral health services (psychiatry or psychology), provided with an immediate telephone crisis consultation, or both. The education group received up to four education sessions, consisting of one in-person site visit and two or three teleconference calls.

Among all patients, 99% were women; mean age was 61.5 years; and 18% were Asian, 17% were Black, 26% were Hispanic, and 37% were White. Disease stages were similar in the two groups, with 82% having stage 0 to II disease.

Key Findings

During the consultation visit, 596 patients (80%) at intervention sites vs 3 patients (< 1%) at education sites were offered PHQ-9 screening. Among the 569 patients, 57 (10%) had moderate scores and 6 (1%) had severe scores.

Overall, 59 patients (7.9%) in the tailored program group vs 1 patient (0.1%) in the education group received referrals to behavioral health clinicians (difference = 7.8%, 95% confidence interval [CI] = 5.8%–9.8%). Referrals were completed by 44 (75%) of 59 patients at the intervention sites vs the 1 patient at the education site.  

Through May 2019, proportions of intervention vs education group patients having visits for services were 18% vs 11% for any behavioral health, 9% vs 3% for depression management, 4% vs 3% for psychiatry, and 8% vs 5% for social services.

In adjusted models, patients at intervention sites had significantly fewer outpatient visits in medical oncology (rate ratio [RR] = 0.86, 95% CI = 0.86–0.89, P = .001), with no significant differences observed for primary care (RR = 1.07, 95% CI = 0.93–1.24), urgent care (RR = 0.84, 95% CI = 0.51–1.38), or emergency department visits (RR = 1.16, 95% CI = 0.84–1.62).

The investigators concluded, “Among patients with breast cancer treated in community-based oncology practices, tailored strategies for implementation of routine depression screening compared with an education-only control group resulted in a greater proportion of referrals to behavioral care. Further research is needed to understand the clinical benefit and cost-effectiveness of this program.”

Erin E. Hahn, PhD, MPH, of the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, is the corresponding author for the JAMA article.

Disclosure: The study was supported by a grant from the California Breast Cancer Research Program. For full disclosures of the study authors, visit jamanetwork.com.