Mental health experts have spent years coaxing oncologists to be concerned about depression in their cancer patients. There are still only a few who do, so perhaps it's time for a new tack.
One idea is to keep the oncologist's involvement as short as possible by listening for key words from the patient that can flag depression. That saves time, and at least opens the subject up for more doctor-patient discussion or a referral.
A more novel idea is to relieve the oncologist of the task entirely by making depression detection the job of other clinic staff members. As in cancer pain, cancer depression could be tackled by a psychiatrist or a team of palliative care specialists who keep the oncologist informed but not directly involved.
There is no question cancer patients are at risk for depression, with estimates that 20 to 30 percent of patients become clinically depressed. As with anyone, it can ruin the quality of their lives.
And some studies, albeit controversial, suggest that oncology patients with untreated depression have worse outcomes after cancer therapy. All in all, diagnosing and dealing with depression can only be a good thing.
But as usual, it's a matter of time. Managing a life-threatening disease, its treatments, and their side effects, not to mention insurance, compliance, and comorbid conditions, all take up the physician's face-to-face time with patients.
If ask about depression is on the to-do list, it's likely at the bottom, with a good chance of not happening.
Taking Depression Out of Oncologists' Hands
Researchers at the Winship Cancer Institute at Emory University are developing a program that will essentially relieve oncologists of the task of diagnosing depression.
We've been at this game of encouraging oncologists to ask about depression, and it's not been terribly successful, said Andrew H. Miller, MD, Professor of Psychiatry and Behavioral Sciences at Emory and Director of Molecular and Clinical Psycho-Oncology at Winship.
It is miserable how much depression is tolerated, and this has not changed in 10 or 20 years.
Figure. Andrew H. Mi...Image Tools
Dr. Miller is Director of a program in development to make depression values a vital sign for cancer patients. Nurses or social workers will administer questionnaires regarding patient mood just as they take vital signs and monitor hematocrit or white blood cell counts.
If depression is indicated, the staff will refer patients to psychological services and notify the oncologist.
It may be enough for oncologists just to know about the depression and to know someone is on top of it, Dr. Miller said, noting that oncologists are supporting the nascent program because it takes something off instead of adding more to the oncologist's tasks.
Eyes Glaze Over
The Winship program is a paradoxical approach, a response to oncologists whose eyes glaze over during lectures about depression screening, Dr. Miller said.
Rather than banging them over the head telling them to ask about depression, we're setting up a system so someone else does this. He compared treating depression in cancer with treating cancer pain, which has long been undertreated.
Dr. Miller hopes the project can lead to multispecialty teams in cancer centers coordinating care for depression and pain, and palliative care in general.
Oncologists who are concerned and want to investigate depression in their patients won't be pushed aside by this program, Dr. Miller said. The degree of oncologist involvement will depend on how they like to practice.
And practitioners can still try their hand at prescribing antidepressants, as long as the doses are sufficient and treatment lasts long enough-which is not always the case.
For example, interferon alpha is known to cause depression, but the depression is often undertreated by oncologists, Dr. Miller said. Psychiatrists, on the other hand, are familiar with the drugs and are not afraid to administer high doses and get results.
And interferon alpha demonstrated the value of early diagnosis and depression prevention. In a double-blind placebo-controlled study at Emory of 40 patients treated with interferon alpha for melanoma and hepatitis C, researchers tested depression prevention with antidepressants before chemotherapy began.
Half of the placebo patients had clinically significant depression after chemotherapy, versus just 11% of those pretreated with antidepressants (N Engl J Med 2001;344:961-966).
Single Question Better than None
The hands off solution doesn't appeal to everyone. One psychiatrist said he would not advocate taking depression off the oncologist's list of the things to do.
Do we want to start taking various types of distress off the oncologist's checklist so they are not paying attention to things like pain, nausea, or symptom-management issues-sources of tremendous suffering?, asked Harvey Max Chochinov, MD, PhD, Canada Research Chair in Palliative Care, Director of the Manitoba Palliative Care Research Unit, and Professor of Psychiatry at the University of Manitoba.
If the person managing the cancer defines their job as only including tasks very specific to treating malignancy and eliminates everything else, where does that leave the patient? It would seem to be a very disjointed way of trying to organize care.
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Oncologists can't be specialists in everything, he agrees, but it's a reasonable expectation that the person managing cancer has at least an awareness of the various sources of discomfort for the patient.
That is not asking too much. If they aren't familiar with all the particulars around treatment or the lines of treatment available, it's fair that at some point they pass along the care to someone with specialty expertise.
Dr. Chochinov said that oncologists asking some very simple questions can uncover depression quite effectively. A study done in Winnipeg asking patients if they felt depressed most of the time led to a very high rate of detection.
The take-home message is that if we ask patients if they are feeling depressed most of the time, their answer can lead to a further and more exhaustive evaluation, Dr. Chochinov said, adding that a single question can't be expected to substitute for a thorough evaluation and diagnosis.
Worthless Words
If an oncologist is willing to spend time in an interview asking about depression, the key-word approach can help reveal its presence.
David Spiegel, MD, Willson Professor and Associate Chair of the Department of Psychiatry & Behavioral Sciences at Stanford University School of Medicine, says the word worthless is a red flag suggesting that patients feel bad about themselves rather than about their condition.
Patients can feel hopeless because they have a bad disease, or helpless because they cannot do much about it, Dr. Spiegel said. But when sadness extends beyond the effects of the illness to some assumption they make on themselves-they're worthless, have little value, are a burden to others, deserve what is happening to them-that's a sign of depression.
The oncologist who decides to ask about depression should consider the wording correctly, to prevent answers the patient might think the doctor wants to hear.
There are a lot of ways to ask a question if you don't want to hear the answer, said Donald Rosenstein, MD, Chief of Liaison Psychiatry Services at the National Institute of Mental Health Intramural Research Program, such as 'Are you felling okay? Good.'
Dr. Rosenstein warns that If you're going to ask the question, you have to be ready to hear the answer. You may not feel you have the time to hear all the details, but you have to be prepared to spend a couple of extra minutes, or to say you don't have time right now but you can call them tonight or set up an appointment. Address it and don't put it off.
Lots of patients over the years have told me that major depression was the worst part of their cancer experience by far, Dr. Rosenstein continued. That was the most psychically painful part of it for them.
Somatic Symptoms
If the tip-off about depression is from somatic symptoms of depression, Dr. Spiegel says it's not enough just to treat the symptoms.
If patients have insomnia because they are depressed, just giving them a sleeping pill is not going to do it, he said. The best treatment is a combination of psychotherapy and pharmacotherapy, he believes.
Many symptoms of depression such as fatigue, insomnia, and loss of appetite overlap with symptoms of cancer or its treatment.
And some apparent red flags signaling depression are actually red herrings, Dr. Rosenstein warned.
Patients can look depressed and not be. Before making the depression diagnosis too quickly you want to make sure it is nothing else that looks like depression-endocrine problems, for example.
Dr. Rosenstein said depression-like symptoms can also result from pain, anger, anxiety, delirium, adverse reactions to medications, or akathisia.
Figure. David Spiege...Image Tools
Akathisia, often a side effect of dopamine-blocking antiemetics including Compazine and Reglan, is a very uncomfortable feeling, Dr. Rosenstein said. People get a subjective sense they have to move, they're restless, and objectively they have increased motor activity-they look anxious and depressed but they are not.
He said most of what is known about major depression is from non-medical non-oncology samples of patients. The Diagnostic and Statistical Manual of Mental Disorders has very specific criteria of both number of symptoms and duration and severity that make a diagnosis of major depression.
The problem in cancer patients is teasing apart what is due to the malignancy and what is due to the depression, Dr. Rosenstein said.
Figure. Donald Rosen...Image Tools
He is adding details on features that mimic cancer depression in his revised chapter on psychopharmacologic management of depression in the NIH's Bethesda Handbook of Clinical Oncology (edited by Jame Abraham, MD, and Carmen Allegra, MD, Lippincott Williams & Wilkins, 2001).
You can make things worse by treating what you think is depression when it's not, by adding an antidepressant, Dr. Rosenstein said.
For example, a patient receiving a highly emetogenic chemotherapy might be prescribed Compazine suppositories to use every four to six hours around the clock. The person develops akathisia, and if there is enough blockade of dopamine receptors, the patient can look depressed or Parkinsonian.
Diagnosed as depressed, the patient is given an antidepressant, which can have side effects of nausea and GI distress-so the patient is given more Compazine.
The error is not necessarily life threatening, but it delays accurate improvement of symptoms, Dr. Rosenstein said.
Antidepressants
A wide selection of safe, effective antidepressants are available today for oncologists who want to prescribe for their patients' depression or suspected depression.
I am not cavalier about it but my threshold has dropped for treating subdiagnostic or subsyndromal depression, Dr. Rosenstein said. The patient who can't concentrate, can't sleep, may not meet criteria for major depression, but if we put them on a dose of a medication it might help them get through this course of chemotherapy more easily.
For patients who present with only one symptom, such as insomnia, Dr. Rosenstein doesn't believe in overgeneralizing and assuming that is the beginning of a depression.
There are many reasons for a person to have insomnia; you don't necessarily go straight to an antidepressant, he said.
For complaints of loss of energy or fatigue, some practitioners have been prescribing modafanil (Provigil), a wakefulness-promoting agent, he said.
I don't have a problem with using a non-antidepressant in a targeted fashion, but at some point if you get to a critical mass of symptoms that may be manifestations of an impending depression, then my view is to take the approach similar to the pain experts-that is, that it is better and easier to prevent pain than to get rid of it.
Biology of Cancer Depression
Depression in cancer patients is thought of as the psychology relating to the cancer-reinforcing depression, but we are beginning to see something in the biology, too, said David Spiegel, MD.
We find that patients who have disruptive patterns of diurnal cortisol seen in depression-rather than having a high level in the morning and a low level in the evening, it is high throughout the day-are not only more likely to be depressed but also more likely to have more rapid cancer progression. So some of the biology of depression is consistent with things we are finding related to rapid disease progression.
He said that is another rationale for being aggressive about diagnosing and treating depression in cancer patients.
Andrew H. Miller, MD, said that patients being treated with interferon alpha exhibit a high rate of nervous system side effects including depression and fatigue. They also show marked activation of interleukin (IL)-6 and the hypothalamic-pituitary-adrenal axis, with the resultant release of glucocorticoids.
He said he and his colleagues believe IL-6 is responsible for glucocorticoid induction during interferon alpha treatment, but that tumor necrosis factor or IL-1 may be responsible for the behavioral toxicity.
Not Over 'Til It's Over
Depression starting after a diagnosis of cancer doesn't necessarily resolve when the cancer is successfully treated, said David Spiegel, MD.
When acute treatment stops, many patients feel worse because now they're not doing anything to fight the illness, and they feel more vulnerable. Even after treatment is over and there is no evidence of relapse, depressed patients tend to see the worst in their future, and they need help with that perspective.
© 2003 Lippincott Williams & Wilkins, Inc.