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Is Mrs S Depressed? Diagnosing Depression in the Cancer Patient

Mark A. Hoffman, Joseph S. Weiner

From the Division of Hematology-Oncology and the Palliative Care Service of the Department of Medicine, and the Division of Consultation Liaison Psychiatry, Department of Psychiatry, and of Long Island Jewish Hospital campus of the Albert Einstein College of Medicine, New Hyde Park, NY

Address reprint requests to Mark Hoffman, MD, Long Island Jewish Medical Center, 270-05 76th Ave, New Hyde Park, NY 11040; e-mail: mhoffman{at}lij.edu

INTRODUCTION

A 43-year-old woman, Mrs S, was seen for a follow-up visit 6 months after completing adjuvant chemotherapy and radiotherapy for a 2.5-cm estrogen receptor/progesterone receptor–negative, node-negative breast cancer. Her visit took place in the middle of the day in a busy ambulatory practice. Mrs S was premenopausal at diagnosis and her periods ceased after chemotherapy.

When asked how she was doing overall, she replied "I'm doing OK, but I'm having some problems." She went on to say that she was still quite fatigued and as a result had not yet returned to work.

I asked her, "How is the fatigue affecting your daily life?" Before diagnosis, Mrs S played tennis on a regular basis and had an active social calendar. She said, "I get tired playing, so I don't play often. We go out with friends, but it takes a lot out of me." She was also having from four to six hot flashes per day and had vaginal dryness and dyspareunia.

By now, her physical demeanor had changed and she appeared downcast. At this point, I said, "It must be very hard to have all these body changes happen to you in such a short time." She broke into tears and said, "It's so overwhelming. I should be happy that my cancer is in remission. I'm sorry for crying."

"That's OK. It's healthy to get your feelings out. Do you find yourself crying a lot?"

She replied, "There are times when I feel sorry for myself, because I can't do the same things I did before. It's frustrating that I don't have the energy for things. But I can snap myself out of it. My husband and friends are very supportive. "

Thinking that she might be depressed, I asked if she could still get pleasure from things, and she replied, "Definitely." She denied any sleep or appetite problems, excessive guilt, memory or concentration difficulties, hopelessness, or suicidality. I wondered in passing if she was minimizing her symptoms, but I decided not to pursue it because of time constraints.

I said, "With regards to fatigue, it's very common for it to persist after finishing treatment. It's especially tough when you're such an active person and can't do everything you want to do right now. The fatigue will definitely improve over time, but I understand your impatience. Going into menopause after treatment can also be very difficult. Many of my patients have hot flashes, and they can be very bothersome. A medication, venlafaxine, can, in my experience, can be helpful to reduce their frequency."¹

"Decreased sex drive and vaginal dryness are unfortunately also common with chemotherapy-induced menopause.² The vaginal dryness can be a real problem. There are good personal lubricants available." I noted to myself that I was feeling rushed due to the need to see waiting patients.

Then, I proceeded with the physical examination, which was normal. I ended the visit by saying, "There seems to be so much that you're dealing with. It would be good to bring your husband next time to talk more about how we can help you deal with all this." Mrs S thanked me for listening, was given a prescription for venlafaxine for her hot flashes, and told to purchase a lubricant for the vaginal dryness. I asked my secretary to schedule her next visit as the last one of that day, so I would not feel rushed.

On the follow-up visit, her husband stated, "Normally, she's an upbeat and optimistic person. Unfortunately, she's having a lot of these side effects, and she doesn't see them getting any better. It's getting her down." Wondering if she was minimizing her symptoms of depression during the last visit, I asked her, "Your husband thinks you've been down. What's your take on it?" She replied, "I don't like to complain. I should be able to snap myself out of it. I know I'm in remission and should be grateful, but I've noticed lately that I can't even enjoy being with my grandchildren. I'm worried about this, and I'm not able to sleep well."

At this juncture, I was more certain Mrs S was depressed, but I thought she would benefit from expert consultation. I referred her to a psychiatrist for further evaluation and treatment. Although reluctant, she agreed. In addition, I gave her literature and contact information regarding support groups.

On a follow-up visit 8 weeks later, she had seen the psychiatrist, who diagnosed her with major depression, as she had had at least 2 weeks of depressed mood, anhedonia, diminished sleep and energy, and reduced self-worth. She had no history of manic symptoms, suicidality, psychotic symptoms, or significant anxiety. He raised her dose of venlafaxine and began cognitive behavioral psychotherapy. Her mood improved, and she was experiencing more energy. The hot flashes had also abated somewhat. Overall, she said, "I'm coping better with things."

In someone like Mrs S, who is dealing with multiple treatment-related adverse effects, how may the oncologist be attuned to a diagnosis of depression?

The diagnosis of depression in cancer patients is very important, given the increased prevalence in this population.³ However, making the diagnosis can be challenging. In general, oncologists are more likely to identify and treat their patient's physical problems than they are to identify psychosocial issues.⁴ Reasons for the underdetection of depression include a lack of clinician and patient education, the stigma of the diagnosis, and physician time constraints.

STRATEGIES TO ENHANCE THE BUSY ONCOLOGIST'S ABILITY TO DETECT AND DIAGNOSE DEPRESSION IN HIS OR HER PATIENTS

Expand Your Differential Diagnosis of Somatic Symptoms to Include Depression
The case of Mrs S illustrates the overlap between the somatic symptoms of cancer, sequelae of cancer treatment, and depression. Thus, the oncologist may not consider depression in the differential diagnosis of a patient who presents with multiple somatic complaints. Yet, given the high prevalence of depression in patients with cancer, it behooves the oncologist to maintain a high index of suspicion when a cancer patient has subjective complaints disproportionate to objective medical findings.

Obtain the Observations of People Close to the Patient
Patients who are depressed often lack insight into their condition or feel potential embarrassment when they contemplate divulging their symptoms to a health professional. Even if the patient does not share his or her suffering with people close to them, friends and family often observe significant changes in the patient's demeanor and behavior. Communication may be enhanced by inviting a person close to the patient to share his or her perspective on how the patient is coping. The recruitment of Mr S in this case helped to more firmly establish the diagnosis of depression.

Follow the Patient's Mood Longitudinally
Repeated assessments of the patient's mood, either through direct questioning or through observation, is important. The patient may have emotional and social resources to cope with some parts of the illness trajectory better than others. Thus the lack of depressive symptoms at one point in time does not preclude the emergence of depression at another. Because the oncologist has the advantage of a longitudinal patient-physician relationship, such changes in coping ability can be more readily detected.

Compare the Patient's Responses With Normative Responses
The oncologist should compare the patient's emotional state with what is expected at different stages of the disease trajectory.⁵ For example, although patients are often devastated by a diagnosis of cancer, by the time they begin treatment, most will have mobilized some optimism with the aid of their own coping mechanisms and support systems. Therefore, the patient who remains mostly dysphoric, passive, and overwhelmed should be evaluated for coexisting depression.

Be Aware of Disease Phases Associated With Patient Distress
Patients in active treatment who experience severe or unexpected treatment-induced symptoms, such as recurrent nausea and vomiting, may become depressed, since physical and emotional well-being are interconnected. Patients achieving remission after adjuvant therapy may also become depressed. For example, the lingering treatment-related adverse effects triggered Mrs S's depression. With the advent of more effective, but also more protracted and potentially more toxic adjuvant therapies, this scenario will likely become more common.

Patients completing adjuvant treatment may also experience anxiety and/or depression as their perceived safety network of frequent visits and professional coaching come to an abrupt end.

Before scheduled follow-up visits, some patients may have a flashback of prior adverse effects of therapy or fear discovery of recurrence. This stress may predispose to a sense of helplessness and depression.

Relapse of the cancer is often devastating for patients, who must face their changed prognosis and the need for further antineoplastic therapy, which might have been poorly tolerated previously. Transition from curative or life-extending treatment to exclusively palliative care is also a very difficult phase. Patients are now confronting their death. They may also fear pain, suffering, and physician abandonment. If the patent's distress at these times is not recognized and handled well by the oncologist, depression may ensue.⁶

Finally, several stresses, which may be repeatedly experienced during each phase of the illness, can precipitate a depressive episode: financial hardship from limitations in insurance coverage, change in employment status leading to loss of income and meaning, fear of recurrence or disease progression, and disruptions in usual family dynamics.

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS FOURTH EDITION REVISED CRITERIA FOR DEPRESSION

Once the oncologist has a suspicion that the patient is depressed, clear criteria should be utilized to confirm the diagnosis, as one would for any medical condition. The Diagnostic and Statistical Manual of Mental Disorders fourth edition text revision (DSM-IV-TR) criteria are presented in Table 1. ⁷

POTENTIAL ROLE OF SCREENING INSTRUMENTS

Some investigators have advocated for the use of screening questionnaires in a medical practice setting to assist in the detection of distress and depression. The hope is that screening questionnaires can save the clinician valuable time and help structure psychiatric decision making for the nonmental health professional. It is perhaps surprising that the uniform administration of well-validated depression screening instruments has not been found to substantially influence actual clinician behavior.¹⁰ It appears that routine administration of depression-screening instruments for case finding only becomes effective when the instrument is administered and scored by a physician-extender, and only those patients with high scores have their results fed back to the physician.¹⁰ This is unlikely to become a widely used model for the busy oncologist.

We do recommend the following specific protocol to screen for depression, which has some evidence supporting its usefulness for the busy clinician (Fig 1).¹¹ Ask the patient the following two questions: have you been feeling down, depressed, or hopeless in the last month? Have you been bothered by little interest or pleasure in doing things? If the patient answers yes to both questions, one study demonstrated a 94% sensitivity, that he or she meets DSM criteria for major depression.¹¹ If the patient answers yes only to the first question (depressed mood), the sensitivity diminishes, but it still indicates that depression is a possibility worth exploring, particularly if the depressed mood is impacting daily functioning. If the patient answers yes only to the second question (anhedonia), it is unlikely that he or she has major depression.¹¹

View larger version (47K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 1. Practical protocol: depression screening for the busy oncologist. DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, fourth edition.

DETECTING SUICIDALITY AND DIAGNOSING BIPOLAR DISORDER

The oncologist must additionally keep two things in mind while diagnosing depression. First, is the patient suicidal? Second, does the patient have a history of manic symptoms?

The reasons to detect suicidality are self-evident. The first of two useful, direct questions is, do you have suicidal thoughts? And, if the patient answers yes, then ask: There's a big difference between having a thought and acting on a thought. Will you actually try to kill yourself? If the patient answers yes to the first question, but no to the second, arrange a psychiatric follow-up. If the patient answers yes to both questions, call 911 for the patient to be taken to the emergency room. One dilemma for the oncologist is when the patient affirms suicidal thoughts, but the oncologist is not sure whether he or she will act on them. A good rule of thumb is if the oncologist will lose sleep that night wondering if the patient is still alive, then that person should be sent to the emergency room for evaluation.

If the oncologist wishes to initiate antidepressant therapy, a history of mania should be sought, as antidepressant treatment can precipitate its re-emergence. Table 2 contains sample questions for the screening of mania. ^12,13 If the patient endorses any of these symptoms, he or she should be referred to a psychiatrist for evaluation and initiation of treatment.

The oncologist is typically under much time pressure during an average visit. If a patient has mild to moderate symptoms that are suggestive of depression, the oncologist can space his or her evaluation over two meetings, as in the case of Mrs S, thus relieving the pressure to do everything during one appointment. By spacing out the evaluation, the clinician can also assess how enduring the symptoms are. For example, sometimes the patient will present with an adjustment disorder that will resolve as he or she recovers from treatment-related adverse effects.

The oncologist should try to form good working relationships with mental health professionals who can contribute their diagnostic and treatment expertise, as well as attend to the time-consuming care that the patient deserves to have. The American Psychosocial Oncology Society offers a referral helpline to patients and caregivers.¹⁴

TREATMENT OF DEPRESSION IN THE CONTEXT OF CANCER

The treatment of depression is outside the scope of this article. Some oncologists may feel more comfortable than others in initiating and monitoring treatment. The oncologist should keep in mind the potential for drug interactions between antidepressant and cancer therapies.¹⁵ The reader is referred to an excellent review of the issues¹⁶ and to the American Psychosocial Oncology Society, which offers a free Web-based video lecture on depression and suicidality in the cancer patient.¹⁷

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

NOTES

Supported in part by a Faculty Scholar Award from the Project on Death in America (J.S.W.), and generous grants from the Fan Fox and Leslie R. Samuels Foundation (J.S.W.) and the UJA Federation of New York (J.S.W.).

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

REFERENCES

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Submitted October 19, 2006; accepted December 4, 2006.

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