Clinical Review & Education

Review

Depression and Survival in Patients

With Head and Neck Cancer
A Systematic Review
Brittany Barber, MD; Jace Dergousoff, MD; Linda Slater, MLIS; Jeffrey Harris, MD, MHA, FRCSC;
Daniel OConnell, MD, MSc, FRCSC; Hamdy El-Hakim, MBChB; Vincent L. Biron, MD, PhD, FRCSC;
Nicholas Mitchell, MD, FRCPC; Hadi Seikaly, MD, MAL, FRCSC

IMPORTANCE The incidence of depression in patients with head and neck cancer (HNC) is
estimated to be as high as 40%. Previous studies have demonstrated an effect of depression
on rehabilitation and survival in the posttreatment period.
OBJECTIVE To systematically review the relationship between depression and survival in
patients with HNC undergoing curative treatment.
EVIDENCE REVIEW A search of electronic databases as well as gray literature was undertaken
from January 1, 1974, to August 20, 2014, including MEDLINE (via Ovid), EMBASE (via Ovid),
CINAHL, EBSCO, PsycINFO (via Ovid), Elsevier Scopus, and Institute for Scientific Information
Web of Science Core Collection, using controlled vocabulary and medical subject headings
representing HNC, depression, and survival. Articles in these databases were reviewed for
inclusion by 2 independent reviewers according to predetermined eligibility criteria and were
adjudicated by a third reviewer. The articles were then quantitatively scored using the GRACE
(Good Research for Comparative Effectiveness) tool, a validated instrument for assessing the
quality of observational studies. Qualitative assessment of each article was then undertaken.
FINDINGS A total of 654 references were retrieved across all databases. A review of the
abstracts and full texts identified 3 articles, each describing a distinct, single study, including a
total of 431 patients, that were eligible for analysis. Scores for the articles as assessed with the
GRACE tool ranged from 9 to 11. In each of the 3 studies used in the analysis, the comparison
groups were depressed and nondepressed patients as established by a standardized
psychiatric assessment tool. Two of the 3 studies demonstrated a statistically significant
difference in survival for patients with HNC and depression; however, a sensitivity analysis
was not possible due to the incompatible statistical analyses performed in each study.
CONCLUSIONS AND RELEVANCE An association between depression and survival in patients
with HNC is apparent; however, the strength and etiology of this association is not yet clear.
Further directed and multi-institutional study is required to investigate this association and
determine appropriate screening and management strategies.
Author Affiliations: Division of
OtolaryngologyHead & Neck
Surgery, University of Alberta,
Edmonton, Canada (Barber, Harris,
OConnell, El-Hakim, Biron, Seikaly);
Department of Psychiatry, University
of Alberta, Edmonton, Canada
(Dergousoff, Mitchell); University of
Alberta Libraries, University of
Alberta, Edmonton, Canada (Slater).

JAMA Otolaryngol Head Neck Surg. 2016;142(3):284-288. doi:10.1001/jamaoto.2015.3171

Published online January 21, 2016.
284

Corresponding Author: Brittany

Barber, MD, Division of
OtolaryngologyHead & Neck
Surgery, University of Alberta,
1E4, Walter Mackenzie Centre,
8440-112 St, Edmonton,
AB T6G 2B7, Canada
(brittanybarber0@gmail.com).
(Reprinted) jamaotolaryngology.com

Copyright 2016 American Medical Association. All rights reserved.

Downloaded From: http://archotol.jamanetwork.com/ by a Duke Medical Center Library User on 04/04/2016

Depression and Survival in Patients With Head and Neck Cancer

Review Clinical Review & Education

ead and neck cancer (HNC) is a debilitating disease

because of its effects on oral intake, communication,
and cosmesis. These effects can decrease ability and
motivation to function in society, which can result in isolation and
depression.1,2
Approximately 40% of patients develop major depressive
disorder (MDD) during diagnosis and treatment for HNC.3 Misono
et al4 have shown that patients with oral-cavity and laryngeal
cancer constitute 2 of the 4 cancer populations with the highest risk
of suicide. In addition, depressive symptoms in these patients have
a significant effect on other determinants of rehabilitation and survival, including posttreatment functional outcomes and treatment
adherence.5,6 As such, growing concern exists regarding the effect
of these symptoms on survival in patients with HNC.
Although previous studies have demonstrated inferior functional outcomes in depressed patients with HNC, a consensus has
not been reached regarding HNC as a predictor of survival. We conducted a study to systematically review the literature to better delineate the association between depression and survival in patients with HNC.

Table 1. Study Inclusion and Exclusion Criteria

Inclusion

Exclusion

Design: Randomized clinical trial, prospective

and retrospective cohort, quasi-experimental
and interrupted time series

Pertained to ocular, thyroid,

or esophageal cancer

Population: Adult patients undergoing any

treatment for HNC, including surgery,
chemoradiation, radiation therapy, or a
combination

Results not specific for

patients with HNC

Comparison: Depressive symptoms, including

depression, anxiety

Did not use a validated

diagnostic depression tool

Outcome: Overall or disease-specific survival

with at least 12-month follow-up

Did not specify survival as

an outcome
Did not adjust for TNM
staging

Abbreviation: HNC, head and neck cancer.

data if necessary. Institutional review board approval was waived

by the University of Alberta, as no patient data were accessed for
the study.

Study Quality

Methods
A systematic literature search was undertaken from January 1,
1974, to August 20, 2014, to determine whether, in adult patients
undergoing treatment for HNC, depressive symptoms are associated with poorer survival outcomes. For this purpose, the following electronic databases were searched by a professional librarian
on August 20, 2014: MEDLINE (via Ovid) in-process and other
non-indexed citations 1946 to present, National Library of Medicine, EMBASE (via Ovid) 1974 to present, PsycINFO (via Ovid)
1806 to August 2014, Evidence-Based Medicine Reviews (via
Ovid) (Cochrane Database of Systematic Reviews, Cochrane Methodology Register, Database of Abstracts of Reviews of Effects),
Elsevier Scopus 1960 to present, EBSCO CINAHL Plus 1937 to present, and Institute for Scientific Information Web of Science Core
Collection, 1900 to present. Gray literature, including sources outside of commercial or academic publishing and distribution channels, was searched for relevant articles. The search was limited to
articles written in English.
Controlled vocabulary (where applicable) and text word terms
representing the following concepts were combined as follows: HNC
terms AND depression terms AND survival terms. Specific database functions such as apply related words and explosion were
used to maximize the search. Reference lists of retrieved articles were
further screened for additional relevant publications. Inclusion and
exclusion criteria are given in Table 1.

Data Extraction
Study-specific descriptive information collected included author
and year of publication, study design, type of statistical analysis,
TNM staging, patient comorbidities, and findings regarding overall
survival (OS) and disease-specific survival (DSS) in patients with
depressive symptoms. Data extraction was independently performed by 2 of us (B.B. and J.D.), and discrepancies were adjudicated by a third author (H.S.). Authors of primary studies were
contacted to obtain additional information regarding published
jamaotolaryngology.com

The quality of studies in the literature search was assessed with the
Good Research for Comparative Effectiveness (GRACE) checklist,7
an 11-item checklist developed and validated to evaluate the quality of noninterventional studies. Study quality was independently
assessed by two of us (B.B. and J.D.). Discrepancies were adjudicated by a third reviewer (H.S.).

Results
Literature Overview
A total of 654 references were retrieved across all databases, with
455 references remaining after duplicates were removed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) diagram in the Figure summarizes the reasons for the exclusion of studies. Three articles, each describing a single specific
study,8-10 with a total of 431 patients, met the eligibility criteria for
the study. The studies reported in these articles were published from
2001 to 2009. The characteristics of each study are presented in
Table 2.

A Quantitative Examination of the Included Studies

Depression was assessed with 3 validated psychiatric assessment
tools: the Center for Epidemiologic Studies for Depression (CES-D),11
the Beck Depression Inventory (BDI),12 and the Hamilton Depression Rating Scale (HAM-D).13 The mean follow-up time for all included studies was 33 months.
Scores on the GRACE checklist ranged from 9 to 11 of a total score
of 11 for all studies. A significant difference in survival for depressed
patients was demonstrated in 2 of the 3 studies included in the present study (Table 2). Findings for each study are summarized in
Table 3.

A Qualitative Examination of the Included Studies

Within the context of a prospective thesis design, Ehlers et al10 conducted a series of studies examining the relationship between depression and survival in patients with HNC, additionally evaluating

(Reprinted) JAMA OtolaryngologyHead & Neck Surgery March 2016 Volume 142, Number 3

Copyright 2016 American Medical Association. All rights reserved.

Downloaded From: http://archotol.jamanetwork.com/ by a Duke Medical Center Library User on 04/04/2016

285

Clinical Review & Education Review

Depression and Survival in Patients With Head and Neck Cancer

for the interplay of substance abuse. The BDI was used to rate depressive symptoms, and tobacco and alcohol use was selfreported. Absolute scores on the BDI and the change in score from
baseline to 3 and 12 months after its administration were compared with OS 12 months later. The study found significantly worse
OS in patients with high baseline scores on the BDI , as well as in those
with an increasing score over the second 12-month period in which
it was assessed. This effect was independent of race, sex, TNM stage,
treatment, or history of substance abuse. Although the study was
thoroughly designed and conducted, leaving little to further examine, an argument can be made that OS, rather than DSS, may be a
more appropriate measure of survival. Depression during diagnosis and treatment for HNC probably affects a number of factors not
specifically related to cancer, and it may not be directly associated
with death from cancer. These factors may include malnutrition and
failure to thrive,14 an increased hospital stay,15-17 and resultant nosoFigure. Preferred Reporting Items for Systematic Reviews and MetaAnalyses Diagram Detailing Selection of Studies Included for Review
654 Studies
199 Article duplicates removed
455 Studies
239 Articles referring to illness
other than HNC
216 Studies
28 Articles referring to alternate
meaning of depression

comial infections, as well as physical rehabilitation and worsened performance of activities of daily living.5,18,19 Further directed study regarding the effect of these factors on survival in patients with HNC
is necessary to determine the appropriate survival measure.
de Graeff et al9 assessed the effect of a number of sociodemographic factors, including sex, marital status, supports, family income, occupation, and depression on time to progression of disease (TTP), OS, and recurrence in 266 patients with HNC. They
measured depressive symptoms with the CES-D, and in a thorough
evaluation of associations between sociodemographic factors, TTP,
and OS, they distinguished cognitive functioning (relative risk of
death, 1.90; 95% CI, 1.10-3.26) and marital status (relative risk of
death, 1.82; 95% CI, 1.03-3.23) as independent predictors of OS, independent of stage and grade of disease. Scores on the CES-D were
not found to be associated with rates of recurrence or survival using
univariate statistics. However, the total mean (SD) score on the CES-D
for the entire patient cohort was 12.4 (8.0) patients. Only 77 (29%)
patients in the cohort had a score of 16 or more on the CES-D, indicating clinical depression. Because OS is a binary variable, it may have
been more appropriate to evaluate its association with depression
in a binary fashion. In addition, a large number of patients (58 [22%])
reported that they were unable to participate because of emotional factors, giving rise to a significant selection bias because these
patients were more likely to have belonged to the depressed group.
Lazure et al8 performed a retrospective analysis at 24 months
after the prophylactic pretreatment use of citalopram hydrobromide in a randomized controlled trial of patients with HNC. All adult
patients with newly diagnosed or recurrent HNC requiring more than

188 Studies
1 Article referring to alternate
meaning for survival

Table 3. Summary of Findings Based on Eligible Studies Discussing

Depression and Survival in Patients With Head and Neck Cancer
From 1951 to 2014

187 Studies
183 Articles not specifically
referring to depression and
survival in patients with HNC
4 Studies
2 Articles not controlling for
TNM stage

Source

Summary of Findings

de Graeff et al,9
2001

Patients who are unmarried or have less than

optimal cognitive functioning have a relative risk
of mortality of 1.90 and 1.92, respectively.
Depression did not predict survival. (Calculation
of relative risk not possible.)

Ehlers,10 2002

Significant difference in mortality with score

>7 on BDI; 70% higher chance of mortality
with a score 1 SD above the mean in total BDI.
Relative risk of mortality increased by 5%
with every additional point scored on BDI.
(Calculation of relative risk not possible.)

Lazure et al,8 2009

Significant difference in mortality and

recurrence, of 50% vs 20%, with score >15 on
HAM-D. (Calculated relative risk for death or
recurrence = 2.5.)

2 Studies
1 Article included
from reference list
of Trevino et al
3 Eligible studies

Depression and Survival in the Head and Neck Cancer Literature (no further
description necessary).

Abbreviations: BDI, Beck Depression Inventory; HAM-D, Hamilton Depression

scale.

Table 2. Characteristics of Relevant Studies of the Relationship Between Depressive Symptoms and Survival in Patients With Head and Neck Cancer
Median
Follow-up, mo

Adjusted for
TNM Staging

Significant Difference
in Overall Survival,
P Valuea

GRACE
Checklist Score

Source

Study
Design

No. of
Patients

Psychiatric
Assessment Tool

de Graeff et al,9 2001

PC

266

CES-D

39

Yes

>.05

9/11

Ehlers,10 2002

PC

131

BDI

32

Yes

<.01

11/11

Lazure et al,8 2009

RR

34

HAM-D

28

Yes

.03

11/11

Abbreviations: BDI, Beck Depression Inventory; CES-D, Center for Epidemiological Studies Depression scale; GRACE, Good Research for Comparative Effectiveness;
HAM-D, Hamilton Depression scale; PC, prospective cohort; RR, retrospective review.
a

286

See Table 3 for summary of findings.

JAMA OtolaryngologyHead & Neck Surgery March 2016 Volume 142, Number 3 (Reprinted)

Copyright 2016 American Medical Association. All rights reserved.

Downloaded From: http://archotol.jamanetwork.com/ by a Duke Medical Center Library User on 04/04/2016

jamaotolaryngology.com

Depression and Survival in Patients With Head and Neck Cancer

Review Clinical Review & Education

limited excision were included in the original trial. Patients were excluded if they had a Mini-Mental Status Examination score of less
than 24, if they were suicidal, met diagnostic criteria for psychosis
or schizophrenia, or were currently taking antidepressant medication. Patients with a baseline depression score of 15 or lower according to the HAM-D were also excluded from the trial. The patients were
randomized in a 1:1 fashion to treatment with citalopram hydrobromide at 40 mg/d for 12 weeks or to placebo, and they were then followed up for recurrence and OS for 24 months after their enrolment. Patients with a HAM-D score of 15 or lower at any point during
the 16-week trial had a significantly shorter OS and greater frequency of disease recurrence than did the nondepressed group
(P = .03). This effect was observed in the absence of differences in
age, sex, TNM stage, treatment type, and tumor site between groups.
The follow-up study was conducted only 24 months after the baseline assessment, but the effect of depression on survival is likely
to be seen within this time frame. Furthermore, recurrence and OS
were assessed together as a single outcome. Conversely, the effect
of depression on survival in this cohort was probably underestimated because patients with baseline depression were excluded
from the initial trial and would not have been included in the follow-up study.

Discussion
Given the small number of studies in the literature, and degree of
heterogeneity in these studies, it is difficult to illustrate the association between depression and survival in patients with HNC. There
was a significant decrease in survival in depressed patients in 2 of
the 3 studies that met the inclusion criteria for the study described
here. Calculation of relative risk was possible in only 1 of the 3 studies, precluding meta-analyses. Overall, further studies are needed
to prospectively evaluate the association between depression and
survival in patients with HNC.
Our study has a number of strengths, including an exhaustive
search strategy spanning multiple surgical, psychiatric, and thesis databases and gray literature, clearly defined criteria to minimize selection bias, and standardized appraisal using a validated scoring tool for
observational studies. Our study also has a number of limitations: several studies in the literature had to be excluded because of the use of
nonvalidated assessment tools or outcome measures that varied from
depression as a diagnosis. Our study was also limited to Englishlanguage publications. In addition, the diverse representation of data
in the few relevant studies used in our study precludes computation
and comparison of risk ratios or hazard ratios among them.
The findings of our study have been made by previous investigators in other types of cancer. A systematic review by Satin et al19
of the effect of depressive symptoms on cancer progression and survival in a variety of patients with breast, lung, brain, skin, and hematologic cancers found a 25% higher mortality in patients with deARTICLE INFORMATION
Submitted for Publication: August 6, 2015; final
revision received October 7, 2015; accepted
November 5, 2015.
Published Online: January 21, 2016.
doi:10.1001/jamaoto.2015.3171.

jamaotolaryngology.com

pressive symptoms and up to a 39% higher mortality in patients with

major or minor depression, even when controlled for known clinical prognosticators of cancer survival. However, Satin et al found no
difference in cancer progression, implying that depression or depressive symptoms probably affect OS rather than DSS. Similar findings were made by Brown et al.20 Nevertheless, the finding of an association between depressive symptoms and survival in HNC is of
major importance, and larger investigative studies of etiologies,
screening, and management programs for depression in patients
with cancer are warranted.
Etiologies for decreased survival in the population with HNC are
likely to be multifactorial. Demographic factors, such as sex, social
network, and/or marital status,21,22 may contribute to the development of depression and potentially affect survival, yet they are not
directly modifiable. However, other factors associated with poorer
outcomes in patients with cancer, such as decreased treatment
adherence,6,23,24 decreased functional status,5,18,19 return to detrimental prognostic habits,25-27 increased hospital stay,15-17 or failure
to thrive14 may be addressed by a multidisciplinary team, using a standardized screening, monitoring, and management program. A
2-tiered program, using both psychological screening and a multicomponent collaborative treatment program, has been evaluated
in randomized controlled trials.28-30 This approach has been shown
to decrease rates of depression, anxiety, pain, and fatigue and to improve functioning, health, quality of life, and perceived quality of depression care in a number of studies of patients with cancer. Other,
similar psychiatric interventions have also been successful in increasing quality of life and mood in patients with HNC during and
after treatment for such cancer.31-33
Depression is increasingly recognized as an important comorbidity for identification and treatment in individuals with cancer. International organizations have indicated that screening for and treating psychosocial conditions should be integrated into cancer care.
For example, the National Institute for Clinical Excellence 34 has published recommendations for the screening and management of patients with HNC, and the American College of Surgeons Commission on Cancer requires that to qualify for accreditation, all cancer
centers in the United States must have screening programs for psychosocial distress by 2015.35 Routine surveillance for depression in
individuals with cancer may allow an improved understanding of its
effects on survival and other functional outcomes.

Conclusions
We found depression to be an independent predictor of survival in
2 of the 3 evaluated studies in the study described here, even after
adjustment for known prognostic indicators. However, the mechanism by which this occurs is not clear, and further study is needed
to determine factors contributing to the development of depression in patients with HNC and to its optimal management.

Author Contributions: Dr Barber had full access to

all of the data in the study and takes responsibility
for the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Barber, Harris, OConnell,
El-Hakim, Biron.

Acquisition, analysis, or interpretation of data:

Barber, Dergousoff, Slater, El-Hakim, Seikaly.
Drafting of the manuscript: Barber, Dergousoff,
Slater, Harris, Mitchell, Seikaly.

(Reprinted) JAMA OtolaryngologyHead & Neck Surgery March 2016 Volume 142, Number 3

Copyright 2016 American Medical Association. All rights reserved.

Downloaded From: http://archotol.jamanetwork.com/ by a Duke Medical Center Library User on 04/04/2016

287

Clinical Review & Education Review

Depression and Survival in Patients With Head and Neck Cancer

Critical revision of the manuscript for important

intellectual content: Barber, OConnell, El-Hakim,
Biron, Seikaly.
Statistical analysis: Barber, Dergousoff, Harris, Biron.
Obtained funding: Seikaly.
Administrative, technical, or material support:
Barber, Harris, OConnell, Mitchell.
Study supervision: Barber, Harris, OConnell,
El-Hakim, Mirchell, Seikaly
Conflict of Interest Disclosures: None reported.
REFERENCES
1. Dropkin MJ. Coping with disfigurement and
dysfunction after head and neck cancer surgery:
a conceptual framework. Semin Oncol Nurs. 1989;5
(3):213-219.
2. Pruyn JF, de Jong PC, Bosman LJ, et al.
Psychosocial aspects of head and neck cancera
review of the literature. Clin Otolaryngol Allied Sci.
1986;11(6):469-474.
3. Sehlen S, Lenk M, Herschbach P, et al.
Depressive symptoms during and after
radiotherapy for head and neck cancer. Head Neck.
2003;25(12):1004-1018.
4. Misono S, Weiss NS, Fann JR, Redman M, Yueh
B. Incidence of suicide in persons with cancer. J Clin
Oncol. 2008;26(29):4731-4738.
5. Lin BM, Starmer HM, Gourin CG. The relationship
between depressive symptoms, quality of life, and
swallowing function in head and neck cancer
patients 1 year after definitive therapy. Laryngoscope.
2012;122(7):1518-1525.
6. Barber B, Dergousoff J, Nesbitt M, et al.
Depression as a predictor of postoperative
functional performance status (PFPS) and
treatment adherence in head and neck cancer
patients: a prospective study. J Otolaryngol Head
Neck Surg. 2015;44(1):38.

13. Hamilton M. A rating scale for depression.

J Neurol Neurosurg Psychiatry. 1960;23:56-62.
14. Britton B, Clover K, Bateman L, et al. Baseline
depression predicts malnutrition in head and neck
cancer patients undergoing radiotherapy. Support
Care Cancer. 2012;20(2):335-342.
15. Kitagawa R, Yasui-Furukori N, Tsushima T,
Kaneko S, Fukuda I. Depression increases the length
of hospitalization for patients undergoing thoracic
surgery: a preliminary study. Psychosomatics. 2011;
52(5):428-432.
16. Zhang XD, Zhao QY, Fang Y, et al. Perioperative
comprehensive supportive care interventions for
chinese patients with esophageal carcinoma:
a prospective study. Asian Pac J Cancer Prev. 2013;
14(12):7359-7366.
17. Trer N, Nursal TZ, Calikan K, et al. The effect
of the psychological status of breast cancer patients
on the short-term clinical outcome after
mastectomy. Acta Chir Belg. 2010;110(4):
467-470.
18. Mainio A, Hakko H, Niemel A, Koivukangas J,
Rsnen P. Depression and functional outcome in
patients with brain tumors: a population-based
1-year follow-up study. J Neurosurg. 2005;103(5):
841-847.
19. Satin JR, Linden W, Phillips MJ. Depression as
a predictor of disease progression and mortality in
cancer patients: a meta-analysis. Cancer. 2009;115
(22):5349-5361.
20. Brown KW, Levy AR, Rosberger Z, Edgar L.
Psychological distress and cancer survival:
a follow-up 10 years after diagnosis. Psychosom Med.
2003;65(4):636-643.

7. Dreyer N, Velentgas P, Westrich K, Dubois R.

The GRACE Checklist for rating the quality of
observational studies of comparative effectiveness:
a tale of hope and caution. J Manag Care Spec Pharm.
2010;16(6):467-471.

21. de Leeuw JRJ, de Graeff A, Ros WJ, Blijham GH,

Hordijk G-J, Winnubst JA. Prediction of depressive
symptomatology after treatment of head and neck
cancer: the influence of pre-treatment physical and
depressive symptoms, coping, and social support.
Head Neck. 2000;22(8):799-807.

8. Lazure KE, Lydiatt WM, Denman D, Burke WJ.

Association between depression and survival or
disease recurrence in patients with head and neck
cancer enrolled in a depression prevention trial.
Head Neck. 2009;31(7):888-892.

22. Llewellyn CD, McGurk M, Weinman J. Are

psycho-social and behavioural factors related to
health related-quality of life in patients with head
and neck cancer? A systematic review. Oral Oncol.
2005;41(5):440-454.

9. de Graeff A, de Leeuw JR, Ros WJ, Hordijk GJ,

Blijham GH, Winnubst JA. Sociodemographic
factors and quality of life as prognostic indicators in
head and neck cancer. Eur J Cancer. 2001;37(3):
332-339.

23. Arrieta O, Angulo LP, Nez-Valencia C, et al.

Association of depression and anxiety on quality of
life, treatment adherence, and prognosis in patients
with advanced non-small cell lung cancer. Ann Surg
Oncol. 2013;20(6):1941-1948.

10. Ehlers S. Effects of Depression and Substance Use

on Head and Neck Cancer Mortality [dissertation]. Iowa
City: University of Iowa; 2002.

24. Hu LY, Ku FC, Wang YP, et al. Anxiety and

depressive disorders among patients with
esophageal cancer in Taiwan: a nationwide
population-based study. Support Care Cancer. 2015;
23(3):733-740.

11. Radloff L. The CES-D scale: a self-report

depression scale for research in the general
population. Appl Psychol Meas. 1977;1:385-401.

288

12. Beck AT, Ward CH, Mendelson M, Mock J,

Erbaugh J. An inventory for measuring depression.
Arch Gen Psychiatry. 1961;4:561-571.

25. Gritz ER, Schacherer C, Koehly L, Nielsen IR,

Abemayor E. Smoking withdrawal and relapse in
head and neck cancer patients. Head Neck. 1999;21
(5):420-427.
26. Deleyiannis FW, Thomas DB, Vaughan TL,
Davis S. Alcoholism: independent predictor of
survival in patients with head and neck cancer.
J Natl Cancer Inst. 1996;88(8):542-549.
27. Falk RT, Pickle LW, Brown LM, Mason TJ,
Buffler PA, Fraumeni JF Jr. Effect of smoking and
alcohol consumption on laryngeal cancer risk in
coastal Texas. Cancer Res.
28. Strong V, Waters R, Hibberd C, et al.
Management of depression for people with cancer
(SMaRT oncology 1): a randomised trial. Lancet.
2008;372(9632):40-48.
29. Sharpe M, Walker J, Holm Hansen C, et al;
SMaRT (Symptom Management Research Trials)
Oncology-2 Team. Integrated collaborative care for
comorbid major depression in patients with cancer
(SMaRT Oncology-2): a multicentre randomised
controlled effectiveness trial. Lancet. 2014;384
(9948):1099-1108.
30. Walker J, Hansen CH, Martin P, et al; SMaRT
(Symptom Management Research Trials)
Oncology-3 Team. Integrated collaborative care for
major depression comorbid with a poor prognosis
cancer (SMaRT Oncology-3): a multicentre
randomised controlled trial in patients with lung
cancer. Lancet Oncol. 2014;15(10):1168-1176.
31. van der Meulen IC, May AM, Ros WJ, et al.
One-year effect of a nurse-led psychosocial
intervention on depressive symptoms in patients
with head and neck cancer: a randomized
controlled trial. Oncologist. 2013;18(3):336-344.
32. van der Meulen IC, May AM, de Leeuw JR, et al.
Long-term effect of a nurse-led psychosocial
intervention on health-related quality of life in
patients with head and neck cancer: a randomised
controlled trial. Br J Cancer. 2014;110(3):593-601.
33. Lydiatt WM, Denman D, McNeilly DP,
Puumula SE, Burke WJ. A randomized,
placebo-controlled trial of citalopram for the
prevention of major depression during treatment
for head and neck cancer. Arch Otolaryngol Head
Neck Surg. 2008;134(5):528-535.
34. Guidance on Cancer Services, National Institute
for Clinical Excellence. Improving Outcomes in Head
and Neck Cancers. London, England: National
Institute for Clinical Excellence; 2004.
35. American College of Surgeons. Cancer Program
Standards 2012, Version 1.2.1: Ensuring
Patient-Centered Care. Chicago, IL: American College
of Surgeons; December 2011.
36. Chiou WY, Lee MS, Ho HC, et al.
Prognosticators and the relationship of depression
and quality of life in head and neck cancer. Indian J
Cancer. 2013;50(1):14-20.

JAMA OtolaryngologyHead & Neck Surgery March 2016 Volume 142, Number 3 (Reprinted)

Copyright 2016 American Medical Association. All rights reserved.

Downloaded From: http://archotol.jamanetwork.com/ by a Duke Medical Center Library User on 04/04/2016

jamaotolaryngology.com