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Depression in Cancer Patients

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Background

Managing patient responses to cancer diagnosis and treatment remains a challenge. In spite of objective measures of response to treatment, measuring response to the burden of cancer is more difficult and often nonexistent. Depression, for example, may be masked within clusters of treatment responses, making it difficult to diagnose and treat.1-3 Recent studies suggest that depression may be a risk factor in cancer progression.1,2 Clinicians do not typically recognize depression, which should be part of the baseline assessment.4

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Diagnosing Depression

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classifies depression as an adjustment disorder, symptoms of which may include5,6

  • Depressed mood (feelings of sadness)
  • Loss of interest or pleasure
  • Sleep disturbances
  • Loss of energy or feelings of fatigue
  • Difficulty in concentrating or decision making
  • Appetite or weight changes
  • Psychomotor agitation or psychomotor retardation
  • Feelings of worthlessness or excessive guilt
  • Suicidal thoughts or intentions

Diagnostic criteria for depression are the core symptom (depressed mood) plus 4 of the other symptoms lasting for at least 2 weeks and occurring on most days, except for thoughts of suicide or death.6

Depression is often underdiagnosed because of many factors, including7

  • Difficulty making the diagnosis in the medically ill patient
  • Provider discomfort in exploring patient distress
  • Provider lack of knowledge (assessment techniques and treatment options)

In patients with cancer, a number of physical manifestations or treatment-related symptoms may contribute to the somatic symptoms of depression, making this diagnosis challenging.8 Sadness and grief are normal reactions during any stage of cancer, but many studies show a higher prevalence of depression with advanced disease. The prevalence of major depression and depressive symptoms ranges widely, from 1% to 42%3—an estimated 2 to 3 times that in the general population.4,8,9

Table 1. Risk Factors for Depression

Cancer-Related Risk Factors Non–Cancer-Related Risk Factors11,12
Depression at diagnosis Prior history of depression; past treatment of psychological disorders
Uncontrolled pain and symptom clusters: pain, fatigue, sleep, and cognitive changes3,10 Lack of family support
Advanced stages of disease Additional life stressors
Increased physical impairment or discomfort Family history of depression or suicide
Type of cancer associated with alterations in cellular activity13 Previous suicide attempts
Treatment with certain pharmacologic agents and interaction with cancer treatment regimens13 History of alcoholism or drug abuse; concurrent illnesses

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Assessment

Depression can affect quality and meaning of life in patients with cancer, so timely diagnosis and management are crucial. There is no consensus on a single assessment technique, but combinations of 3 approaches should be considered: self-report, response to simple questions, and/or brief screening instruments and clinical interview (the latter considered the most effective).2 Long or ultrashort tools have their place—if only to rule out levels of depression warranting intervention. There are no specific tools for assessing depression in cancer patients.

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Self-Report: Simple Questions

In addition to asking about somatic symptoms, which are not specific to depression, asking patients how often they feel depressed or hopeless helps identify those at risk. Additional questions about lack of interest or pleasure in daily living and activities may be useful in detecting core symptoms.7 Other questions may be asked: How are you sleeping? How would you describe your mood or energy level over the past 2 weeks?14 The fear of cancer and its potential consequences is very real, yet admitting to feeling depressed or down may carry a stigma. Patients may fear their depression is a sign of weakness and inability to tolerate treatment—they may even fear withdrawal of treatment.3,11 Because of the potential stigma, the NCCN Panel uses the more neutral term “distress” to characterize psychosocial symptoms.15


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Self-Report: Screening Instruments

Structured instruments and symptom scales may be useful in diagnosing major depression and its severity over a specific time period. In clinical settings, drawbacks of some instruments include time to administer and score.

Table 2. Examples of Self-Report Screening Tools

Name Comments
Diagnostic and Statistical Manual of Mental Disorders 5-7 Widely held standard for assessing other tools
Hospital Anxiety and Depression Scale (HADS)4 14-item measure of psychologic distress, perhaps most frequently used16
Brief Symptom Inventory (BSI-18)4 18-item overview of a patient's symptoms and intensity at specific point in time
Distress Thermometer4,15 Single-item rating of distress on a scale of 1-10 (no distress to extreme distress). From a checklist of 5 categories, patients select what may have been the possible source of their distress
Zung Self-Rating Depression Scale8 20-item scale that measures the severity of depression
Beck Depression Inventory (BDI)2 21-item inventory that reduces influence of somatic concerns

Clinical or Diagnostic Interview11

Screening tools can help determine need for follow-up or referral to the most appropriate mental health professional. Acute or severe depression with risk of suicidal thoughts warrants psychiatric intervention.10 The oncologist, advanced practice nurse, or psychiatrist may order drug therapy, considering symptoms and known drug interactions. Patients with anxiety or adjustment issues (but severe depression), social workers, psychiatric liaison nurses, or clergy may guide patients in identifying the stressors of cancer and its treatment.

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Clinical Practice Guidelines

The National Comprehensive Cancer Network (NCCN) practice guidelines for distress management advise an assessment initially and at appropriate intervals. The guidelines suggest timing interventions based on the patient’s “distress thermometer” responses. http://www.nccn.org/professionals/physician_gls/PDF/distress.pdf

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Patient Care Management Protocols or Algorithms

The Oncology Nursing Society (ONS) has published an evidence-based practice quick-reference card (ONS PEP card) on depression management, which may be accessed at http://ons.org/outcomes/volume2/depression/PEPCard_Detailed_Depression.shtml

Additional guides to assessment tools to measure oncology nursing outcomes may be accessed at http://www.ons.org/outcomes/volume2/depression/References_Depression.shtml

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Treatment Options

Pharmacology

Overall, there is limited evidence of clinical trials specifically studying pharmacologic treatment of depression in cancer patients.9,16 There is no record of randomized, controlled studies of alternative medicine interventions.16 For pharmacologic treatment of cancer-related depression, consider the following:

  • If prior therapy for depression was successful, start with the same agent7
  • Selective serotonin reuptake inhibitors (SSRIs) are considered agents of choice due to low side effects7
  • Antidepressants should be started at low doses to decrease potential side effects and interaction with cancer therapy, then titrated upward to effect14
  • Instruct patients to report use of herbals to avoid dangerous drug interactions14

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Psychosocial or Psychoeducational

Evidence exists that psychosocial or psychoeducational interventions are beneficial for depression in patients with cancer and are often combined with pharmacologic therapy.7,16,17,18 Traditional psychotherapy is not recommended, since patients dealing with cancer often cannot commit to self-exploration.10 Cognitive-behavioral concepts are considered effective because

  • Thoughts (not events, people, or circumstances) such as those that accompany hearing the diagnosis of cancer can influence feelings and behaviors7
  • Changing thoughts can ameliorate depressive feelings, even if the situation does not change
  • Group and individual settings can be beneficial
  • Team members can address negative thoughts by reframing the thoughts and giving context to behaviors, since they have long-term relationships with cancer patients8
  • Outcomes are measurable, with change evident in a short time period

A challenge for both oncology nurses and patients is the use of oral agents with patients seen infrequently, making psychosocial assessment and appropriate intervention difficult.

 

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Nursing Management

Depression may coexist with other symptoms: identifying them and planning their management may relieve a depressed mood. Deviation from routines or habits is very individual, with self- reporting either over or under the actual deviation from normal routine.

  • Pain—frequent contributor to depression, which cannot be controlled if pain persists.8,10 The WHO 3-step analgesic ladder is useful for pain relief 3
  • Fatigue—assessing anemia, sleep patterns, and level of fatigue helps to plan care
  • Appetite—establishing prior eating routine and foods helps in assessing differences during treatment
  • Performance status—changes offer insights into altering care options

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Outcomes of Untreated Depression

Depression should be managed to avoid

  • Lack of adherence to treatment regimens2,4
  • Poor satisfaction with care
  • Diminished quality of life11
  • Failure to receive drug therapy that could offer relief

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Future Research

Depression is the most frequently studied psychological condition in patients with cancer.2 Nevertheless, its screening is not routine, so depression remains underrecognized, and undertreated. Areas of needed research on depression in cancer are

  • Nutrition and the role of omega-3 fatty acids11
  • Tumor biology causing inflammation as an inducer of behavior changes, such as fatigue leading to depression7,13
  • Neuroendocrine, neuroimmune, neurochemical alterations1,2,7,8
    • Antidepressant drug therapy, including polypharmacy, in patients with cancer and comorbid conditions
  • Stress as an inducer of tumor growth through cytokine activity13
  • Red cell folate levels and synthesis of monoamines, a class of antidepressants11

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References

  1. Steel JL, Geller DA, Gamblin TC, et al. Depression, immunity and survival in patients with hepatobiliary carcinoma. J Clin Oncol. 2007;25:2397-2405.     
  2. Massie MJ. Prevalence of depression in patients with cancer. J Natl Cancer Inst Monogr. 2004;32:57-71.
  3. Patrick DL, Ferketich, SL, Frame PS, et al. National Institutes of Health state-of-the science conference statement: symptom management in cancer: pain, depression, and fatigue, July15-17, 2002. J Natl Cancer Inst. 2003;95:1110-1117.
  4. Jacobsen PB, Donovan KA, Trask PC, et al. Screening for psychologic distress in ambulatory cancer patients. Cancer. 2005;103:1494-1502.
  5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington DC: American Psychiatric Press; 1994.
  6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IVTR. 4th ed. Washington DC: American Psychiatric Press; 2000.
  7. Schwartz L, Lander M, Chochinov HM. Current management of depression in cancer patients. Oncology. 2002;16:1102-1115.
  8. Bowers L, Boyle D. Depression in patients with advanced cancer. Clin J Oncol Nurs. 2003;7:281-288.
  9. Rodin G, Lloyd N, Green E, et al. The treatment of depression in cancer patients: a systematic review. Curr Cancer. 2007;14:180-188.
  10. Fulcher CD. Depression management during cancer treatment. Oncol Nurs Forum. 2006;33:33-35.
  11. Sharpe K. Depression: the essentials. Clin J Oncol Nurs. 2005;9:519-525.
  12. Depression (PDQ): Overview. National Cancer Institute Web site.
    http://www.cancer.gov/cancertopics/pdq/supportivecare/depression/healthprofessional 
    Accessed April 25, 2008.
  13. Irwin MR. Depression and risk of cancer progression: an elusive link [editorial]. J Clin Oncol. 2007;25:2343-2345.
  14. Van Fleet S. Assessment and pharmacotherapy of depression. Clin J Oncol Nurs. 2006;10:158-161.
  15. NCCN. Clinical Practice Guidelines in Oncology: Distress Management—v.1.2008. Supportive care treatment guidelines for patients with cancer. http://www.nccn.org/professionals/physician_gls/PDF/distress.pdf Accessed April 25, 2008.
  16. Pirl WF. Evidence report on the occurrence, assessment, and treatment of depression in cancer patients. J Natl Cancer Inst Monogr. 2004;32:32-39.
  17. Barsevick AM, Sweeney C, Haney E, Chung E. A systematic qualitative analysis of psychoeducational interventions for depression in patients with cancer. Oncol Nurs Forum. 2002;29:73-84.
  18. Williams S, Dale J. The effectiveness of treatment for depression/depressive symptoms in adults with cancer: a systematic review. Br J Cancer. 2006;94:372-390.

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Key Definitions

psychomotor agitation - restlessness, a psychomotor expression of emotional tension

psychomotor retardation - slowed psychic or motor activity, or both

somatic - having to do with the body

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This page was last modified on 6/23/2008, at 10:21:08 am ET.