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DEPRESSION AND CANCER

DEPRESSION AND CANCER. Dr . Hussein Morsy. DEPRESSION AND CANCER A synopsis based on the WPA volume “Depression and Cancer” (Kissane D, Maj M, Sartorius N, eds. – Chichester: Wiley, 2010). Epidemiology of depression in cancer patients.

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DEPRESSION AND CANCER

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  1. DEPRESSIONAND CANCER Dr. HusseinMorsy

  2. DEPRESSION AND CANCER A synopsis based on the WPA volume “Depression and Cancer” (Kissane D, Maj M, Sartorius N, eds. – Chichester: Wiley, 2010)

  3. Epidemiology of depression in cancer patients • Many groups have assessed depression in cancer patients along the years, and the reported prevalence varies widely (major depression, 3 to 38%; depression spectrum syndromes, 1.5 to 52%). • Cancer types highly associated with depression include brain (41-93%), pancreas (up to 50%), head and neck (up to 42%), breast (4.5-37%), gynecological (23%) and lung (11%). • From Massie MJ et al. The prevalence of depression in people with cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  4. Methodological problems in epidemiological studies on depression in cancer patients • The wide range of prevalence rates reflects differences across studies (different definitions of depression, use of self-report questionnaires or psychiatric interviews, cancer type or stage, cancer treatments). • Depression may be difficult to assess in cancer patients, because depressive symptoms occur on a continuum ranging from normal feelings of sadness to a major affective disorder. • Diagnosing major depression in cancer patients may be challenging, because DSM-IV diagnostic criteria include several symptoms overlapping with symptoms of cancer or side effects of treatments (appetite loss, weight loss, sleep disturbances, fatigue, loss of energy, difficulty concentrating, psychomotor retardation). • From Passik SD, Lowery AE. Recognition and screening of depression in people with cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  5. Depression and demoralization Depression in cancer patients should be distinguished from demoralization. The depressed person has lost the ability to experience pleasure generally, whereas a demoralized person may enjoy the present moment, if distracted from demoralizing thoughts. The demoralized person feels inhibited in action by not knowing what to do, feeling helpless and incompetent; the depressed person has lost motivation and drive, and is unable to act even when an appropriate direction of action is known. From Massie MJ et al. The prevalence of depression in people with cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  6. Barriers to the recognition of depression in cancer patients • Oncology visits tend to primarily focus on physical treatment and management of its side effects and secondarily on pain and symptom management. Emotional symptoms may be overlooked or even discounted as expected consequences of having cancer. • Patients may be reluctant to visit their physicians for an emotional complaint because of fear that it may distract the physician from curative efforts, or they may fear negative cultural attitudes toward depression. • From Passik SD, Lowery AE. Recognition and screening of depression in people with cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  7. Evaluation of screening tools for depression in cancer patients Data based on the meta-analysis by Vodermaier et al. (J. Natl. Cancer Inst. 2009;101:1464-1488). PHQ-9, Patient Health Questionnaire-9; BSI-18, Brief Symptom Inventory-18; CES-D, Center for Epidemiological Studies - Depression Scale; EPDS, Edinburgh Postnatal Depression Scale; HADS, Hospital Anxiety and Depression Scale; ZSDS, Zung Self-Rating Depression Scale; BDI, Beck Depression Inventory; GHQ-28, General Health Questionnaire-28. From Passik SD, Lowery AE. Recognition and screening of depression in people with cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  8. Factors affecting emotional response to cancer A person’s emotional response to cancer is determined by three factors: a) view of diagnosis (e.g., as a challenge or threat), b) perception of control (some or none), and c) view of prognosis (good or bad). From Clarke DM. Psychological adaptation, demoralization and depression in people with cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  9. Styles of adjustment to cancer View of Control Prognosis illness Fighting Challenge Some control Good spirit AvoidanceMinimal Irrelevant Good or denial threat Fatalism Minor No control Uncertain - accepted threat with equanimity Hopelessness- Major threat No control Inevitably helplessness or loss negative Anxious Major Uncertain Uncertain preoccupation threat control According to Moorey and Grey (Psychological therapy for patients with cancer: a new approach. Washington: American Psychiatric Press, 1989). From Clarke DM. Psychological adaptation, demoralization and depression in people with cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  10. Cytokines and neurobehavioural symptoms in cancer patients • Pro-inflammatory cytokines (including TNF-alpha, IL-1 and IL-6) can induce a syndrome of sickness behaviour which has several overlapping features with major depression. • The syndrome includes anhedonia, cognitive dysfunction, anxiety/irritability, psychomotor slowing, fatigue, anorexia, sleep alterations and increased sensitivity to pain. • Pro-inflammatory cytokines are elevated in cancer patients with depression and their levels correlate with symptoms of sickness behaviour. • From Musselman DL et al. Biology of depression and cytokines in cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  11. The presence of depression affects survival in cancer patients • A study of breast cancer patients documented that, at 5-year follow-up, women with higher levels of depression had a significantly reduced likelihood of survival (Watson et al., 1999). • In a population-based study with over 10,000 participants, cancer patients with depression had a significantly greater risk of death at 8-year follow-up than those who were not depressed (Onitilo et al., 2006). • A mediator of the relationship between depression and cancer survival is non-adherence to treatment, which is higher when patients are depressed (DiMatteo et al., 2000). • From DiMatteo RM, Haskard-Zolnierek KB. Impact of depression on treatment adherence and survival from cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  12. Ways by which depression affects adherence to anti-cancer treatments • Inability to integrate cancer diagnosis and treatment information • Reduced motivation towards self-care; difficulty planning • Negative health beliefs and pessimism about treatment • Avoidance of health-promoting behaviors • Social isolation and withdrawal • Reduced use of community resources • Greater difficulty tolerating treatment side effects • From DiMatteo RM, Haskard-Zolnierek KB. Impact of depression on treatment adherence and survival from cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  13. The presence of depression increases the risk of suicide in cancer patients • Cancer patients are about two times more likely to commit suicide than the general population (Rockett et al., 2007). • Depression is a known factor in half of all suicides, and individuals suffering from depression are at a 25 times greater risk of suicide (Breitbart et al., 2006). • Additional risk factors for suicide in people with cancer include feelings like a burden to others, loss of autonomy, wish to control one’s death, physical symptoms, hopelessness, existential concerns, lack of social support, and fear of the future (Hudson et al., 2006). • From Breitbart W et al. Suicide and desire for hastened death in people with cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  14. Guidelines for the assessment of suicide risk in cancer patients - I Based on the National Breast Cancer Centre and National Cancer Control Initiative Clinical Practice Guidelines (2003) and Hudson et al. (Palliat. Med. 2006;200:703-710). From Breitbart W et al. Suicide and desire for hastened death in people with cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  15. Guidelines for the assessment of suicide risk in cancer patients - II Based on the National Breast Cancer Centre and National Cancer Control Initiative Clinical Practice Guidelines (2003) and Hudson et al. (Palliat. Med. 2006;200:703-710). From Breitbart W et al. Suicide and desire for hastened death in people with cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  16. Cognitive therapy for depression in cancer patients - I From Kissane DW et al. Psychotherapy for depression in cancer and palliative care. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  17. Cognitive therapy for depression in cancer patients - II From Kissane DW et al. Psychotherapy for depression in cancer and palliative care. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  18. CALM therapy for depression in patients with advanced cancer - I From Kissane DW et al. Psychotherapy for depression in cancer and palliative care. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  19. CALM therapy for depression in patients with advanced cancer - II From Kissane DW et al. Psychotherapy for depression in cancer and palliative care. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  20. Interventions for the suicidal patients Adapted from Holland et al. (eds). Quick reference for oncology clinicians. Charlottsville: IPOS Press, 2006. From Breitbart W et al. Suicide and desire for hastened death in people with cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  21. Antidepressant medications and their use in cancer patients - I From Grassi L et al. Pharmacotherapy of depression in people with cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  22. Antidepressant medications and their use in cancer patients - II From Grassi L et al. Pharmacotherapy of depression in people with cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  23. Antidepressant medications and their use in cancer patients - III From Grassi L et al. Pharmacotherapy of depression in people with cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

  24. Guidelines for use of antidepressants in cancer patients • Start the treatment at low doses followed by a period of dose titration to achieve an optimum individualized response (low doses may help to avoid unwanted initial side effects, particularly in patients in poor physical conditions). • Inform and reassure patients of latency period and possible side effects, in order to avoid premature drop-out, especially if patients are receiving other medications. • Treat the patient for 4-6 months in order to avoid relapses or new episodes of depression after remission. • Regularly monitor the patient's physical variables and concomitant use of medications for cancer (e.g., steroids, antiemetics, antibiotics, antiestrogen and chemotherapy agents). • Discontinue medications by tapering the dose by 50% over a couple of weeks to reduce the risk of withdrawal symptoms that can be distressing and may be mistaken for symptoms of cancer illness or relapse into depression. • Reassurance and education of the patients are extremely important in oncology settings. • From Grassi L et al. Pharmacotherapy of depression in people with cancer. In: Depression and Cancer. Kissane D, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

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