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Often unrecognized, depression can be a debilitating side effect of cancer
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Up to 25% percent of patients with cancer experience depression at some point during their treatment, according to the National Cancer Institute.
Despite this prevalence — as well as research that suggests depression may be a predictor of mortality in such cases — depression often remains unrecognized.
“We could do a much better job of identifying cancer patients with depression and navigating them to appropriate treatments,” Lynne I. Wagner, PhD, associate professor in the Department of Psychiatry and Behavioral Sciences at the Northwestern University Feinberg School of Medicine and a member of the Robert H. Lurie Comprehensive Cancer Center at Northwestern University, told HemOnc Today. “We’re moving in the right direction, but we can definitely do a better job of implementing the routine assessment of patients, identifying patients who have depression and connecting them with services.”
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Several factors contribute to the lack of recognition, according to Walter F. Baile, MD, a member of the HemOnc Today Editorial Board and a professor in the Department of Behavioral Science at The University of Texas MD Anderson Cancer Center.
Some patients choose not to inform oncologists that their mental health is suffering, either because they feel ashamed that they are not coping well with their cancer or they believe members of the care team do not care about such issues.
Physicians may be uncomfortable broaching the subject with patients or suggesting antidepressant medication.
Several myths also get in the way. Among them: All patients with cancer are depressed, depression is normal and treatments are not helpful.
“These myths tend to be deterrents to patients getting adequate treatment,” Baile said. “These are all barriers that need to be overcome.”
HemOnc Today spoke with several leaders in psycho-oncology to find out how oncologists can recognize depression, understand its effect on patients, and help alleviate what can be a common side effect of cancer and cancer treatment.
Symptom overlap
Recognizing clinical depression in patients with cancer can be challenging.
The symptoms are similar to common side effects of treatment, such as fatigue, difficulty sleeping, loss of appetite and cognitive problems.
It also is hard to distinguish depression from the grief a patient may feel upon learning his or her diagnosis.
“Most people who go through a diagnosis of cancer are going to have periods of profound sadness,” Lorenzo Norris, MD, director of psychiatric services at The George Washington University Cancer Institute Survivorship Center and director of the Consult-Liaison Service at The George Washington University Hospital, told HemOnc Today. “This, along with the side effects of cancer and treatment, are going to overlap and make the diagnosis of depression difficult.”
It is expected that patients have an acute stress reaction when receiving bad news, and it is expected that patients will experience grief.
“Cancer is a disease of loss,” Baile said. “People lose their sense of safety about themselves and they lose their sense of expectations for the future because they don’t know how the disease is going to turn out. People need to travel that psychological distance from being better to less well. That means acknowledging the losses and readjusting your future to new expectations.”
The key is for physicians to try to distinguish grief from depression, according to Erik Fromme, MD, medical director of the palliative medicine and comfort care team and associate professor of medicine at Oregon Health & Science University Knight Cancer Institute.
“One indicator that I lean on is whether a patient’s depression is constant,” Fromme said in an interview. “Grief comes and goes in waves, and patients can feel intense depression when they have a wave of grief. But grief goes away after a while, whereas depression sticks around.”
Recognizing the signs
There are signs of clinical depression — beyond those that mimic the side effects of cancer — for which oncologists can look. They include loss of energy and loss of interest.
“Two of the most important symptoms of depression are a depressed mood – that is feeling sad and withdrawn – and anhedonia, which is an inability to derive pleasure from activities that are usually found enjoyable,” Tomer Levin, MD, a psycho-oncologist at Memorial Sloan-Kettering Cancer Center, told HemOnc Today. “There are also thought patterns suggestive of depression that an oncologist can recognize, such as overwhelming helplessness, abandonment or pessimism. Patients feeling helplessness may say things like ‘There is nothing I can do’ and ‘It’s all out of my hands.’”
A sense of abandonment is evident when patients say something like “No one really cares whether I live or die.” Pessimism — when patients say “There’s just no point” — also indicate depression if pervasive, Levin said.
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Fromme uses a three-step guide to try to determine whether a patient has depression: Is the depressed mood continuous? Is the patient able to enjoy things that once brought him or her pleasure? Is the patient excessively hard on himself or herself?
“People with grief, as opposed to depression, do enjoy things,” Fromme said. “They find joy and pleasure in little things.”
Norris said oncologists should be mindful of behavioral changes that are atypical among patients, such as whether they become noncompliant, do not appear as motivated or stop following up on treatment.
Wagner encourages oncologists to focus on cognitive symptoms, which include a lack of interest or pleasure in everyday activities, hopelessness and irritability.
“If an oncologist is trying to engage with a patient and the patient doesn’t respond in terms of social interaction, this is a sign of depression,” Wagner said.
Communication is key
Oncologists can identify depression by talking with patients and inquiring about how they are dealing with the stress of their illness.
Norris said such conversations are particularly important at specific transition periods, including diagnosis, the start of treatment and discharge.
Asking patients about their mood is critical, Baile said. They often will not volunteer such information because they believe they are coping adequately or they feel discussing such issues would take too much of a doctor’s time.
“Doctors need to ask patients, ‘How are you coping?’” Baile said. “Many doctors are afraid of opening a Pandora’s box of emotions and problems that they don’t know how to deal with. Most patients answer the question with a simple sentence like, ‘I’m not doing too well.’ Exploring that and encouraging the patient to elaborate on that is very useful in allowing the patients to express what’s going on.”
Oncologists also have the option of having patients complete the PHQ-9, a nine-item depression screening questionnaire.
A score equal to or higher than 5 on two consecutive occasions is a good indication the patient is depressed, Levin said.
“The PHQ-9 can be useful in helping patients gauge where they are and perhaps realize that some of their symptoms are related more to the cancer or the treatment than depression,” Fromme said. “Instead of me making a judgment about a patient, this tool takes it out of that realm and allows the patient to report what he or she is experiencing.”
Risk factors
The risk for depression varies based on several factors.
In the general population, there is a higher prevalence of depression in women. This also is true among cancer patients, Wagner said.
The incidence of depression also increases depending on the stage of the cancer and the patient’s life circumstances, Norris said.
Patients with pancreatic cancer have rates of depression up to 50%, Norris said. Lung, brain, head and neck, and colon cancers also carry elevated risk for depression, Norris said.
Treatment also plays a role.
High-dose interferon, used to treat melanoma and renal cell cancer, has been associated with severe depression, Wagner said.
Patients treated with steroids — especially in combination with chemotherapy — can be at increased risk.
So are patients who receive more aggressive treatments, such as chemotherapy and radiation together, Wagner said.
Patient history and family history also must be taken into account, Baile said.
“If a patient is taking an antidepressant, oncologists should ask the patient how the treatment is working for them,” Baile said. “To establish whether there is a family history, oncologists should be sure to ask whether any family members, particularly parents or siblings, have a depressive illness. Patients with this type of history may be more vulnerable to depression.”
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Effects on the patient
Several studies have examined the link between depression and mortality.
In a meta-analysis of 25 studies, published in the journal Cancer, researchers found that mortality rates were up to 25% higher in patients experiencing depressive symptoms (P<.001), and up to 39% higher in patients diagnosed with major or minor depression (P=.03). Depression had no effect on cancer progression.
In another study published in the Journal of Clinical Oncology, 125 women with metastatic breast cancer completed a depression symptom measure at baseline and again at three follow-up points. The median survival time was 53.6 months with decreasing depression and 25.1 months for women with increasing depression, indicating that those who have decreasing depression actually had longer survival.
Depression can interfere with treatment compliance, including following up on medical appointments, as well as with general function, such as attendance at work and managing daily responsibilities.
Another key component is its effect on interpersonal relationships.
“People who have depression tend to withdraw and have decreased social interactions,” Wagner said. “We are social creatures by nature. When you reduce that critical social interaction, it can lead to more depression and compromise relationships, including marital relationships, work relationships, and relationships with friends and family.”
Patients’ abilities to process information may become compromised, which could prevent them from making the most informed choices or affect their ability to report side effects of treatment to their oncologists.
Physical pain and difficulty sleeping also can occur, Norris said.
“Sleep is necessary to aid in the healing of the body,” Norris said. “Disrupting that sleep cycle while undergoing cancer treatment can be detrimental.”
Biochemical changes also may occur.
For example, depression is associated with increased cortisol levels, Norris said. That can suppress the immune system and therefore is particularly relevant to patients with cancer.
Oncologists also should pay close attention to the risk for suicide.
Suicidal ideation may take two forms, active — in which people have a plan for taking their own life — and passive — when they don’t make an effort to stay alive.
“Depression isolates people and puts them in a dark hole,” Norris said. “They lose connection to everybody, and there can be a very strong behavioral tendency to give up and to think there is no point. They think people would be better off without them. Every area of their lives is affected.”
Treatment
Before a strategy is devised to treat depression, it is essential the diagnosis is correct, Levin said.
“Diagnostic reliability increases by seeing a patient more than once,” Levin said. “If you see a patient in week 1 and in week 2, and he or she is depressed both times, that increases the chance that the diagnosis is right.”
Levin recommends starting treatment with a selective norepinephrine reuptake inhibitor (SNRI) or a selective serotonin reuptake inhibitor (SSRI), together with a benzodiazepine to help patients who also have significant anxiety. “Mixed anxiety and depression are common in oncology,” he said, “so there is benefit in treating both.”
However, many factors go into determining what treatment will most benefit a particular patient.
One is individual preference. Some patients may be more comfortable with talk therapy — for example, cognitive behavioral therapy, Wagner said.
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Another is the severity of depression, she said. Medication typically is used for people with severe depression.
“Anti-depressant medications need to be carefully selected, monitored and managed because, for some patients, there are interactions,” Wagner said. “For example, SSRIs are not indicated for women with breast cancer who are taking tamoxifen.”
Modern antidepressants are safe and effective, and some have collateral effects that can be used to benefit the patient, Baile said.
For example, venlafaxine (Effexor, Pfizer) can help with nausea in some patients, and it also can help with hot flashes in patients being treated with drugs that block hormones. Mirtazapine can help promote sleep and also increase appetite and reduce nausea in patients. In addition, SSRIs have properties that can reduce anxiety, which often accompanies depression.
“It is really worthwhile for the oncologist to get to know the anti-depressants and some of their benefits,” Baile said. “One mistake often made is starting the patient on too high of a dose. Starting at a low dose and working your way up might be a way of avoiding some of the side effects that cause patients to stop medication.”
Patients with depression should be encouraged to stay active and make sure they are not isolating themselves, Norris said.
Communication between them and their oncologist can help significantly.
“It is essential that oncologists talk to their patients because promoting hope is a great anti-depressant,” Levin said. “The treatment of depression can involve both medication and talk. The oncologist’s words of encouragement and praise are vital to maintain morale,” he explained
Educating oncologists
Asking whether an oncologist should be trained in recognizing and treating depression is similar to asking whether oncologists should be trained to deal with nausea or pain, Baile said.
“Depression is a symptom that can affect up to 25% of patients with cancer, so it is logical that this is something that needs to be recognized and treated,” Baile said. “The job of the oncologist is to recognize these symptoms and know that there are treatments, including listening to the patient, acknowledging their frustrations and being empathic.”
It may not be necessary for oncologists to receive formal training or attend a psycho-oncology conference, Norris said. However, the topics of depression, distress and cancer survivorship should be addressed periodically in tumor board meetings or grand rounds.
Norris suggests periodic in-service meetings about these topics to help ensure oncologists know a few questions they can ask to begin a dialogue with patients who may be exhibiting signs of depression.
“Oncologists do an amazing job and their patients rely on them,” Norris said. “Many oncologists have a very excellent understanding of psychology/psychiatry, but due to time constraints, they don’t get to use this knowledge. The main thing oncologists need to know is how to engage in these conversations with patients.” – by Emily Shafer
For more information:
- Gies-Davis J. J Clin Oncol. 2010;29:413-420.
- Satin JR. Cancer. 2009;115:5349-5361.
Disclosures: Drs. Baile, Fromme, Levin, Norris and Wagner report no relevant disclosures.
Should all patients with cancer be screened for distress?
Yes, because patients do not always volunteer this information.
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All cancer patients should be screened for distress. Patients often don’t volunteer their concerns about their psychosocial needs, and they often think their physicians or nurses are not concerned about such issues. They only report the most pressing things, so if you wait for a patient to volunteer that they are having concerns or problems, you will not hear about them. Unless you systematically ask patients — and let them know you are concerned and would like to help — it may not be evident that patients are distressed.
There are a lot of self-report tools and questionnaires to use in this setting. This is an issue that comes up in primary care, where depression screening is an important issue. Patients with advanced cancer — who have more physical limitations — and patients experiencing more side effects of the disease are going to be at high risk for depression. You either can ask a few questions or have them fill out a questionnaire such as the Distress Thermometer or the PHQ-9 depression screener. Patients can complete these while waiting to see their physician. Someone on the team needs to review what the patient has indicated on that questionnaire and then address their concerns.
When patients screen positive for distress, the next step depends on what issues are identified. The distress may be related to many different things, and the strategy that needs to be taken depends on what the concern is. For example, not being able to take care of their children or not being able to take care of other loved ones would lead to a different intervention than uncontrolled pain. It depends on what is leading to distress. The patient may need to see a mental health professional who is on the team. These questionnaires are for screening, and then someone on the team has to follow through.
Patricia Ganz, MD, is director of cancer prevention and control at Jonsson Comprehensive Cancer Center at UCLA, and professor of medicine and public health at UCLA. Dr. Ganz reports no relevant financial disclosures.
Screening for distress encompasses more than screening for depression.
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Screening for depression is different than screening for distress. Often, the people who advocate for screening for depression are advocating for a very specific kind of assessment for a specific symptom related to cancer. When screening for distress, health care professionals should really look at multiple factors — such as physical, psychological, social and financial issues — that present themselves to patients as they go through their cancer journey.
Distress, as defined by the National Comprehensive Cancer Network, encompasses a full range of potential concerns that might contribute to depression. Depression doesn’t often exist in isolation. It may be a consequence of multiple physical, social, psychological and financial concerns.
The cancer patient experience is complex. A number of concerns are raised, and these concerns contribute to what we call a symptom cluster. To just focus on depression may miss contributing patient issues that we should address. The most prevalent feelings of distress include untreated pain, fatigue, weight loss, and other practical and emotional concerns.
If we focus on depression alone, we might be missing many of the key indicators of where we could easily intervene to improve the quality of life for our patients.
Screening for distress is a simple way to better understand the more complete patient experience. It helps identify major concerns, whether they are physical, practical or psychological. The screening should be done by the oncologist, a social worker, a psychologist or a nurse.
In cancer care, distress has been widely endorsed as the sixth vital sign, thus calling for its routine monitoring. Screening for distress should be part of the entire patient care package.
Barry Bultz, PhD, is program leader of psychosocial oncology, supportive, pain and palliative care at the Tom Baker Cancer Centre and adjunct professor of medicine at the University of Calgary in Alberta, Canada. Dr. Bultz reports no relevant financial disclosures.