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Table of contents
1. Depression Management in Cancer Patients............................................................................................... 1

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Document 1 of 1

Depression Management in Cancer Patients

Author: Kathleen Ell, DSW and Brenda Quon, MD
ProQuest document link
Abstract (Abstract): Persons with cancer are underserved with respect to receipt of current guideline-level care
for major depression. We agree with [Williams] and Dale41 that patients should not be denied treatment for
depression while the efforts to find further evidence of its effectiveness progress. Psychiatrists, as specialty
medical consultants, can play a vital role in advocating optimal mental health care for medically ill cancer patient
with depression.
Full text: Depressive disorders and symptoms are common in cancer patients (up to 58% have depressive
symptoms and up to 38% have major depression),1-3 worsen over the course of cancer treatment, persist long
after cancer therapy,4 recur with the recurrence of cancer,5 and significantly impact quality of life.6-9
Depressive symptom prevalence varies by cancer site, stage, and treatment, as well as by the methods and
criteria used in assessing depression.
Unfortunately, clinicians and patients often perceive depression as an expected and reasonable reaction to
cancer; as a result, depression is frequently underrecognized and undertreated in oncology practice.10-15
Failure to effectively manage depressive symptoms results from patient, provider, and health system barriers to
care. Patients may be reluctant to report symptoms or to see a mental health professional and if treatment is
prescribed, they may be nonadherent, citing concerns about side effects and/or preoccupation with active
cancer treatment. Providers may be reluctant to raise the issue, be less aware of effective treatment, and/or
lack access to mental health professionals.
It is not surprising that low-income patients are particularly unlikely to receive mental health treatment.16,17 In
addition, culturally based preferences for depression care can become a barrier if the preferred mode of care is
not available.18 Personal culturally based explanations for depressive symptoms may influence symptom
expression and patient-provider communication.19-21 Finally, patient perceptions of bias and cultural
competence in health care, family perceptions, and practical barriers, such as cost and transportation to
therapy, may impede receipt of care.22,23
ASSESSING DEPRESSION AND RELATED SYMPTOMS
Establishing a diagnosis of clinical depression among cancer patients is confounded by biologic and physical
symptoms as well as psychological stress attributable to the disease or its treatment.24-27 Cancer and its
treatment-related symptoms (fatigue, anorexia, sleep disturbance, and pain) can mask a depression or
contribute to its development and persistence.
Difficulty in differentiating the symptoms of depression from those of the medical illness makes the identification
and treatment of patients with depression challenging. Indeed, there has been discussion that the presence of
depression in medical illnesses such as cancer represents a broader pathophysiologic syndrome known as
"sickness syndrome," a behavior or group of symptoms occurring under chronic immune stimulation.28
Assessment of depression should include discussion about common symptoms experienced by patients as well
as general distress management,29 and these discussions should continue over the duration of the illness. In
fact, a clinical perspective of comorbid cancer and depression is best understood in relation to a staged
trajectory of illness from diagnosis to treatment to chronic illness management or "cancer survivorship." Cancer
survivorship is a term that has come to represent the state or process of living, following a diagnosis of cancer,
regardless of how long a person lives. Thus, treating the patient for depression may be indicated at any stage in
the illness trajectory.
The National Cancer Institute (NCI) Web site advises clinicians that "evaluation of depression in people with
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cancer should also include a careful assessment of the person's perception of the illness, medical history,
personal or family history of depression or thoughts of suicide, current mental status, and physical status, as
well as treatment and disease effects, concurrent life stressors, and availability of social supports. . . . Suicidal
statements may range from an offhand comment resulting from frustration or disgust with a treatment course: 'If
I have to have one more bone marrow aspiration this year, I'll jump out the window,' to a reflection of significant
despair and an emergent situation: 'I can no longer bear what this disease is doing to all of us, and I am going
to kill myself.' Exploring the seriousness of the thoughts is imperative."30
Based on our experience, we would add that it is important to assess potential cultural differences in the
patient's personal conceptions of both depression and cancer. For example, many of our Hispanic patients
attribute the etiology of depression to life stresses and to cancer-related stress in particular. They also prefer
psychotherapy to medication and express the belief that stress can make the cancer worse.
BIOLOGIC CONSIDERATIONS
The precise physiologic links between depression and cancer are unknown, although various hypotheses have
been discussed in the literature. One of those is dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis.
Hyperactivity of the HPA axis is manifested in increased urinary free cortisol levels, dexamethasone
nonsuppression, blunted corticotropin response to corticotropin-releasing factor (CRF), increased cerebrospinal
fluid CRF concentrations, and adrenal and pituitary hypertrophy.28 Diagnostic findings such as these have been
reported in depressed patients with and without cancer.
A few studies have demonstrated that many cancer patients have dysregulation of the HPA axis similar to that
of depressed patients without cancer. Evans and colleagues31 found that 40% of their female patients with
depression exhibited dexamethasone nonsuppression. However, the small number of studies as well as the
limited number of patients studied precludes final determination of the clinical usefulness of dexamethasone
suppression testing for all cancer patients with depression.
Several investigators have examined the relationship between HPA axis hyperactivity and immune dysfunction
in medically ill cancer patients. Cytokines-hormones that are secreted by cells of the immune system and that
act as inflammatory mediators-have been shown to affect neurotransmitter function, neuroendocrine function,
and behavior.19 Stress-induced cytokine release or HPA hyperactivity in patients with cancer may cause
changes in immunologic function. Proinflammatory cytokines such as interleukin-1, interleukin-6, and tumor
necrosis factor can activate the HPA axis, as well as change the metabolism of neurotransmitters such as
norepinephrine, serotonin, and dopamine.32 These neuroendocrine and immunologic effects can contribute to
the presentation of depressed mood, fatigue, anorexia, pain, or sickness syndrome. Future research in this field
has implications not only for diagnosis but more important, for therapy.
MANAGING DEPRESSION
A broad range of psychosocial and psychological interventions have been reported to aid in reducing
depression and accompanying anxiety, enhancing coping skills, and improving quality of life in patients with
cancer.33-37 In general, more convincing effects are found for patients screened at baseline36,38; however,
few studies have targeted patients with depressive disorders,39 and because the majority of studies have been
of white women,40 the evidence is relatively weak for other populations.
Pharmacotherapy
A systematic review by Williams and Dale41 of 24 randomized controlled trials of either pharmacologic or
psychotherapeutic interventions for cancer patients with depression or depressive symptoms recently concluded
that depression in cancer patients is responsive to antidepressant medication treatment, although some studies
reported high dropout rates and some failed to report adverse events or tolerability. For example, paroxetine
was useful in reducing major depression in patients with malignant melanoma who were receiving high-dose
interferon alpha treatment42 and in reducing depressive symptoms in patients with breast cancer who were
undergoing chemotherapy.43 In a trial by Fisch and colleagues,44 fluoxetine was effective in reducing
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depressive symptoms in patients with solid tumors.

Other studies not analyzed by Williams and Dale report that the tetracyclic antidepressant mianserin reduced
depressive symptoms in patients with breast cancer and that tricyclic antidepressants such as amitriptyline and
desipramine are also useful in the treatment of depression in cancer.45,46 An open-label study of mirtazapine
in cancer patients with depression showed improved functionality and reduced depressive and anorexic
symptoms.47 The tolerability of the above antidepressants appears to be generally good in patients with cancer.
Patients may experience adverse effects, but such effects may be complicated by treatment of the cancer itself.
As already suggested, it is important to consider the treatment implications of simultaneously managing
depression and pain and fatigue in patients with cancer using a variety of evidence-based
interventions.24,48,49 In addition to alleviating symptoms of depression, antidepressant medications may
provide relief of related cancer symptoms. For example, fluoxetine, paroxetine, and venlafaxine have been
effective in reducing hot flashes in patients with cancer.50-52 Patients may have neuropathic pain from the
cancer or the treatments, and bupropion, the tricyclic antidepressants, and venlafaxine have
demonstrated the ability to reduce neuropathic pain.53-55 Avoiding significant drug interactions in patients on
complex chemotherapeutic and pain management regimens requires careful monitoring.26,56 The NCI Web
site provides detailed pharmacologic treatment algorithms that are consistent with current knowledge.
Psychotherapy
There is growing consensus that structured psychotherapy, alone or combined with antidepressant treatment, is
effective in treating depression.57 Under some circumstances, it is the treatment of choice (ie, when preferred
by individual patients, when pharmacologic treatments are contraindicated, and for patients coping with low
social support or environmental stressors; or for maintenance after discontinuation of antidepressant
medication). Clinical benefits from psychotherapy should be evident within 6 to 8 weeks. Medications should be
considered for patients who fail to improve by that time and for those who do not have full remission after 12
weeks of psychotherapy. Structured psychosocial therapies are as effective as antidepressants for moderate
depression and may be more effective in reducing recurrence.58
In a report based on their systematic review of the literature on psychotherapeutic interventions for people with
cancer, Williams and Dale41 concluded that cognitive-behavioral therapy (CBT) appears to be effective, as
does social support, in reducing depressive symptoms. CBT challenges pessimistic or self-critical thoughts,
emphasizes rewarding activities, and decreases behavior that reinforces depression. Alternative modes of
delivery of CBT have been explored, including group CBT and telephone or computer self-help formats.59
Problem-solving therapy (PST) uses behavior activation components of CBT but with less emphasis on
changing cognition and greater emphasis on patient assessment of personal contextual problems and skillbuilding to enhance self-management skills.60 PST adapted for primary care in the multicenter IMPACT
study61 was found to significantly reduce depressive symptoms in older primary care patients, including African
American and Hispanic patients, with major depression or dysthymia,57 and PST was found effective in
reducing depressive symptoms in patients with cancer.15,60,62-65 The brief psychoeducational characteristics
of PST make it feasible to provide and acceptable to patients with a wide range of educational levels. PST is
available in published treatment manuals for depression and for coping with cancer. According to the PST
theoretical framework, experiencing negative life events (such as cancer) can lead to the occurrence of a wide
range of daily problems that are believed to be sources of stress that trigger depressive symptoms. Increasing
problem-solving skills has been shown to reduce depressive symptoms.
REDUCING BARRIERS AND IMPROVING ADHERENCE
Quality-improvement strategies have been shown to be effective in reducing barriers to depression care.66
Organizational strategies generally include multifaceted quality-improvement disease-management
interventions that change the way in which depression care is delivered, such as the implementation of routine
depression screening, systematic application of evidence-based practice guidelines, clinical decision-making
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protocols and algorithms (cancer-specific algorithms available on the NCI and National Comprehensive Cancer
Network Web sites29,30), follow-up through remission and maintenance, enhanced roles of nurses or social
workers as depression care managers, as well as integration between primary care and mental health
specialists or service systems.67
Depression care models that use collaboration between primary care physicians and mental health
professionals, in which expertise in psychopharmacology in treating depression is provided by a psychiatrist and
PST and supportive care management is provided by depression specialist nurses or social workers, has been
found to be effective in primary care.57 A model adapted for oncology was found to be effective in a pilot study
that included 55 low-income Hispanic patients with breast or cervical cancer, all of whom met criteria for major
depression.68 The patients were randomized to either intervention or usual care and results suggested that
cancer patients in public sector oncology clinics can benefit from depression treatment. A full-scale trial
consisting of 425 low-income ethnic minority patients with cancer is currently under way using this model.
Collaborative interventions have also been found to improve patient adherence and prevent relapse.69
Persons with cancer are underserved with respect to receipt of current guideline-level care for major
depression. We agree with Williams and Dale41 that patients should not be denied treatment for depression
while the efforts to find further evidence of its effectiveness progress. Psychiatrists, as specialty medical
consultants, can play a vital role in advocating optimal mental health care for medically ill cancer patient with
depression. For psychiatrists treating patients with depression and cancer, it is imperative that the symptoms of
depression are identified and that the goal of treatment is remission of depressive symptoms via the modalities
mentioned previously. Psychiatrists with medical understanding of the biologic correlations between depression
and cancer are in a good position to advocate effective treatment of the patient's comorbid medical conditions.
These can include pain and the adverse effects of medical treatments for cancer that can contribute to the
patient's experience of depression. In doing so, the patient's psychiatric and medical responses to both
depression and cancer treatments may be optimized.
Dr Ell is the Ernest P. Larson Professor of Poverty, Ethnicity, and Health at the School of Social Work of the
University of Southern California in Los Angeles. Dr Quon is assistant professor of clinical psychiatry at the
Keck School of Medicine
of the University of Southern California in Los Angeles. They report that they have no conflicts of interest with
the subject matter of this article.
Drugs Mentioned in This Article
Amitriptyline (Elavil, Endep)
Bupropion (Wellbutrin)
Desipramine (Norpramin, Pertofrane)
Fluoxetine (Prozac)
Mianserin (Bolvidon, Norval, Tolvan [not available in the United States])
Mirtazapine (Remeron)
Paroxetine (Paxil)
Venlafaxine (Effexor)
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http://www.psychiatrictimes.com/
Copyright 2006 CMP Media LLC. All rights reserved.
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Subject: Mental depression; Cancer; Disease management; Psychiatry; Psychotherapy; Drug therapy;
Publication title: Psychiatric Times
Volume: 23
Issue: 11
Pages: 25
Number of pages: 0
Publication year: 2006
Publication date: Oct 2006
Year: 2006
Section: Special Report DEPRESSION
Publisher: UBM LLC
Place of publication: Manhasset
Country of publication: United States
Publication subject: Medical Sciences--Psychiatry And Neurology
ISSN: 08932905
Source type: Trade Journals
Language of publication: English
Document type: Feature
Document feature: References
ProQuest document ID: 204567628
Document URL: http://search.proquest.com/docview/204567628?accountid=38628
Copyright: (Copyright 2006 CMP Media LLC. All rights reserved.)
Last updated: 2013-06-15
Database: ProQuest Nursing & Allied Health Source

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