Depression in Cancer Patients

Although it still seems intuitive to some people that anyone diagnosed with a life-threatening illness would become depressed, anyone dealing with cancer patients knows that that isn't always the case. Patients may be sad, anxious, and angry, perhaps, but not necessarily depressed. In fact, oncologists describe some people with cancer as being energized by the challenge, determined to put up a fight and hold onto life with all their strength. In contrast, those who become depressed don't stand up and get noticed. By the nature of the disease, they are quiet and self-effacing, hoping not to “cause any more problems than they have already.” But estimates using strict diagnostic criteria suggest that one in four cancer patients are clinically depressed, and under broader definitions as many as 50 percent. “Depression is a terrible complication that wreaks havoc with the cancer patient's quality of life,” says Harvey Chochinov, MD, PhD, Professor of Psychiatry and Family Medicine in the Division of Palliative Care at the University of Manitoba in Winnipeg. “We shouldn't ‘pathologize’ normal human responses to life-threatening situations and sadness is part of the human condition, but depression is more than sadness,” he said in an interview. “It is a devastating psychological experience.” In the extreme, suicide is a risk. More subtly, depression can lead to noncompliance, since depressed patients are more apathetic and less likely to engage in care and follow-up.Figure: Harvey Chochinov, MD, PhDFigure: Ardow Ameduri, MDFigure: Mary Pat Lynch, MSNArdow Ameduri, MD, a radiation oncologist at the Cancer Therapy and Research Center in San Antonio, TX, who was also trained as a psychiatrist, recalled a recent case of a woman being worked up for what might have been a recurrence of her cancer. “Her attitude was that ‘maybe they'll find something,’ because she was getting tired and saw little purpose in going on,” he said. “If that's the psychological state of your patient, they aren't going to be engaged as actively in the process of trying to aggressively preserve their life.” Neuropsychological Testing Dr. Ameduri says he has become a strong proponent of neuropsychological testing in cancer patients. “You need to find out if you are dealing with a reactive or endogenous depression,” he said. “But often testing isn't enough. One of the weaknesses in oncology is that cancer treatment is episodic. Patients are not followed, and for all essential purposes, you lose contact.” That is dangerous if patients are still depressed after therapy has been completed, he says, “because they are not going to get better once they leave you. I believe there are a lot of patients with unrecognized depression who leave the oncologist's office untreated and become very clinically sick.” No Special Treatment Depression is very treatable, with recovery the rule even in cancer patients, says Mary Pat Lynch, MSN, Administrator at Pennsylvania Hospital Cancer Center in Philadelphia. Depression in seriously ill patients is treated the same as in those not otherwise ill, with psychotherapy, medication, or a combination of the two. Selective serotonin reuptake inhibitors (SSRIs) are first-line treatment, but some of the older tricyclic antidepressants have specific effects that might be helpful in cancer patients. Some may be helpful in treating neurologic pain, for example, or insomnia as well as depression. ‘How Are You Coping?’ Dr. Chochinov said simple questions asked during an office visit, such as “Tell me how you are coping with things?” are a reasonable way to start probing for depression. More direct questions might be “Have you lost interest in favorite activities?” or “Are you feeling sad most of the time?” “As a matter of routine, these questions are not time consuming to ask,” Dr. Chochinov said. “And if you open up the door, patients are going to feel freer to walk through that door and talk about their psychological adjustment.” Ms. Lynch said a telling question is “Have you been getting out and doing things?” If patients admit they haven't, that's a flag to look further. If a patient admits to feeling down or having no interest in getting out of the house, the clinician should dig further and ask about feelings of hopelessness and worthlessness and about thoughts of suicide. “If your patient answers yes to those, you can be pretty sure they likely meet diagnostic criteria for depression and at least might warrant a trial of treatment, or if the clinician is so inclined, a referral to a health care professional,” Dr. Chochinov said. This assumes that the clinician thinks to ask, but there may be no prompts that suggest a problem. Dr. Ameduri notes that the anticancer treatments he employs universally cause symptoms that mimic classic depression—fatigue, insomnia, loss of appetite, loss of interest in intimacy, etc. “To really pick up on the cues, you need to pay attention to the patient and have some close follow-up, but we don't do that,” he said. “We cure the cancer, their treatment's over, and we send them home. That's a big glaring hole in the treatment protocols we set up, that nobody who can deal with a depressive situation can follow these people. With modern tools, these people get better, so it is important to make the diagnosis, make sure it is correct, and then treat it.” Joan Hermann, LSW, Director of Social Work Services at Fox Chase Cancer Center in Philadelphia and a member of OT's Editorial Board, notes that it may also be useful to advise patients that they may experience depression once their initial treatment is completed. “This happens when patients lose the safety and security that the health care system symbolizes. Patients may feel that there is nothing ‘fighting the cancer,’ and that belief, along with the loss of emotional support offered by the health care staff, may precipitate a depression,” she explained. “Physicians should advise patients that the effects of chemotherapy and/or radiation therapy continue and that they want to be informed if patients find themselves depressed after their treatment is completed.” Nurses Aware Nurses are often more aware of personal issues and problems that patients are having, and it may be the oncology nurse who notices the symptoms of depression, said Ms. Lynch, who is a certified registered nurse practitioner and an oncology-certified nurse. “It's the nurses who are sitting with the patient, giving them chemotherapy, and talking with family members,” she said. “Asking about depression is another element in nursing supportive care.” Nurses are becoming more aware of fatigue and pain and are asking questions about them, Ms. Lynch said, “and depression fits right in there. Just as we ask ‘How's your pain today?,’ and ‘How's fatigue affecting your daily life?,’ we can routinely ask about depression.” Many people who are depressed don't want to talk about it, Ms. Lynch continued, or they don't realize that is what is happening to them. Therefore it is appropriate to ask family members or caregivers how they think the patient feels. Questioning the family might uncover a history of depression in the patient which has gone unnoticed during cancer treatment. It is an anomaly that some cancer patients with endogenous depression feel relief from their depressive symptoms when they are distracted by the attention they receive during cancer treatment, or because of a sense of belonging to a community of survivors. “But then what may appear to be separation anxiety when treatment is concluded may actually be the return of the depression,” Dr. Ameduri said. Risk Factors Some of the risk factors for depression in patients with a serious illness include: prior history of depression (two or more episodes); early age at first onset of depression; family history of depression or suicide; poorly controlled pain; history of alcoholism or dug abuse; and advanced stage of illness. In addition, certain types of malignancies are associated with a greater incidence of depression, such as retroperitoneal, neurological, and pancreatic cancers. Drugs used in chemotherapy such as anabolic steroids, vinblastine, vincristine, tamoxifen, and interferon can also trigger depression, Ms. Lynch noted. “You may not be able to stop using the drug, but you can treat the depression at the same time.” And between 10 and 15 percent of depression in cancer patients is caused by a medical illness such as hypothyroidism and vitamin B12 deficiency, she added. How much—or how little—a patient is told about his or her disease can also push the person toward depression. Sometimes very little information is shared between the treating doctors and the patient, Dr. Chochinov said, and patients may think they are not being told the entire truth about their prognosis. He said it is not unusual for some patients to be very surprised when they are told their treatment was successful, because they had led themselves to expect the worst. A successful outcome, however, does not prevent depression from occurring. A study from Japan (Uchitomi Y et al: Cancer 2000;89:1172–1179) found that 15 percent of successfully treated lung cancer patients met the criteria for depression at three months after surgery. Helpless, Hopeless, Worthless In a 1995 study published in the American Journal of Psychiatry, Dr. Chochinov looked at the relationships among depression, desire for death, pain, and social support in terminally ill patients, and found that people with a genuine desire to die reported a prevalence of depression of nearly 70 percent, compared with about nine percent who did not report such a desire. He also found a strong association between depression, hopelessness, and thoughts of suicide. “Hopeless” refers to a pessimistic view of the future and an inability to find a sense of meaning or purpose in one's current life, he explained. (In contrast, “helpless” refers to a person's sense of competence and ability to carry out tasks or roles that are seen as integral parts of the person's personality. Someone with a serious illness may feel either helpless or hopeless, both, or neither.) A hopeless prognosis does not mean a hopeless attitude, Dr. Chochinov added. “You might think that people who have a hopeless prognosis are all going to report that they are hopeless about the future, but that is not the case. Only a minority of the terminally ill patients in this study ascribed to themselves a high sense of hopelessness, and those people were most likely to be depressed.” Among dying patients, hope can to take on different meanings and dimensions, Dr. Chochinov explained. A medical prognosis may be hopeless even though the person's mental attitude may be hopeful, hoping that the remaining days will be meaningful, and that there is still time to do some things the person wants to do, or talk with friends and loved ones. Worthlessness, indecision, and a sense of failure or being punished with their disease are more hallmarks of depression. Dr. Chochinov said he has had patients with cancer who were quite profoundly depressed, and who said, “I'm wasting your time; I'm not worthy of this.” “Those kinds of distortions can and do occur in the context of depression, and are particularly terrible when it occurs in the context of cancer,” he said. Ms. Lynch added that depressed patients can have a sense of failure, feelings of being punished, feelings of dissatisfaction, and indecision. “By indecision, I mean they really can't function, they are paralyzed by it,” she said. “They can't choose between treatment options, for example.” Diagnosing and treating depression in cancer patients can make their life tolerable, improve their relationships, and increase compliance. Some theorize it can also improve outcomes. For example, a 1999 study by Faller et al in Germany found that active coping in lung cancer patients was linked with longer survival time, while depressive coping, emotional distress, and depression were linked with shorter survival. And a well-known 1990 study by David Spiegel, MD, et al of women with metastatic breast cancer showed that those who joined in group psychotherapy lived an average of 18 months longer than control patients.

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