As successful as chemotherapy, radiation, and surgery may be for some patients with cancer, the benefits of those therapies usually do not come easily. One well known side effect of cancer treatment is depression, and practitioners have many resources to help their patients cope with it. However, determining the etiology of what patients are feeling may be difficult because patients may be depressed by the rigors of treatment as well as by the diagnosis of cancer and by the illness itself. Their depression may also have nothing to do with their illness or treatment, given that the National Institute of Mental Health reports that depression affects approximately 19 million Americans, or 9.5% of the population in any given 1-year period.1
In some patients, however, depression and the disease coexist, with the result that the prevalence of depression among patients with cancer is greater than it is among the general population. Depression is the only psychological disorder with that distinction.2 It is also the one psychological condition that will remain throughout the patient’s illness, often persisting through recovery. Furthermore, it is the most studied psychological disorder among cancer patients, especially with respect to morbidity and mortality.
CAN DEPRESSION PREDICT OUTCOME?
The very presence of depression might have an adverse effect on the outcome of disease in cancer patients. In fact, according to one meta-analysis, depression may actually predict risk of death, although its presence had no effect on the progression of the disease.2 Mortality rates for patients with symptoms of depression were up to 26% higher than for those who did not exhibit such symptoms. Among patients who were diagnosed with major or minor depression, those rates were up to 39% higher than they were for patients without depression.
The authors of that meta-analysis advise practitioners to recognize and treat depression early, as they recently wrote in Cancer:
“We do know that depression negatively affects adherence to medical treatment protocols, and that the psychological treatment of depression can be efficacious in relieving distress. To us, these facts are ample justification for the proactive identification and treatment of depression in cancer patients, even if their mortality risk was neither cancer specific nor greater than that of the general population.”3
Writing for the End-of-Life Care Consensus Panel, Susan D. Block, MD, cautioned that both the patient and family experience psychological distress in the presence of a terminal illness. She wrote that clinicians can help those patients and their loved ones cope with the disease by paying attention to the diagnosis and treatment of depression: “Clinicians should have a low threshold for treating depression in terminally ill patients.” The paper, published in 2000, is still an excellent guide for the oncology practitioner.4
DEPRESSION IN ADDITION TO DISEASE
The severity of depression among cancer patients is often compounded by the characteristics of the patient’s disease and its specific treatment. For example, while survivors of colorectal cancer had worse depression scores than the general population, they were also coping with chronic bowel and colostomy difficulties. In addition, they reported being distressed regarding having cancer, as is common among cancer patients. Of course, all of this affected their quality of life.5
DESIRE FOR HASTENED DEATH
The psychological impact of having cancer was the subject of a recent study of Korean patients.6 A cross-sectional survey using standardized measures, including the Schedule of Attitudes toward Hastened Death and the Hospital Anxiety and Depression Scale, was given to 131 patients with varied types of cancer. The Desire for Hastened Death (DHD) measurements included age, overall health, and shortness of breath. Researchers found that 13.7% of the participants exhibited moderate DHD while 1.7% experienced high DHD. There was a moderate association of DHD with feelings such as anxiety, helplessness, hopelessness, sadness, and distress.
As can be expected, those patients who had a clinically significant level of anxiety or depression reported higher levels of DHD. This patient group in Korea exhibited other, perhaps culturally significant, feelings such as meaning/peace, impaired dignity, and a sense of burdening their families, as well as thoughts of suicide after receiving their diagnoses. An important note is that helplessness/hopelessness and anxiety were the strongest predictors of DHD among these cancer patients. In light of this finding, the authors suggest that careful monitoring and manage-ment of these depression-associated factors should be an integral part of cancer care to reduce the occurrence of DHD.6
A number of symptoms accompany the diagnosis of cancer; patients may experience disbelief, denial, anger, or overwhelming sadness. Of course, this is normal. People may experience a range of depressed feelings at this time, but those feelings are usually limited to short term. If it seems otherwise, the oncology practitioner is in a unique position to recognize and treat a patient with depression before the psychological disorder affects the physical disease process, and perhaps have an influence on the outcome. ONA
Bette Kaplan is a medical writer in Tenafly, New Jersey.
1. Statistics. National Institute of Mental Health Web site. http://www.nimh.nih.gov/healthtopics/statistics/index.shtml. Accessed July 27, 2010.
2. Satin JR, Linden W, Phillips MJ. Depression as a predictor of disease progression and mortality in cancer patients: a meta-analysis. Cancer. 2009;115(22):5349-5361.
3. Satin JR, Linden W, Phillips MJ. Author Reply. Depression as a predictor of disease progression and mortality in cancer patients: a meta-analysis. Cancer. 2010;116(13):3304-3305.
4. Block SD. Assessing and managing depression in the terminally ill patient. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine. Ann Intern Med. 2000;132(3):209-218.
5. Jansen L, Koch L, Brenner H, Arndt V. Quality of life among long-term (≥5years) colorectal cancer survivors—Systematic review [published online ahead of print July 3, 2010]. Eur J Cancer. doi:10.1016/j.ejca.2010.06.010.
6. Shim EJ, Hahm BJ. Anxiety, helplessness/hopelessness and ‘desire for hastened death’ in Korean cancer patients [published online ahead of print June 29, 2010]. Eur J Cancer Care (Engl). doi:10.1111/j.1365-2354.2010.0120.