Supportive Care in Cancer

, Volume 27, Issue 12, pp 4469–4477 | Cite as

Evaluation of the psychological burden during the early disease trajectory in patients with intracranial tumors by the ultra-brief Patient Health Questionnaire for Depression and Anxiety (PHQ-4)

  • Mirjam RenovanzEmail author
  • Sari Soebianto
  • Helena Tsakmaklis
  • Naureen Keric
  • Minou Nadji-Ohl
  • Manfred Beutel
  • Florian Ringel
  • Daniel Wollschläger
  • Anne-Katrin Hickmann
Original Article



Depressive symptoms of patients with intracranial tumors need to be assessed adequately. The Patient Health Questionnaire for Depression and Anxiety (PHQ-4) is an ultra-short screening tool consisting of four items, a cutoff of six indicates depressive symptoms. The aim was to assess patients’ psychological burden by the PHQ-4 compared with the results of well-established screening instruments.


Patients were screened three times after primary diagnosis postoperatively (t1), after 3 (t2) and 6 (t3) months using the PHQ-4, the Hornheide Screening Instrument (HSI), the NCCN Distress Thermometer (DT), and the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire with its brain module (EORTC QLQ-C30 + BN20). Demographic, tumor-related data, and Karnofsky Performance Scale (KPS) were analyzed. A cutoff value for PHQ-4 indicating a need for support or increased distress was determined by applying receiver operating characteristic (ROC).


The proportion of patients reaching a total score ≥ 6 was n = 32 out of 139 (23%) at t1; at t2, n = 12 out of 117 (10%) scored ≥ 6. At t3, n = 8 out of 96 (8%) scored ≥ 6. At t1, PHQ-4 scores did not differ significantly between gender, age groups, and tumor laterality. A cutoff value of 2.5 was identified to moderately discriminate between patients in or not in distress (sensitivity 76.8%) and between patients wishing further, specific support or not (sensitivity 82.5%).


The PHQ4 can be applied in this patient cohort to detect those with relevant psychological comorbidities. The cutoff value should be re-evaluated in a larger cohort as we observed that a cutoff of 6, as recommended previously, may be too high in order to detect affected patients adequately.


Cancer Oncology Brain tumor Distress Intracranial tumor Psychosocial burden Quality of life Screening 



We thank all patients who participated in the study. We acknowledge all further members of our study group—Markus Haug, Susanne Janz, Güler Savas and Stefan Kindel—for the tremendous support. This work contains parts of the dissertation of Isabell Neppel, Sari Soebianto and Helena Tsakmaklis. This study was funded by the Friedhelm Frees Stiftung, Mainz, Germany.


The study was supported by the Friedhelm Frees Stiftung, Mainz, Germany. The authors have no financial relationship with the organization that sponsored the research.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest. The first author has full control of all primary data and agrees the journal to review the data if requested.

Supplementary material

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Table S3 (DOCX 15.7 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Mirjam Renovanz
    • 1
    • 2
    Email author
  • Sari Soebianto
    • 1
  • Helena Tsakmaklis
    • 1
  • Naureen Keric
    • 1
  • Minou Nadji-Ohl
    • 3
  • Manfred Beutel
    • 4
  • Florian Ringel
    • 1
  • Daniel Wollschläger
    • 5
  • Anne-Katrin Hickmann
    • 3
    • 6
  1. 1.Department of Neurosurgery, University Medical CenterJohannes-Gutenberg-University of MainzMainzGermany
  2. 2.Interdisciplinary Division of Neurooncology, Departments of Neurology & NeurosurgeryUniversity Medical Center TübingenTübingenGermany
  3. 3.Department of NeurosurgeryKlinikum Stuttgart, KatharinenhospitalStuttgartGermany
  4. 4.Department of Psychosomatic Medicine and Psychotherapy, University Medical CenterJohannes-Gutenberg-University of MainzMainzGermany
  5. 5.Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical CenterJohannes-Gutenberg-University of MainzMainzGermany
  6. 6.Department of NeurosurgeryKantonsspital St. GallenSt. GallenSwitzerland

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