Depression in Cancer Patients: Inquire or Don't, but Be Concerned
By Robert H. Carlson
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.
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.
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.
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.