You are on page 1of 4

symposium article Annals of Oncology 23 (Supplement 10): x302x305, 2012


Psychological aspects of depression in cancer

patients: an update
M. Die Trill*
Psycho-Oncology Unit, Hospital Universitario Gregorio Maran, Madrid, Spain

Key words: antidepressants, cancer, depression, (differential) diagnosis, psychotherapy, symptoms

Depression and disorders of the depressive spectrum pancreatic, head and neck), presence of physical symptoms
frequently remain underdiagnosed and undertreated in the from cancer, such as pain, especially if not well controlled;
cancer setting, despite their prevalence and the degree of history of multiple losses; previous psychiatric disorders,

Downloaded from by guest on October 28, 2013

suffering they impose on cancer patients. Initial shock, disbelief especially episodes of depression or suicide attempts; history of
and denial are frequent upon conrmation of the cancer substance abuse and others.
diagnosis. Generally, they begin to resolve within a few weeks Psychological factors that may also inuence the
as the patient receives support from family, friends and beliefs appearance of depression or depressive symptoms in the
in addition to the support and outline provided by the medical oncology setting include but are not limited to the following:
oncologist, of a treatment plan that offers hope and reduces loss of autonomy; confrontation with death and dying; fear of
part of the uncertainty that is so difcult to deal with in suffering; death of other patients; reaction of family members
oncology. However, multiple losses throughout the disease to the illness; presence of unresolved issues; pre-existing

process, beginning with the loss of ones own health (followed family conict; personality factors such as pessimism and a

by loss of body image, professional role, family roles, social tendency to consider life experiences as uncontrollable and
roles, etc.) result in grief reactions and sadness that often inevitable.
accompany the cancer patient throughout the disease process. Ideally, all cancer patients be screened for depression in the
It is not uncommon, therefore, for depressed patients to feel clinic upon their rst visit and on a regular basis thereafter by
depressed or sad at diagnosis, during treatment administration their oncologist, especially when changes occur in their disease
(due to toxicity, physical limitations, loss of body functions, status (remission, recurrence, progression of disease etc.). The
changes in physical appearance, etc.); during remission and distress thermometer is a valid and reliable screening tool.
survival (e.g. due to fear of not receiving treatment that may Patients are asked about the nature and source of their distress
keep the disease from reappearing, or due to inability to (whether it be physical, social, psychological or spiritual). In
conduct life activities prior to diagnosis, among others); and addition to detecting distress, the thermometer facilitates
during disease progression and palliative care (due to physical referral to the appropriate professional working in the oncology
deterioration, confrontation with complex life and death issues, team (mental health, social work, pastoral counselor, etc.) [2].
etc.). Depressive symptoms may, therefore, persist over time Diagnosis of depression in physically healthy individuals
requiring specialized attention. relies heavily on the presence of somatic symptoms (anorexia,
Depression is among the leading causes of disability insomnia and weight loss). However, these are of little value in
worldwide, leading in some cases, to suicide. Reported cancer patients since they are common to both cancer and
prevalence rates of depression among cancer patients can be as depression. Four different approaches have been described in
high as 38% for major depression and 58% for depression the assessment of depression in the medically ill [3, 4]:
spectrum syndromes [1]. Differences in reported prevalence
Inclusive approach: counts all symptoms of depression,
rates are due to differences in assessment methods, as well as
whether or not they may be secondary to the physical illness.
differences in stage and tumor site, among others.
This approach offers high sensitivity but low specicity and
Risk factors for developing depressive symptoms or
does not focus on etiology.
disorders in cancer patients include young age, social isolation
Etiologic approach: This approach counts a depressive
and lack of social support, poverty, previous negative
symptom only if it is presumed not secondary to physical
experience with the disease in the family or personal
experiences of physical illness, recurrence and advanced
Exclusive approach: Eliminates symptoms such as anorexia
disease, physical deterioration, tumor location (lung,
and fatigue, which can be secondary to cancer, and employs
other depression criteria. This approach increases specicity
*Correspondence to: Dr M. Die Trill, Coordinator, Psycho-Oncology Unit, Hospital and lowers sensitivity which may result in lower prevalence
Universitario Gregorio Maran, Madrid, Spain. Tel: +34-91-586-6736; fax: +34-91-
563-1428; E-mail:
and underdiagnosis.

The Author 2012. Published by Oxford University Press on behalf of the European Society for Medical Oncology.
All rights reserved. For permissions, please email:
Annals of Oncology symposium article
Substitutive approach: Replaces indeterminate symptoms Demoralization syndrome, described by Kissane et al. [7],
such as fatigue (frequently secondary to physical illness) should be distinguished from depression and includes affective
with cognitive symptoms such as indecisiveness, brooding symptoms of existential distress (hopelessness or loss of
and hopelessness. meaning in life); pessimism, helplessness, a sense of being
trapped, personal failure or lacking a worthwhile future;
Criteria for the diagnosis of a major depressive disorder absence of motivation to cope differently, and associated
based on the Diagnostic and Statistical Manual of Mental features of social alienation or isolation and lack of support.
Disorders [5] include: Demoralization syndrome is said to occur in at least 20% of
patients who do not meet DSM-IV criteria for the diagnosis of
Five or more of the following symptoms have been present a mental disorder [8].
during the same 2-week period and represent a change from Boredom in people with cancer has received little attention
previous functioning, with at least one of the symptoms being despite clinical observation, suggesting that it has the potential
either depressed mood or loss of interest or pleasure: to affect patients quality of life signicantly. Passik et al. [9]
developed a Purposelessness, Understimulation and Boredom
Scale to identify boredom and found this construct to be
1. Depressed mood most of the day, nearly every day, as
different from depression in the oncology setting.
indicated by either subjective report or observations by
Multiple psychological measurement instruments have been
described as useful in the diagnosis of depression in cancer
2. Markedly diminished interest or pleasure in all or almost all
patients. However, a single-item question: Have you been
activities, most of the day, nearly every day
depressed, most of the day, nearly every day, for the past two
3. Signicant weight loss when not dieting or weight gain, or
weeks or more? seems to be able to identify all cancer
decrease or increase in appetite nearly every day
patients diagnosed as depressed using Research Diagnostic
4. Insomnia or hypersomnia nearly every day
Criteria [10].
5. Psychomotor agitation or retardation nearly every day
Suicide is associated with emotional suffering and, at times,
6. Fatigue or loss of energy nearly every day
with physical disease. Suicide has been reported to be 1.52
7. Feelings of worthlessness or excessive or inappropriate guilt
times higher in cancer patients than in the general population
nearly every day
[11]. Among terminally ill patients with cancer, the request for
8. Diminished ability to think or concentrate, or
euthanasia is about four times higher in patients with
indecisiveness, nearly every day, and
depression than in those without depression [12]. In addition,
9. Recurrent thoughts of death, recurrent suicidal ideation
desire for death in terminally ill cancer patients is frequent. It
without a specic plan, or a suicide attempt or a specic
has been shown to be associated with depression and is
plan for committing suicide.
transitory [13]. Suicide risk protocols should include an
evaluation of thoughts about death, dying and suicide, as
In addition, the symptoms do not meet criteria for a mixed well as an evaluation of the presence of a plan to commit
episode; they cause clinically signicant distress or impairment suicide, the patients intention to carry out such plan and its
in social, occupational or other important areas of functioning; viability.
they are not due to the direct physiological effects of a An association between depression and an increase in pro-
substance; they are not better accounted for by bereavement; inammatory cytokines (e.g. interleukin-1, interleukin-6 and
they persist for longer than 2 months or are characterized by tumor necrosis factor alpha) has been described. Cancer itself
marked functional impairment, morbid preoccupation with and its treatment (medications and surgery) in general can be
worthlessness, suicidal ideation, psychotic symptoms or responsible, together with the individual stress response, for
psychomotor retardation. the production of pro-inammatory cytokines which may
The diagnosis of depression in the oncology setting should contribute to the development of depressive symptoms [14].
depend on psychological not somatic symptoms, in cancer Depression and depressive symptoms should always be
patients [6]: treated in the cancer setting. Because sadness and depressive
Dysphoric mood symptoms are considered to be normal reactions to the
Feelings of helplessness and hopelessness disease and its treatment, quite frequently they remain
Loss of self-esteem undertreated. They tend to be a manifestation or consequence
Feelings of worthlessness or guilt of emotional suffering. Not treating them will trivialize the
Anhedonia patients suffering associated with the disease and death.
Thoughts of death or wishing for death or suicide Adequate treatment of depression in the oncology setting
should combine the control or elimination of potential organic
Differential diagnosis should include normal reactions to causes of depression when possible; pharmacotherapy;
illness and loss; adjustment disorders with depressed and/or psychotherapy and psychological intervention with the
anxious mood, and should determine whether organic factors patients families and staff members. Efcient communication
underlie the depressive syndrome. When physiologic effects of skills between doctor and patient are needed as well.
cancer directly cause depressive syndromes, a diagnosis of The choice of the best psychotropic drug for the
mood disorder due to a general medical condition should be pharmacological treatment of depression in cancer will depend
made. on various factors [14]:

Volume 23 | Supplement 10 | September 2012 doi:10.1093/annonc/mds350 | x

symposium article Annals of Oncology

Which is the safest drug or which has the fewest side-effects provide options to patient. For example, giving him the
for the cancer patient possibility of choosing whether he wants to have his
What the characteristics of the depressive episode are, and medication with water, milk or juice helps the patient believe
Which is the best way of administration for a particular he still has the power to decide over what is happening to
patient ( pills versus liquid versus parenteral). him, especially at times when the patient is hospitalized and
his hospital days revolve around medication intake, doctor
General guidelines for the use of antidepressants in the and nurses visits, medical tests, etc.
cancer setting have been described [14] and include: anticipate patients needs. This will help him feel more in
Starting the dose according to patients condition (usually control of what may happen to him and will reduce fear and
half dose for a few days, then titrate) distress upon the development of new symptoms or changes
Waiting for the effects of the drugs (latency: usually 4 weeks) in the patients body, functions, etc.
Providing continued treatment for 69 months (more if facilitate adaptive coping mechanisms, for example, by
depression or depressive episode are recurrent) identifying with the patient effective ways in which he/she
Discontinuing antidepressant treatment gradually by has confronted and resolved difculties encountered in the
tapering the dose and providing adequate follow-up past
Monitoring symptoms on a continued basis to watch for respect defense mechanisms as long as they do not interfere
potential drug interactions that may occur between with treatment administration
antidepressants and certain chemotherapeutic agents normalize patients feelings
help maintain realistic hope: Even in the context of palliative
Psychotherapy may be an excellent alternative for those who care can hope be maintained. For example, a non-depressed
refuse taking antidepressants. In addition, it has no side effects! dying patient may hope to die without suffering, or after
As with antidepressants, it is necessary to adjust the having solved certain issues, or he may hope that his family
psychotherapeutic modality to patients needs and disease will not suffer in excess after his death.
stage. Psycho-educational interventions such as clarifying remain available to listen to patients worries and fears
information, among others, are effective usually throughout the explain to patient and family that depressive symptoms can
disease continuum, although may be more needed at diagnosis, be treated
when passing from one stage of the illness to another, for provide continuity in patient care
example, initiation and end of treatment; upon starting monitor patients sense of wellbeing and needs in a continued
palliative care, etc. Couple and Family Therapies may be manner along the disease continuum, since they change over
appropriate when conicting relationships within the couple or time
the family contribute substantially or are the main cause of the work with the family: provide basic caretaking guidelines and
patients depressive symptoms. Cognitive techniques may be support for family members. Facilitate their understanding
useful in correcting misconceptions and exacerbated fears. of what depression is and why the patient may be depressed.
Interventions directed to enhance the spiritual aspects in It may be difcult for family members to comprehend,
advanced disease and dying are of utmost importance at this for example, why the patient develops depressive
stage of the illness, when patients are confronted with life- symptomatology upon nishing his treatment.
death issues that generally imply deep existential questioning explore ones own attitudes towards illness, suffering, death
[15]. Helping patients discover the meaning they assign to and dying
their symptoms, to their disease, to life and death, to suffering, inform adequately: staff members should have efcient
etc., and helping them accept suffering as an integral part of training in communication skills as to be able to handle
life, is of utmost importance. Finding meaning in the context difcult interactions with patients at complex moments of the
of advanced or serious illness is quite a challenge that not disease process. Adequate doctorpatient communication will:
everyone is capable of achieving. In addition, interventions
designed to maintain patients dignity have been described as reduce patients fears and anxiety,
well and are very helpful in improving patients mood [16]. help patient understand and elaborate relevant medical
Multidimensional structured and semi-structured group information,
psychotherapies have proven to be effective in reducing increase patients perception of control,
patients depressive symptomatology and improving their allow the patient to discuss relevant worries that may
quality of life [1719]. interfere with treatment administration, with the
Staff play an important role in the improvement of oncologist,
depressive symptoms in the cancer patient. Staff should be enhance treatment adherence,
trained to provide basic emotional support effectively as well as facilitate patients global psychological adjustment.
to communicate efciently with the patient and his/her family. A six-step protocol to deliver bad news and improve doctor
Some simple interventions staff may easily implement are patient communication (SPIKES) has been described [20] and
related to increasing the patients perception of control. Cancer includes the following:
inuences the patient in such a way that it substantially
reduces the perception of control that the patient has over his S Setting: prepare an adequate environment. This may be
own life. In order to help patients regain their sense of control achieved by providing privacy, involving signicant others,
staff members may: establishing rapport with patient, etc.

x | Die Trill Volume 23 | Supplement 10 | September 2012

Annals of Oncology symposium article
P Perception: ask yourself How does the patient perceive his 5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental
medical situation?. And, Before you tell, ask (for example, Disorders, 4th edition, text revision. Arlington, VA: American Psychiatric
Association 2000.
What do you suspect your symptoms are due to?).
6. Massie MJ, Holland J. Overview of normal reactions and prevalence of
I Invitation: obtain patients invitation to deliver medical
psychiatric disorders. In Holland J, Rowland J (ed), Handbook of Psycho-
information. How would you like me to give you your test Oncology: Psychological Care of the Patient with Cancer. New York: Oxford
results? could be a good way to start. University Press 1989; 273282.
K Knowledge: deliver the medical information: I am sorry to 7. Kissane DW, Clarke DM, Street AF. Demoralization syndrome: a
tell you that your test results have revealed . relevant psychiatric diagnosis for palliative care. J Palliat Care 2001; 17:
E Empathizing and Exploring: assess the patients emotions 1221.
using empathetic responses, for example I understand this 8. Grassi L, Holland J, Johansen C et al. Psychiatric concomitants of cancer
must be very difcult for you at this time of your life. screening procedures, and training of health care professionals in oncology: the
paradigms of psycho-oncology in the psychiatry eld. Adv Psychiatr 2005; 2:
S Strategy and Summary: Describe strategy/follow-up and
summarize the interview making sure that the patient has
9. Passik S, Inman A, Kirsch K et al. Initial validation of a scale to measure
understood the information provided. purposelessness, understimulation and boredom in cancer patients. Palliat
Support Care 2003; 1: 4150.
This educational workshop will focus on the diagnosis and
10. Chochinov HM, Wilson KG, Enns M. Are you depressed? Screening for
treatment of depressive disorders in cancer patients. Diagnostic depression in the terminally ill. AM J Psychiatry 1997; 154: 674676.
criteria for depression and for suicide risk as well as 11. Hem E, Loge JH, Haldorsen T et al. Suicide risk in cancer patients from 1960 to
psychotherapeutic guidelines to treat depression effectively will 1999. J Clin Oncol 2004; 22: 42094216.
be provided. Theoretical aspects of the different topics covered 12. Van der Lee ML, van der Bom JG et al. Euthanasia and depression: a
will be illustrated with case vignettes and brief video sketches. prospective cohort study among terminally ill cancer patients. J Clin Oncol 2005;
In summary, depression is frequent in the cancer setting and 23: 66076612.
should receive adequate attention from professionals. As with 13. Chochinov HM, Wilson KG, Enns M et al. Desire for death in the terminally ill.
other illnesses, its correct although sometimes difcult Am J Psychiatry 1995; 152: 11851191.
14. Riba M, Grassi L. WPA Educational Programme on Depressive Disorders,
diagnosis in oncology will allow the design of interventions
Vol. 2. Physical Illness and Depression Disorders in Physical Illness. Chne-
tailored to address patient needs, intensity of symptoms and Bourg, Switzerland: World Psychiatric Association 2008; 7387.
others. Treatment of depression should not be targeted to the 15. Breitbart W. Spirituality and meaning in supportive care: spirituality and meaning-
patient only but should include family and oncology staff centered group psychotherapy interventions in advanced cancer. Support Care
members as well. Cancer 2002; 10(4): 272280.
16. Chochinov HM, Hack T, Hassard T et al. Dignity therapy: a novel
psychotherapeutic intervention for patients near the end of life. J Clin Oncol
disclosure 2005; 23(24): 55205525.
The author has declared no conicts of interest. 17. Spiegel D, Spira J. Supportive Expressive Group Therapy: a Treatment Manual of
Psychosocial Intervention for Woman with Recurrent Breast Cancer. Palo Alto,
CA: Psychosocial Treatment Laboratory, Stanford University School of Medicine
references 1991.
18. Kissane DW, Love A, Hatton A et al. The effect of cognitive-existential group
1. Massie MJ. Prevalence of depression in patients with cancer. J Natl Cancer Inst
psychotherapy on survival in early stage breast cancer. J Clin Oncol 2004; 22
Monogr 2004; 32: 5771.
(21): 42554260.
2. Holland J, Bultz B. The NCCN guideline for distress management: a case for
19. Fawzy FI, Fawzy N, Hyun CS et al. Malignant melanoma: effects of an early
making distress the sixth vital sign. J Natl Compr Canc Netw 2007; 5: 37.
structured psychiatric intervention, coping and affective state on recurrence and
3. Cohen-Cole SA, Brown FN, McDaniel JS. Diagnostic assessment of depression in survival 6 years later. Arch General Psychiatr 1993; 50(9): 681689.
the medically ill. In Stoudmire A, Fogel B (eds), Psychiatric Care of the Medical
20. Baile WF, Buckman R, Lenzi R et al. SIKESa six-step protocol for
Patient. New York: Oxford University Press 1993; 5370.
delivering bad news: application to the patient with cancer. Oncologist 2000; 5:
4. Endicott J. Measurement of depression in patients with cancer. Cancer 1984; 302311.
53: 22432249.

Volume 23 | Supplement 10 | September 2012 doi:10.1093/annonc/mds350 | x