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| Subscribe to Clinical Compass™ | VOLUME 3, ISSUE 15 - JULY 15, 2008 | ||||||||||||||||||||||||
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Managing Mood Disorders in Cancer: A Critical Part of Treating the Whole Patient by Kara Gobron, PhD Approximately 50 percent of patients with advanced cancer meet criteria for a psychiatric disorder, especially major depressive disorder and anxiety.(1) Mood disorders can be related to the cancer diagnosis itself, the thought of a severe and possibly life-threatening illness, the presence of unpleasant side effects from treatment, disruptions of life plans, diminished quality of life, and the possibility of disease recurrence or progression, etc.(2) Anxiety and/or depression may persist for months or even years following successful cancer treatment.(3) Depression is an independent predictor of survival in patients with advanced cancer.(4) Treating these psychiatric conditions can greatly improve the quality of life and also possibly the outcome for cancer patients.(1) A 2007 World Health Organization survey(5) reported that depression had an especially large decrement in health when it was comorbid with a chronic medical condition, such as cancer. Management of depression in these patients has been found to be inadequate.(6-8) A recent report in the Lancet(9) assessed the efficacy of an intervention for the treatment of major depressive disorder in patients with cancer. A total of 200 patients with comorbid major depression were randomly assigned to either a standard of care (i.e., no treatment for depression) control group (n = 99) or to a group that had an intervention added (n = 101). There was a significant decrease in the mean depression score on the self-reported Symptom Checklist-20 depression scale at 3, 6, and 12 months for the group that had the intervention. Anxiety and fatigue were also improved. An author of this study, Michael Sharpe, MD, from the University of Edinburgh in Scotland stated, “We need to devote as much attention to treating the person with cancer as the cancer itself.” Cancer patients with major depressive disorder often go untreated as it is assumed that the sadness or difficulties they experience as a result of their cancer are expected, and not something that needs to be managed medically. However, since 50% of cancer patients meet the diagnostic criteria for a psychiatric disorder,(1) it is not something that happens in all cancer patients, but for the ones in which it does, it can affect their prognosis.(4) The impact of mood disorders on patients with cancer is not trivial. Psychological status seems to predict the length of survival in many types of cancer including melanoma, breast cancer, and non-small cell lung cancer.(10) Depression is an independent predictor of early death in patients with many types of advanced cancer,(4) and therefore early screening, diagnosis, and intervention for depression are critically important. Treatment of depression in patients with cancer is an essential component of comprehensive care, yet it is often overlooked or ignored.(2) Many times the barrier is the lack of recognition of the need for this intervention or lack of professionals available to provide psychosocial care to cancer patients.(2) Oncologists are also unfamiliar with depressive disorders and do not refer patients for treatment often enough.(10) However, treatment goals for patients with cancer are broadening to include not only concern over longevity, but also over quality of life.(11) Oncologists and other healthcare providers working with patients with cancer can and should avail themselves of several published guidelines that describe strategies for comprehensive patient care. The National Comprehensive Cancer Network has developed Guidelines for Distress Management(12) and within these guidelines are recommendations for management of anxiety and mood disorders. These recommendations assume that the patient will have been referred to a mental health professional, which is not always the case. In 2003, the Clinical Practice Guidelines for the Psychosocial Care of Adults with Cancer(13) was published. These guidelines recommend cognitive behavioral therapy and psychoeducational interventions. More recently, consensus-driven practice guidelines have been developed for the treatment of depression in cancer patients and these include pharmacological treatments.(14) There is a lack of research on treatment of anxiety and depression in patients with cancer,(15) although it is known that some antidepressants may pose risk to patients with cancer due to anticholinergic side effects (tricyclic antidepressants), proemetic effects (SSRI’s), as well as their potential for drug interactions.(10) The complexity of pharmacotherapy for mood disorders in this population may reduce the willingness of some physicians to attempt to manage the depressive symptoms. Nevertheless, patients with cancer need treatment for their mood disorders as it is well-documented in this patient population.(16,17) Treatment of mood disorders in cancer patients needs to be tailored for each patient. Oncologists need to be trained to screen for depression in their patients(18) and then they need to refer these patients to mental health professionals. The mental health professionals need to be trained specifically on treating depression and anxiety in cancer patients. Oncologists and psychiatrists need to work together to better diagnose and treat mood disorders in cancer patients to improve not only the quality of these patients’ lives but maybe also the quantity of their lives as well. Do you have feedback for the author? Click here to send us an email. References
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