Supportive Care in Cancer

, Volume 20, Issue 11, pp 2795–2802

Frequency of depression among oncology outpatients and association with other symptoms

  • Wadih Rhondali
  • Elise Perceau
  • Julien Berthiller
  • Pierre Saltel
  • Veronique Trillet-Lenoir
  • Olivier Tredan
  • Jean-Pierre Coulon
  • Eduardo Bruera
  • Marilene Filbet
Original Article



Depression occurs among an estimated 15% of cancer patients (range, 1–77.5%). Our main objective was to identify the frequency of reported depression by using the Brief Edinburgh Depression Scale (BEDS) among cancer outpatients. Our secondary objective was to identify associated symptoms of cancer using the Edmonton Symptom Assessment System (ESAS) and to evaluate the screening performance of depression between ESAS and BEDS.


In this multicenter prospective study conducted, we used the ESAS to collect information on nine symptoms: pain, fatigue, nausea, depression, anxiety, drowsiness, shortness of breath, lack of appetite, and feeling of well-being (each rated from 0 to 10). The BEDS was used to assess for “probable depression” (score >6). Data were analyzed using a parametric and nonparametric test.


A total of 146 patients completed the study. The prevalence of probable depression was 43/146 (29%). Probable depression was associated with increased fatigue (p = 0.008), depression (p < 0.0001), anxiety (p < 0.0001), shortness of breath (p = 0.01), and decreased feeling of well-being (p < 0.001). Among patients with probable depression, 42 (98%) patients were not using antidepressants. Regarding the sensitivity and the specificity, we determined that the optimal cutoff for using the ESAS as a depression screening tool was ≥2.


We found significant associations between probable depression as determined with the BEDS and five symptoms as detected with the ESAS. The vast majority of patients with probable depression were not receiving pharmacological treatment. Depression should be suspected in patients with higher symptom distress as for any one of these 5 ESAS items.


Depression Cancer Outpatient Screening 


  1. 1.
    Trask PC (2004) Assessment of depression in cancer patients. J Natl Cancer Inst Monogr 32:80–92Google Scholar
  2. 2.
    Hotopf M, Chidgey J, Addington-Hall J, Ly KL (2002) Depression in advanced disease: a systematic review. Part 1. Prevalence and case finding. Palliat Med 16:81–97PubMedCrossRefGoogle Scholar
  3. 3.
    Meyer HA, Sinnott C, Seed PT (2003) Depressive symptoms in advanced cancer. Part 1. Assessing depression: the mood evaluation questionnaire. Palliat Med 17:596–603PubMedCrossRefGoogle Scholar
  4. 4.
    Reeve JL, Lloyd-Williams M, Dowrick C (2008) Revisiting depression in palliative care settings: the need to focus on clinical utility over validity. Palliat Med 22:383–391PubMedCrossRefGoogle Scholar
  5. 5.
    Mitchell AJ, Chan M, Bhatti H, Halton M, Grassi L, Johansen C, Meader N (2011) Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies. Lancet Oncol 12:160–174PubMedCrossRefGoogle Scholar
  6. 6.
    Passik SD, Dugan W, McDonald MV, Rosenfeld B, Theobald DE, Edgerton S (1998) Oncologists' recognition of depression in their patients with cancer. J Clin Oncol 16:1594–1600PubMedGoogle Scholar
  7. 7.
    Fallowfield L, Ratcliffe D, Jenkins V, Saul J (2001) Psychiatric morbidity and its recognition by doctors in patients with cancer. Br J Cancer 84:1011–1015PubMedCrossRefGoogle Scholar
  8. 8.
    Lawrie I, Lloyd-Williams M, Taylor F (2004) How do palliative medicine physicians assess and manage depression. Palliat Med 18:234–238PubMedCrossRefGoogle Scholar
  9. 9.
    Breitbart W (1995) Identifying patients at risk for, and treatment of major psychiatric complications of cancer. Support Care Cancer 3:45–60PubMedCrossRefGoogle Scholar
  10. 10.
    Uitterhoeve RJ, Vernooy M, Litjens M, Potting K, Bensing J, De Mulder P, van Achterberg T (2004) Psychosocial interventions for patients with advanced cancer—a systematic review of the literature. Br J Cancer 91:1050–1062PubMedGoogle Scholar
  11. 11.
    Rodin G, Lloyd N, Katz M, Green E, Mackay JA, Wong RK (2007) The treatment of depression in cancer patients: a systematic review. Support Care Cancer 15:123–136PubMedCrossRefGoogle Scholar
  12. 12.
    Rayner L, Price A, Evans A, Valsraj K, Hotopf M, Higginson IJ (2011) Antidepressants for the treatment of depression in palliative care: systematic review and meta-analysis. Palliat Med 25:36–51PubMedCrossRefGoogle Scholar
  13. 13.
    Stiefel R, Die Trill M, Berney A, Olarte JM, Razavi A (2001) Depression in palliative care: a pragmatic report from the Expert Working Group of the European Association for Palliative Care. Support Care Cancer 9:477–488PubMedCrossRefGoogle Scholar
  14. 14.
    Jacobsen PB, Shibata D, Siegel EM, Lee JH, Fulp WJ, Alemany C, Abesada-Terk G, Jr, Brown R, Cartwright T, Faig D, Kim G, Levine R, Markham MJ, Schreiber F, Sharp P, Malafa M (2011) Evaluating the quality of psychosocial care in outpatient medical oncology settings using performance indicators. Psychooncology 20(11):1221–1227Google Scholar
  15. 15.
    Lloyd-Williams M, Dennis M, Taylor F (2004) A prospective study to determine the association between physical symptoms and depression in patients with advanced cancer. Palliat Med 18:558–563PubMedCrossRefGoogle Scholar
  16. 16.
    Laird BJ, Boyd AC, Colvin LA, Fallon MT (2009) Are cancer pain and depression interdependent? A systematic review. Psychooncology 18:459–464PubMedCrossRefGoogle Scholar
  17. 17.
    Lo C, Zimmermann C, Rydall A, Walsh A, Jones JM, Moore MJ, Shepherd FA, Gagliese L, Rodin G (2010) Longitudinal study of depressive symptoms in patients with metastatic gastrointestinal and lung cancer. J Clin Oncol 28:3084–3089PubMedCrossRefGoogle Scholar
  18. 18.
    Salvo N, Zeng L, Zhang L, Leung M, Khan L, Presutti R, Nguyen J, Holden L, Culleton S, Chow E (2012) Frequency of reporting and predictive factors for anxiety and depression in patients with advanced cancer. Clin Oncol (R Coll Radiol) 24(2):139–148Google Scholar
  19. 19.
    DiMatteo MR, Lepper HS, Croghan TW (2000) Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 160:2101–2107PubMedCrossRefGoogle Scholar
  20. 20.
    Pelletier G, Verhoef MJ, Khatri N, Hagen N (2002) Quality of life in brain tumor patients: the relative contributions of depression, fatigue, emotional distress, and existential issues. J Neurooncol 57:41–49PubMedCrossRefGoogle Scholar
  21. 21.
    Cukor D, Rosenthal DS, Jindal RM, Brown CD, Kimmel PL (2009) Depression is an important contributor to low medication adherence in hemodialyzed patients and transplant recipients. Kidney Int 75:1223–1229PubMedCrossRefGoogle Scholar
  22. 22.
    Holland JC, Alici Y (2010) Management of distress in cancer patients. J Support Oncol 8:4–12PubMedGoogle Scholar
  23. 23.
    Satin JR, Linden W, Phillips MJ (2009) Depression as a predictor of disease progression and mortality in cancer patients: a meta-analysis. Cancer 115:5349–5361PubMedCrossRefGoogle Scholar
  24. 24.
    Lloyd-Williams M, Shiels C, Taylor F, Dennis M (2009) Depression—an independent predictor of early death in patients with advanced cancer. J Affect Disord 113:127–132PubMedCrossRefGoogle Scholar
  25. 25.
    Mitchell AJ, Kaar S, Coggan C, Herdman J (2008) Acceptability of common screening methods used to detect distress and related mood disorders—preferences of cancer specialists and non-specialists. Psychooncology 17:226–236PubMedCrossRefGoogle Scholar
  26. 26.
    Rhondali W, Perceau E, Blay JY, Fournel-Federico C, Saltel P, Trillet-Lenoir V, Tredan O, Coulon JP, Bruera E, Filbet M (2012) Depression assessment by oncologists and palliative care physicians. Palliat Support Care 10(4), in pressGoogle Scholar
  27. 27.
    Lees N, Lloyd-Williams M (1999) Assessing depression in palliative care patients using the visual analogue scale: a pilot study. Eur J Cancer Care (Engl) 8:220–223CrossRefGoogle Scholar
  28. 28.
    Vignaroli E, Pace EA, Willey J, Palmer JL, Zhang T, Bruera E (2006) The Edmonton Symptom Assessment System as a screening tool for depression and anxiety. J Palliat Med 9:296–303PubMedCrossRefGoogle Scholar
  29. 29.
    Wasteson E, Brenne E, Higginson IJ, Hotopf M, Lloyd-Williams M, Kaasa S, Loge JH (2009) Depression assessment and classification in palliative cancer patients: a systematic literature review. Palliat Med 23:739–753PubMedCrossRefGoogle Scholar
  30. 30.
    Dugan W, McDonald MV, Passik SD, Rosenfeld BD, Theobald D, Edgerton S (1998) Use of the Zung Self-Rating Depression Scale in cancer patients: feasibility as a screening tool. Psychooncology 7:483–493PubMedCrossRefGoogle Scholar
  31. 31.
    Lloyd-Williams M, Shiels C, Dowrick C (2007) The development of the Brief Edinburgh Depression Scale (BEDS) to screen for depression in patients with advanced cancer. J Affect Disord 99:259–264PubMedCrossRefGoogle Scholar
  32. 32.
    Rhondali W, Perceau E, Saltel P, Girard R, Filbet M (2011) Translation and validation of Brief Edinburgh Depression Scale (BEDS) in French. Bull Cancer 98:199–208PubMedGoogle Scholar
  33. 33.
    Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, Carbone PP (1982) Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 5:649–655PubMedCrossRefGoogle Scholar
  34. 34.
    Cummings G, Biondo PD, Campbell D, Stiles C, Fainsinger R, Muise M, Hagen N (2011) Can the global uptake of palliative care innovations be improved? Insights from a bibliometric analysis of the edmonton symptom assessment system. Palliat Med 25:71–82PubMedCrossRefGoogle Scholar
  35. 35.
    Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K (1991) The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care 7:6–9PubMedGoogle Scholar
  36. 36.
    Chang VT, Hwang SS, Feuerman M (2000) Validation of the Edmonton Symptom Assessment Scale. Cancer 88:2164–2171PubMedCrossRefGoogle Scholar
  37. 37.
    Richardson LA, Jones GW (2009) A review of the reliability and validity of the Edmonton Symptom Assessment System. Curr Oncol 16:55PubMedCrossRefGoogle Scholar
  38. 38.
    Bruera E, MacMillan K, Hanson J, MacDonald RN (1989) The Edmonton staging system for cancer pain: preliminary report. Pain 37:203–209PubMedCrossRefGoogle Scholar
  39. 39.
    Cheung WY, Barmala N, Zarinehbaf S, Rodin G, Le LW, Zimmermann C (2009) The association of physical and psychological symptom burden with time to death among palliative cancer outpatients. J Pain Symptom Manage 37:297–304PubMedCrossRefGoogle Scholar
  40. 40.
    Moro C, Brunelli C, Miccinesi G, Fallai M, Morino P, Piazza M, Labianca R, Ripamonti C (2006) Edmonton symptom assessment scale: Italian validation in two palliative care settings. Support Care Cancer 14:30–37PubMedCrossRefGoogle Scholar
  41. 41.
    Carvajal A, Centeno C, Watson R, Bruera E (2011) A comprehensive study of psychometric properties of the Edmonton Symptom Assessment System (ESAS) in Spanish advanced cancer patients. Eur J Cancer 47:1863–1872PubMedCrossRefGoogle Scholar
  42. 42.
    Zeng L, Koo K, Zhang L, Jon F, Dennis K, Holden L, Nguyen J, Tsao M, Barnes E, Danjoux C, Sahgal A, Chow E (2011) Fatigue in advanced cancer patients attending an outpatient palliative radiotherapy clinic as screened by the Edmonton Symptom Assessment System. Support Care CancerGoogle Scholar
  43. 43.
    Kroenke K, Zhong X, Theobald D, Wu J, Tu W, Carpenter JS (2010) Somatic symptoms in patients with cancer experiencing pain or depression: prevalence, disability, and health care use. Arch Intern Med 170:1686–1694PubMedCrossRefGoogle Scholar
  44. 44.
    Laird BJ, Scott AC, Colvin LA, McKeon AL, Murray GD, Fearon KC, Fallon MT (2011) Pain, depression, and fatigue as a symptom cluster in advanced cancer. J Pain Symptom Manage 42:1–11PubMedCrossRefGoogle Scholar
  45. 45.
    Kroenke K, Spitzer RL, Williams JB (2001) The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 16:606–613PubMedCrossRefGoogle Scholar
  46. 46.
    Thekkumpurath P, Walker J, Butcher I, Hodges L, Kleiboer A, O'Connor M, Wall L, Murray G, Kroenke K, Sharpe M. Screening for major depression in cancer outpatients: the diagnostic accuracy of the 9-item patient health questionnaire. Cancer 117(1):218–227Google Scholar
  47. 47.
    Schroevers MJ, Sanderman R, van Sonderen E, Ranchor AV (2000) The evaluation of the Center for Epidemiologic Studies Depression (CES-D) scale: depressed and positive affect in cancer patients and healthy reference subjects. Qual Life Res 9:1015–1029PubMedCrossRefGoogle Scholar
  48. 48.
    Hann D, Winter K, Jacobsen P (1999) Measurement of depressive symptoms in cancer patients: evaluation of the Center for Epidemiological Studies Depression Scale (CES-D). J Psychosom Res 46:437–443PubMedCrossRefGoogle Scholar
  49. 49.
    Luckett T, Butow PN, King MT, Oguchi M, Heading G, Hackl NA, Rankin N, Price MA (2010) A review and recommendations for optimal outcome measures of anxiety, depression and general distress in studies evaluating psychosocial interventions for English-speaking adults with heterogeneous cancer diagnoses. Support Care Cancer 18:1241–1262PubMedCrossRefGoogle Scholar
  50. 50.
    Mitchell AJ (2010) Short screening tools for cancer-related distress: a review and diagnostic validity meta-analysis. J Natl Compr Canc Netw 8:487–494PubMedGoogle Scholar
  51. 51.
    Johnston M, Pollard B, Hennessey P (2000) Construct validation of the hospital anxiety and depression scale with clinical populations. J Psychosom Res 48:579–584PubMedCrossRefGoogle Scholar
  52. 52.
    Berard RM, Boermeester F, Viljoen G (1998) Depressive disorders in an out-patient oncology setting: prevalence, assessment, and management. Psychooncology 7:112–120PubMedCrossRefGoogle Scholar
  53. 53.
    Yennurajalingam S, Urbauer DL, Casper KL, Reyes-Gibby CC, Chacko R, Poulter V, Bruera E (2010) Impact of a palliative care consultation team on cancer-related symptoms in advanced cancer patients referred to an outpatient supportive care clinic. J Pain Symptom Manage. doi:10.1016/j.jpainsymman.2010.03.017
  54. 54.
    Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA, Lynch TJ (2010) Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363:733–742PubMedCrossRefGoogle Scholar
  55. 55.
    Hotopf M (2008) Review: screening or case-finding questionnaires used alone are not effective in the management of depression. ACP J Club 149:9PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Wadih Rhondali
    • 1
    • 2
  • Elise Perceau
    • 2
  • Julien Berthiller
    • 3
  • Pierre Saltel
    • 4
  • Veronique Trillet-Lenoir
    • 2
  • Olivier Tredan
    • 4
  • Jean-Pierre Coulon
    • 5
  • Eduardo Bruera
    • 1
  • Marilene Filbet
    • 2
  1. 1.Department of Palliative Care and Rehabilitation Medicine, Unit 1414The University of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.Centre Hospitalier de Lyon-SudHospices Civils de LyonLyonFrance
  3. 3.Pole Information Médicale Evaluation RechercheHospices Civils de LyonLyonFrance
  4. 4.Centre Léon BérardLyonFrance
  5. 5.Clinique Francois ChenieuxLimogesFrance

Personalised recommendations