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Know how to assess and treat depression in patients with cancer.

In the past few decades, more attention has been given to the psychological issues that can accompany the diagnosis and treatment of cancer. Depression associated with cancer has received considerable attention in the literature. Many healthcare providers do not look for depression or assume that depression is a normal reaction to cancer that does not warrant treatment. Although feeling depressed very soon after an initial diagnosis of cancer is normal, most patients begin to accept their situations within a few weeks and their moods improve. Patients should not continue to feel depressed months after diagnosis and into the treatment phase. The consequences of untreated depression can be severe, resulting in significant morbidity and mortality as well as affecting treatment outcomes and quality of life.

Prevalence of Depression

The American Psychiatric Association (2000) defined depression as the presence of depressed mood or loss of interest or pleasure in nearly all activities for a period of at least two weeks. According to the association, an individual also must present with four of the following symptoms to be considered depressed.

* Depressed mood

* Anhedonia (an inability to experience pleasure from normally pleasurable life events)

* Insomnia or hypersomnia

* Fatigue or loss of energy

* Significant weight or appetite changes (increased or decreased)

* Psychomotor agitation or retardation

* Feelings of worthlessness or guilt

* Reduced concentration, ability to think, or indecisiveness

* Recurrent thoughts of death or suicide


Depressive disorders are experienced by a significant number of patients with cancer, with reported rates of up to 58% (Massie, 2004). The most common symptoms of depression are depressed mood, insomnia, and fatigue.

Depressed women outnumber depressed men by 2 to 1. Massie also found cancer types highly associated with depression: oropharyngeal (22%-57%), pancreatic (33%-50%), breast (1.5%-46%), and lung (11%-44%). High symptom distress, pain, disability, and the absence of perceived social support are related to higher depression rates (Fulcher, 2006).

Assessment of Depression

The physical symptoms associated with depression and cancer can confound the assessment of depression. Symptoms of depression often are similar to those of physical illness or its treatment. Screening patients for signs of distress and depression is essential. Several screening tools have been developed and validated for use in the cancer population. Some can be time consuming and burdensome to patients, who already may be experiencing side effects from treatment. Evidence suggests that simply asking patients the question "Do you feel depressed most of the time?" can be effective in screening for depression (Schwartz, Lander, & Chochinov, 2002).

Treatment of Depression

Antidepressant therapy is the mainstay of depression management and appears to be beneficial in the treatment of depression in patients with cancer (Pirl, 2004). The clinical efficacy of antidepressants in abating depressive symptoms is attributed primarily to their effects on the 5-HT neurotransmission system with secondary effects on the norepinephrine and dopamine neurotransmitter systems, which influence mood states (Bowers & Boyle, 2003). Medications combined with individual counseling or participation in support groups can be quite effective. Management of depression should be monitored at regular intervals, with particular follow-up for changes in medication therapy or changes in disease status. Berney, Stiefel, Mazzocato, and Buclin (2000) recommended referral to a psychiatrist after consecutive trials of two different antidepressants are unsuccessful. Worsening symptoms or suicidal risk necessitate immediate intervention by a psychiatrist.

Future Directions

Depression is highly prevalent in people with cancer. More research is needed on factors that may cause varying degrees of depression and that predict which patients are most at risk. In addition, clinicians should focus on more consistent use of screening tools for depression. More research needs to be directed to support current clinical practices in the prescribing of medications in the treatment and management of depression.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Arlington, VA: Author.

Berney, A., Stiefel, F., Mazzocato, C., & Buclin, T. (2000). Psychopharmacology in supportive care of cancer: A review for the clinician. III. Antidepressants. Supportive Care in Cancer, 8, 278-286.

Bowers, L., & Boyle, D.A. (2003). Depression in patients with advanced cancer. Clinical Journal of Oncology Nursing, 7, 281-288.

Fulcher, C.D. (2006). Clinical challenges: Depression management during cancer treatment. Oncology Nursing Forum, 33, 33-35.

Massie, M.J. (2004). Prevalence of depression in patients with cancer. Journal of the National Cancer Institute Monographs, 32, 57-71.

Pirl, W.F. (2204). Evidence report on the occurrence, assessment, and treatment of depression in cancer patients. Journal of the National Cancer Institute Monographs, 32, 32-39.

Schwartz, L., Lander, M., & Chochinov, H.M. (2002). Current management of depression in cancer patients. Oncology, 16, 1102-1110.

Susan D. Bruce, RN, MSN, OCN[R], Contributing Editor

Contributing Editor Susan D. Bruce, RN, MSN, OCN[R], is an oncology staff nurse at Duke Raleigh Hospital in North Carolina.
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Title Annotation:STRAIGHT TALK
Author:Bruce, Susan D.
Publication:ONS Connect
Geographic Code:1USA
Date:Apr 1, 2007
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