Recognizing and treating depression in your patients with cancer

The prevalence rates of depressive disorders in oncology vary widely depending on the time and stage of cancer, patient population (sex, age), social support available, diagnostic criteria applied and method of assessment. Ranges of the prevalence of depression mentioned in the literature are from 1% to 42%.

Patients with cancer may present with a variety of depression-related symptoms. Psychological features such as sadness, anhedonia, hopelessness, helplessness, low self-esteem, guilt feelings and suicidal ideations are more relevant than somatic symptoms such as anorexia, fatigue and weight loss.

Cancer-related risk factors for developing depression are:

• Depression at time of cancer diagnosis.
• Poorly controlled pain.
• Advanced stage of cancer.
• Increased physical impairment or pain.
• Pancreatic cancer.
• Being unmarried and having head and neck cancer.

Noncancer-related risk factors for developing depression are:

• History of depression.
• Lack of family support.
• Life stressors.
• Family history of depression.
• Previous suicide attempts.
• History of alcoholism or drug abuse.

Depressive disorders in cancer patients increase the risk of relapse after treatment, decrease the compliance for antineoplastic therapy and may also constitute an independent risk factor for increased mortality.

Screening methods

To date, there is no proven screening method to diagnose depression in cancer patients. Simply asking a patient if he is depressed is often times insufficient; society still places a social stigma on mental illness, and a patient may be reluctant to admit to feeling depressed. In addition, there is a normal amount of sad feeling associated with a diagnosis of cancer.

Many of the somatic criteria in the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision (DSM-IV-TR) for the diagnosis of depression are common symptoms experienced by individuals with cancer who are not depressed.

Christine A. Zawistowski

A few of the subjective self-reporting tools are accurate screening tools for depression in cancer patients. For example, the Hamilton Rating Scale for Depression (HRSD) has a sensitivity of 81.3% and a specificity of 87.5%; the Brief Edinburgh Depression Scale (BEDS) has a sensitivity of 72% and a specificity of 83%.

The Hospital Anxiety and Depression Scale has also been found to be a reliable instrument to detect states of depression in cancer patients.

Another approach is to assess a patient’s social interactions with family and friends and listen to subtle remarks made by the patient or family member. If one of the screening tools is positive or depression is suspected based on subtle remarks, a comprehensive psychiatric evaluation is warranted.

Treatment

Treatment of depression in cancer patients requires focus on appropriate diagnosis, effective treatment and recovery factors that are patient specific. A combined model of pharmacological treatment and psychotherapy is recommended.

Two classes of antidepressants have proved most effective in treating cancer patients with depression. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac, Eli Lilly), have a favorable adverse-effect profile that does not worsen gastrointestinal symptoms such as delayed motility and constipation. These agents also are effective in the relief of chronic pain.

Dual-acting serotonin and norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine (Effexor, Wyeth) and duloxetine (Cymbalta, Eli Lilly), have shown improved efficacy in producing a full remission of symptoms in certain patients while maintaining a favorable adverse-effect profile and have the added benefit of being more effective than SSRIs in relieving pain.

Cognitive behavioral therapy is one of the gold standards for psychotherapeutic treatment of depression. It has been shown to be effective in reducing emotional distress and controlling physical symptoms in cancer patients. Cancer support groups, in addition to individual counseling, can be beneficial, and supportive counseling may also be necessary and/or helpful for immediate family members of the patient.

Depression can be a common problem for cancer patients. Recognition of risk factors and screening can help clinicians identify patients requiring referral. The mainstay of treatment is medication plus counseling. Newer antidepressant agents have favorable adverse-effect profiles and may also aid in treating the patient’s chronic pain. Appropriate treatment of depression can markedly improve the quality of life of patients with cancer.

Christine A. Zawistowski, MD, is an Assistant Professor of Pediatrics, Division of Critical Care at Mount Sinai Krevis Children’s Hospital, New York, N.Y.