symposium article
doi:10.1093/annonc/mds350
Psychological aspects of depression in cancer
patients: an update
M. Die Trill*
Psycho-Oncology Unit, Hospital Universitario Gregorio Marañón, Madrid, Spain
Key words: antidepressants, cancer, depression, (differential) diagnosis, psychotherapy, symptoms
Depression and disorders of the depressive spectrum
frequently remain underdiagnosed and undertreated in the
cancer setting, despite their prevalence and the degree of
suffering they impose on cancer patients. Initial shock, disbelief
and denial are frequent upon confirmation of the cancer
diagnosis. Generally, they begin to resolve within a few weeks
as the patient receives support from family, friends and beliefs
in addition to the support and outline provided by the medical
oncologist, of a treatment plan that offers hope and reduces
part of the uncertainty that is so difficult to deal with in
oncology. However, multiple losses throughout the disease
symposium
process, beginning with the loss of one’s own health (followed
article
by loss of body image, professional role, family roles, social
roles, etc.) result in grief reactions and sadness that often
accompany the cancer patient throughout the disease process.
It is not uncommon, therefore, for depressed patients to feel
depressed or sad at diagnosis, during treatment administration
(due to toxicity, physical limitations, loss of body functions,
changes in physical appearance, etc.); during remission and
survival (e.g. due to fear of not receiving treatment that may
keep the disease from reappearing, or due to inability to
conduct life activities prior to diagnosis, among others); and
during disease progression and palliative care (due to physical
deterioration, confrontation with complex life and death issues,
etc.). Depressive symptoms may, therefore, persist over time
requiring specialized attention.
Depression is among the leading causes of disability
worldwide, leading in some cases, to suicide. Reported
prevalence rates of depression among cancer patients can be as
high as 38% for major depression and 58% for depression
spectrum syndromes [1]. Differences in reported prevalence
rates are due to differences in assessment methods, as well as
differences in stage and tumor site, among others.
Risk factors for developing depressive symptoms or
disorders in cancer patients include young age, social isolation
and lack of social support, poverty, previous negative
experience with the disease in the family or personal
experiences of physical illness, recurrence and advanced
disease, physical deterioration, tumor location (lung,
*Correspondence to: Dr M. Die Trill, Coordinator, Psycho-Oncology Unit, Hospital
Universitario Gregorio Marañón, Madrid, Spain. Tel: +34-91-586-6736; fax: +34-91-
563-1428; E-mail: mdietrill@gmail.com.
© The Author 2012. Published by Oxford University Press on behalf of the European Society for Medical Oncology.
All rights reserved. For permissions, please email: journals.permissions@oup.com.
Annals of Oncology 23 (Supplement 10): x302–x305, 2012
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pancreatic, head and neck), presence of physical symptoms
from cancer, such as pain, especially if not well controlled;
history of multiple losses; previous psychiatric disorders,
especially episodes of depression or suicide attempts; history of
substance abuse and others.
Psychological factors that may also influence the
appearance of depression or depressive symptoms in the
oncology setting include but are not limited to the following:
loss of autonomy; confrontation with death and dying; fear of
suffering; death of other patients; reaction of family members
to the illness; presence of unresolved issues; pre-existing
family conflict; personality factors such as pessimism and a
tendency to consider life experiences as uncontrollable and
inevitable.
Ideally, all cancer patients be screened for depression in the
clinic upon their first visit and on a regular basis thereafter by
their oncologist, especially when changes occur in their disease
status (remission, recurrence, progression of disease etc.). The
distress thermometer is a valid and reliable screening tool.
Patients are asked about the nature and source of their distress
(whether it be physical, social, psychological or spiritual). In
addition to detecting distress, the thermometer facilitates
referral to the appropriate professional working in the oncology
team (mental health, social work, pastoral counselor, etc.) [2].
Diagnosis of depression in physically healthy individuals
relies heavily on the presence of somatic symptoms (anorexia,
insomnia and weight loss). However, these are of little value in
cancer patients since they are common to both cancer and
depression. Four different approaches have been described in
the assessment of depression in the medically ill [3, 4]:
• Inclusive approach: counts all symptoms of depression,
whether or not they may be secondary to the physical illness.
This approach offers high sensitivity but low specificity and
does not focus on etiology.
• Etiologic approach: This approach counts a depressive
symptom only if it is presumed not secondary to physical
illness.
• Exclusive approach: Eliminates symptoms such as anorexia
and fatigue, which can be secondary to cancer, and employs
other depression criteria. This approach increases specificity
and lowers sensitivity which may result in lower prevalence
and underdiagnosis.
Annals of Oncology
• Substitutive approach: Replaces indeterminate symptoms
such as fatigue (frequently secondary to physical illness)
with cognitive symptoms such as indecisiveness, brooding
and hopelessness.
Criteria for the diagnosis of a major depressive disorder
based on the Diagnostic and Statistical Manual of Mental
Disorders [5] include:
Five or more of the following symptoms have been present
during the same 2-week period and represent a change from
previous functioning, with at least one of the symptoms being
either depressed mood or loss of interest or pleasure:
1. Depressed mood most of the day, nearly every day, as
indicated by either subjective report or observations by
others
2. Markedly diminished interest or pleasure in all or almost all
activities, most of the day, nearly every day
3. Significant weight loss when not dieting or weight gain, or
decrease or increase in appetite nearly every day
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt
nearly every day
8. Diminished ability to think or concentrate, or
indecisiveness, nearly every day, and
9. Recurrent thoughts of death, recurrent suicidal ideation
without a specific plan, or a suicide attempt or a specific
plan for committing suicide.
In addition, the symptoms do not meet criteria for a mixed
episode; they cause clinically significant distress or impairment
in social, occupational or other important areas of functioning;
they are not due to the direct physiological effects of a
substance; they are not better accounted for by bereavement;
they persist for longer than 2 months or are characterized by
marked functional impairment, morbid preoccupation with
worthlessness, suicidal ideation, psychotic symptoms or
psychomotor retardation.
The diagnosis of depression in the oncology setting should
depend on psychological not somatic symptoms, in cancer
patients [6]:
• Dysphoric mood
• Feelings of helplessness and hopelessness
• Loss of self-esteem
• Feelings of worthlessness or guilt
• Anhedonia
• Thoughts of death or wishing for death or suicide
Differential diagnosis should include normal reactions to
illness and loss; adjustment disorders with depressed and/or
anxious mood, and should determine whether organic factors
underlie the depressive syndrome. When physiologic effects of
cancer directly cause depressive syndromes, a diagnosis of
mood disorder due to a general medical condition should be
made.
Volume 23 | Supplement 10 | September 2012
symposium article
Demoralization syndrome, described by Kissane et al. [7],
should be distinguished from depression and includes affective
symptoms of existential distress (hopelessness or loss of
meaning in life); pessimism, helplessness, a sense of being
trapped, personal failure or lacking a worthwhile future;
absence of motivation to cope differently, and associated
features of social alienation or isolation and lack of support.
Demoralization syndrome is said to occur in at least 20% of
patients who do not meet DSM-IV criteria for the diagnosis of
a mental disorder [8].
Boredom in people with cancer has received little attention
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despite clinical observation, suggesting that it has the potential
to affect patient’s quality of life significantly. Passik et al. [9]
developed a Purposelessness, Understimulation and Boredom
Scale to identify boredom and found this construct to be
different from depression in the oncology setting.
Multiple psychological measurement instruments have been
described as useful in the diagnosis of depression in cancer
patients. However, a single-item question: ‘Have you been
depressed, most of the day, nearly every day, for the past two
weeks or more?’ seems to be able to identify all cancer
patients diagnosed as depressed using Research Diagnostic
Criteria [10].
Suicide is associated with emotional suffering and, at times,
with physical disease. Suicide has been reported to be 1.5–2
times higher in cancer patients than in the general population
[11]. Among terminally ill patients with cancer, the request for
euthanasia is about four times higher in patients with
depression than in those without depression [12]. In addition,
desire for death in terminally ill cancer patients is frequent. It
has been shown to be associated with depression and is
transitory [13]. Suicide risk protocols should include an
evaluation of thoughts about death, dying and suicide, as
well as an evaluation of the presence of a plan to commit
suicide, the patient’s intention to carry out such plan and its
viability.
An association between depression and an increase in pro-
inflammatory cytokines (e.g. interleukin-1, interleukin-6 and
tumor necrosis factor alpha) has been described. Cancer itself
and its treatment (medications and surgery) in general can be
responsible, together with the individual stress response, for
the production of pro-inflammatory cytokines which may
contribute to the development of depressive symptoms [14].
Depression and depressive symptoms should always be
treated in the cancer setting. Because sadness and depressive
symptoms are considered to be ‘normal’ reactions to the
disease and its treatment, quite frequently they remain
undertreated. They tend to be a manifestation or consequence
of emotional suffering. Not treating them will trivialize the
patient’s suffering associated with the disease and death.
Adequate treatment of depression in the oncology setting
should combine the control or elimination of potential organic
causes of depression when possible; pharmacotherapy;
psychotherapy and psychological intervention with the
patients’ families and staff members. Efficient communication
skills between doctor and patient are needed as well.
The choice of the best psychotropic drug for the
pharmacological treatment of depression in cancer will depend
on various factors [14]:
doi:10.1093/annonc/mds350 | x
symposium article
• Which is the safest drug or which has the fewest side-effects
for the cancer patient
• What the characteristics of the depressive episode are, and
• Which is the best way of administration for a particular
patient ( pills versus liquid versus parenteral).
General guidelines for the use of antidepressants in the
cancer setting have been described [14] and include:
• Starting the dose according to patients’ condition (usually
half dose for a few days, then titrate)
• Waiting for the effects of the drugs (latency: usually 4 weeks)
• Providing continued treatment for 6–9 months (more if
depression or depressive episode are recurrent)
• Discontinuing antidepressant treatment gradually by
tapering the dose and providing adequate follow-up
• Monitoring symptoms on a continued basis to watch for
potential drug interactions that may occur between
antidepressants and certain chemotherapeutic agents
Psychotherapy may be an excellent alternative for those who
refuse taking antidepressants. In addition, it has no side effects!
As with antidepressants, it is necessary to adjust the
psychotherapeutic modality to patient’s needs and disease
stage. Psycho-educational interventions such as clarifying
information, among others, are effective usually throughout the
disease continuum, although may be more needed at diagnosis,
when passing from one stage of the illness to another, for
example, initiation and end of treatment; upon starting
palliative care, etc. Couple and Family Therapies may be
appropriate when conflicting relationships within the couple or
the family contribute substantially or are the main cause of the
patients’ depressive symptoms. Cognitive techniques may be
useful in correcting misconceptions and exacerbated fears.
Interventions directed to enhance the spiritual aspects in
advanced disease and dying are of utmost importance at this
stage of the illness, when patients are confronted with life-
death issues that generally imply deep existential questioning
[15]. Helping patients discover the meaning they assign to
their symptoms, to their disease, to life and death, to suffering,
etc., and helping them accept suffering as an integral part of
life, is of utmost importance. Finding meaning in the context
of advanced or serious illness is quite a challenge that not
everyone is capable of achieving. In addition, interventions
designed to maintain patients’ dignity have been described as
well and are very helpful in improving patients’ mood [16].
Multidimensional structured and semi-structured group
psychotherapies have proven to be effective in reducing
patients’ depressive symptomatology and improving their
quality of life [17–19].
Staff play an important role in the improvement of
depressive symptoms in the cancer patient. Staff should be
trained to provide basic emotional support effectively as well as
to communicate efficiently with the patient and his/her family.
Some simple interventions staff may easily implement are
related to increasing the patient’s perception of control. Cancer
influences the patient in such a way that it substantially
reduces the perception of control that the patient has over his
own life. In order to help patients regain their sense of control
staff members may:
x | Die Trill
Annals of Oncology
• provide options to patient. For example, giving him the
possibility of choosing whether he wants to have his
medication with water, milk or juice helps the patient believe
he still has the power to decide over what is happening to
him, especially at times when the patient is hospitalized and
his hospital days revolve around medication intake, doctor
and nurses’ visits, medical tests, etc.
• anticipate patients’ needs. This will help him feel more in
control of what may happen to him and will reduce fear and
distress upon the development of new symptoms or changes
in the patient’s body, functions, etc.
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• facilitate adaptive coping mechanisms, for example, by
identifying with the patient effective ways in which he/she
has confronted and resolved difficulties encountered in the
past
• respect defense mechanisms as long as they do not interfere
with treatment administration
• normalize patient’s feelings
• help maintain realistic hope: Even in the context of palliative
care can hope be maintained. For example, a non-depressed
dying patient may hope to die without suffering, or after
having solved certain issues, or he may hope that his family
will not suffer in excess after his death.
• remain available to listen to patient’s worries and fears
• explain to patient and family that depressive symptoms can
be treated
• provide continuity in patient care
• monitor patient’s sense of wellbeing and needs in a continued
manner along the disease continuum, since they change over
time
• work with the family: provide basic caretaking guidelines and
support for family members. Facilitate their understanding
of what depression is and why the patient may be depressed.
It may be difficult for family members to comprehend,
for example, why the patient develops depressive
symptomatology upon finishing his treatment.
• explore one’s own attitudes towards illness, suffering, death
and dying
• inform adequately: staff members should have efficient
training in communication skills as to be able to handle
difficult interactions with patients at complex moments of the
disease process. Adequate doctor–patient communication will:
• reduce patient’s fears and anxiety,
• help patient understand and elaborate relevant medical
information,
• increase patient’s perception of control,
• allow the patient to discuss relevant worries that may
interfere with treatment administration, with the
oncologist,
• enhance treatment adherence,
• facilitate patient’s global psychological adjustment.
A six-step protocol to deliver bad news and improve doctor–
patient communication (SPIKES) has been described [20] and
includes the following:
• S Setting: prepare an adequate environment. This may be
achieved by providing privacy, involving significant others,
establishing rapport with patient, etc.
Volume 23 | Supplement 10 | September 2012
Annals of Oncology
• P Perception: ask yourself ‘How does the patient perceive his
medical situation?’. And, ‘Before you tell, ask’ (for example,
‘What do you suspect your symptoms are due to?’).
• I Invitation: obtain patient’s invitation to deliver medical
information. ‘How would you like me to give you your test
results?’ could be a good way to start.
• K Knowledge: deliver the medical information: ‘I am sorry to
tell you that your test results have revealed …’.
• E Empathizing and Exploring: assess the patients emotions
using empathetic responses, for example ‘I understand this
must be very difficult for you at this time of your life’.
• S Strategy and Summary: Describe strategy/follow-up and
summarize the interview making sure that the patient has
understood the information provided.
This educational workshop will focus on the diagnosis and
treatment of depressive disorders in cancer patients. Diagnostic
criteria for depression and for suicide risk as well as
psychotherapeutic guidelines to treat depression effectively will
be provided. Theoretical aspects of the different topics covered
will be illustrated with case vignettes and brief video sketches.
In summary, depression is frequent in the cancer setting and
should receive adequate attention from professionals. As with
other illnesses, its correct although sometimes difficult
diagnosis in oncology will allow the design of interventions
tailored to address patient needs, intensity of symptoms and
others. Treatment of depression should not be targeted to the
patient only but should include family and oncology staff
members as well.
disclosure
The author has declared no conflicts of interest.
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