Depression in Cancer Patients

Quick Facts

• Depression or adjustment disorder is often underdiagnosed in patients with cancer
• Depression is often hidden within clusters of symptom responses to treatment and the burden of cancer, such as pain, fatigue, sleep disturbance, and cognitive changes
• Early diagnosis and management of depression in cancer patients may contribute to improving quality of life and treatment adherence
• Research on emotional distress includes its role in tumor progression and increased risk of cancer mortality

Background

A diagnosis of cancer is a life-altering event and carries with it both physical and psychological burdens. Measuring response to an individual’s psychological burden of cancer is difficult and may be nonexistent. Depression, for example, may be masked within clusters of treatment responses, making it difficult to diagnose and treat.1-3Recent studies suggest that depression may be a risk factor in cancer progression1,2,4 and may increase the risk of death.4 Clinicians, patients and family members may not recognize depression; therefore assessment for depression should be part of baseline and ongoing examinations.5 

Diagnosing Depression

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classifies depression as an adjustment disorder, symptoms of which may include6,7 

• 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.7
Depression is often underdiagnosed because of many factors, including8  

• Difficulty screening 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.9 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.5,9,10 

Table 1. Risk Factors for Depression

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  

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.8 Other questions may be asked:  

• How are you sleeping?
• How would you describe your mood or energy level over the past 2 weeks?15

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.3,12 Because of the potential stigma, the National Comprehensive Cancer Network (NCCN) Panel uses the more neutral term “distress” to characterize psychosocial symptoms.16

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. Relatively brief but validated questionnaires may be the preferred choice for routine screening of cancer patients’ emotional distress. Brief self-reports are easy to administer, inexpensive (some are even free), and, if properly validated, can help identify those patients most in need of professional mental health support. A systematic review of assessment tools to screen for emotional distress in people with cancer was published by Vodermaier, Linden and Siu. Included in the review are both newly developed and well-established distress screening tools that have been validated in patients with cancer.17 

Table 2. Examples of Self-Report Screening Tools 

Clinical or Diagnostic Interview12

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 immediate psychiatric intervention.11 The oncologist, advanced practice nurse, or psychiatrist may order drug therapy; social workers, psychiatric liaison nurses, or clergy may guide patients in identifying the stressors of cancer and its treatment. 

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  Accessed February 9, 2010.

Patient Care Management Protocols or Algorithms

The Oncology Nursing Society (ONS) has published evidence-based practice guidelines and recommendations on depression management, which may be accessed at
http://ons.metapress.com/content/l58q05783728n170/  Accessed February 9, 2010.

Additional ONS guides to measure oncology nursing outcomes for depression may be accessed athttp://www.ons.org/Research/NursingSensitive/Summaries/Depression Accessed February 9, 2010.

Treatment Options

Pharmacology 
Overall, there is limited evidence of clinical trials specifically studying pharmacologic treatment of depression in cancer patients.10,18 There is no record of randomized, controlled studies of alternative medicine interventions.18 For pharmacologic treatment of cancer-related depression, consider the following:  

• If prior therapy for depression was successful, start with the same agent8
• Selective serotonin reuptake inhibitors (SSRIs) are considered agents of choice due to low side effects8
• Antidepressants should be started at low doses to decrease potential side effects and interaction with cancer therapy, then titrated upward to effect15
• Instruct patients to report use of herbals to avoid dangerous drug interactions15

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.8,18,20,21 Traditional psychotherapy is not recommended, since patients dealing with cancer often cannot commit to self-exploration.11 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 behaviors8
• 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 patients9
• Outcomes are measurable, with change evident in a short time period

A challenge for both oncology nurses and patients is the use of oral antidepressants with patients seen infrequently, making psychosocial assessment and appropriate intervention difficult. In this situation, communication with the patient’s primary healthcare provider is essential.

An integrated approach to recognizing and managing depression in people with cancer may have better outcomes than medication or counseling alone. A study by University of Edinburgh researchers studied 200 cancer patients who scored high for depression on a baseline screening exam. Participants were randomized to an intervention group (n=101) that included usual care plus participation in a program given by specially-trained cancer nurses. The intervention emphasized screening for depression, antidepressant medication, and teaching patients problem-solving skills. The control group (n=99) received usual care. At 3 months, scores for depression fell in both groups, though by a significantly greater amount in the group working with the nurses. The results at 6- and 12-months follow-up reflected similar findings. In both groups, there was a significant increase in antidepressant use. Patients in the intervention group reported less anxiety and fatigue at both 3 and 6 months compared to those receiving usual care only.22

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.9,11 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

Outcomes of Untreated Depression

Depression should be managed to avoid

•  Lack of adherence to treatment regimens2,5
•  Poor satisfaction with care
•  Diminished quality of life12
•  Failure to receive drug therapy that could offer relief

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 acids12
• Tumor biology causing inflammation as an inducer of behavior changes, such as fatigue leading to depression8,14
• Neuroendocrine, neuroimmune, neurochemical alterations1,2,8,9
• Antidepressant drug therapy, including polypharmacy, in patients with cancer and comorbid conditions
• Stress as an inducer of tumor growth through cytokine activity14
• Red cell folate levels and synthesis of monoamines, a class of antidepressants12

Resources

Livestrong® (Lance Armstrong Foundation). Cancer Support: Sadness and Depression. Available athttp://www.livestrong.org/site/c.khLXK1PxHmF/b.2660683/k.F789/Emotional_Effects_Sadness_and_Depression.htm  Accessed February 9, 2010.

ChemoCare.com (Scott Hamilton CARES Initiative/Cleveland Clinic Foundation) Depression and Chemotherapy. Available athttp://www.chemocare.com/managing/depression_and_chemotherapy.asp  Accessed February 9, 2010.

National Cancer Institute. Depression (PDQ®). Patient Version.  http://www.cancer.gov/cancertopics/pdq/supportivecare/depression/Patient/page1 Last modified April 22, 2009. Accessed February 9, 2010.

Oncology Nursing Society. The Cancer Journey: Depression. Available at http://www.thecancerjourney.org/side/se-6 Accessed February 9, 2010.

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. Satin JR, Linden W, Phillips MJ. Depression as a predictor of disease progression and mortality in cancer patients: a meta-analysis. Cancer. 2009;115:5349-5361.
5. Jacobsen PB, Donovan KA, Trask PC, et al. Screening for psychologic distress in ambulatory cancer patients. Cancer. 2005;103:1494-1502.
6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington DC: American Psychiatric Press; 1994.
7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IVTR. 4th ed. Washington DC: American Psychiatric Press; 2000.
8. Schwartz L, Lander M, Chochinov HM. Current management of depression in cancer patients. Oncology. 2002;16:1102-1115.
9. Bowers L, Boyle D. Depression in patients with advanced cancer. Clin J Oncol Nurs. 2003;7:281-288.
10. Rodin G, Lloyd N, Green E, et al. The treatment of depression in cancer patients: a systematic review. Curr Cancer. 2007;14:180-188.
11. Fulcher CD. Depression management during cancer treatment. Oncol Nurs Forum. 2006;33:33-35.
12. Sharpe K. Depression: the essentials. Clin J Oncol Nurs. 2005;9:519-525.
13. National Cancer Institute (NCI). Depression (PDQ®) [Health Professional Version]http://www.cancer.gov/cancertopics/pdq/supportivecare/depression/HealthProfessional Last modified January 8, 2010. Accessed February 9, 2010.
14. Irwin MR. Depression and risk of cancer progression: an elusive link [editorial]. J Clin Oncol. 2007;25:2343-2345.
15. Van Fleet S. Assessment and pharmacotherapy of depression. Clin J Oncol Nurs. 2006;10:158-161.
16. National Comprehensive Cancer Network (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 February 9, 2010.
17. Vodermaier A, Linden W, Siu C. Screening for emotional distress in cancer patients: A systematic review of assessment instruments. J Natl Cancer Inst.2009;101:1464–1488.
18. Pirl WF. Evidence report on the occurrence, assessment, and treatment of depression in cancer patients. J Natl Cancer Inst Monogr. 2004;32:32-39.
19. Lloyd-Williams M, Shiels C, Dowrick C. The development of the Brief Edinburgh Depression Scale (BEDS) to screen for depression in patients with advanced cancer. J Affect Disord. 2007;99:259-264.
20. 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.
21. 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.
22. Strong V, Waters R, Hibberd C, et al. Management of depression for people with cancer (SMaRT oncology 1): a randomised trial. Lancet. 2008;372:40-48.

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