The diagnosis and treatment of cancer almost invariably, and understandably, evoke in patients fear of the unknown and sadness over physical and psychosocial losses. Most often, both the patient and family members experience these emotions at specific transition points along the cancer trajectory: diagnosis, treatment, recurrence, and progressive illness. Even in patients in long-term remission and those considered survivors, fears of recurrence and disabilities caused by cancer treatment can continue to cause feelings of uncertainty and anguish.
The National Comprehensive Cancer Network (NCCN) chose the word distress to characterize the psychosocial nature of the cancer experience (NCCN, 2007). The NCCN defines distress as a multifactorial, unpleasant experience that is emotional, psychological, social, or spiritual in nature. Distress can occur at any point along the cancer continuum and can range from normal feelings of vulnerability, fear, and sadness to disabling conditions such as clinical depression, anxiety and panic, isolation, and existential or spiritual crises (NCCN, 1999). Basing its framework on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) (APA, 2007), the NCCN identified the seven psychosocial disorders most often seen in patients with cancer: dementia and delirium (cognitive changes), substance abuse–related disorder, personality disorder, and (those discussed in this chapter) adjustment disorder, mood disorder, and anxiety disorder.
The state of feeling sad is often referred to as “depression,” and the state of fear or apprehension about a perceived threat often is referred to as “anxiety.” Yet, both depression and anxiety can range from an acute, transient distress to a major psychiatric illness. Depression and anxiety are common emotional responses to cancer, and these two diagnoses often coexist. The intensity, duration, and extent to which these symptoms interfere with the patient’s ability to function differentiate a depressive or anxiety disorder from normal emotional responses to chronic illness (Pasacreta et al., 2006; Bowers & Boyle, 2003). Depression and anxiety consist of a cluster of psychological and physiologic symptoms that, if recognized, often respond to treatment but if unrecognized interfere with coping and quality of life. Untreated depression places the patient at risk for suicide; this makes diagnosis and treatment imperative (see Chapter 45).
Depression has been defined as a more intense and debilitating version of sadness (Bowers and Boyle, 2003) and as a complex, progressive, neurologic-cognitive response to loss or deprivation (Lovejoy et al., 2000b). The neurophysiology of depression involves an imbalance of neurotransmitters (i.e., dopamine, norepinephrine, and serotonin [5-HT]) in the mood-sensitive areas of the brain (the limbic system, basal ganglia, and hypothalamus) (Townsend, 2004; Bowers & Boyle, 2003; Lovejoy et al., 2000a; Keltner et al., 1998). A decrease in neurotransmitters, particularly serotonin, negatively affects homeostasis throughout the body, causing cognitive, behavioral, and systemic symptoms (Box 8-1). It is important to note that depressive disorders are biologic in nature (Barry, 2002) and that symptoms reflect a progressive derangement of underlying neurologic circuits (Lovejoy et al., 2000b). A person does not choose to be depressed. Stressful experiences can “burn out” neurologic circuits in the brain; or, as in the case of hereditary depression, neurotransmitter systems may fail first, contributing to responses of sadness and ineffective coping when the individual is faced with stressful situations, such as cancer (Lovejoy et al., 2000b).
BOX 8-1
CRITERIA FOR MAJOR DEPRESSIVE EPISODE
Five or more of the following symptoms must be present during the same 2-week period and must represent a change from previous functioning; at least one of the symptoms must be depressed mood or loss of interest or pleasure.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or objective report by others (e.g., appears tearful).
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (e.g., withdrawn).
3. Significant weight loss while not dieting, or weight gain (e.g., a change of more than 5% of body weight in a month), or a decrease or increase in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (e.g., irritable mood).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day.
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
Data from American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders. (4th ed., text rev.). Washington, D.C.: The Association. Physical symptoms of depression may mirror symptoms caused by cancer and its treatment; assessment, therefore, should focus on mood and psychological changes in the patient with cancer.
Anxiety has been defined as severe apprehension or worry, and although it is a normal response to stressful events such as cancer, anxiety becomes a pathologic condition if it persists and interferes with the patient’s ability to function (Noyes et al., 1998). Fear is a normal affective response to the real threat of a cancer diagnosis or treatment, whereas anxiety is the affective response to a perceived threat or danger. Therefore fear is the cognitive appraisal that cancer is a threat to well-being, and anxiety is the emotional response to that cognitive appraisal (Beck & Emery, 1985). Thus fear and anxiety are interrelated. Fear leads to the stress response of fight or flight; in contrast, anxiety reduces the individual’s ability to act. Severe anxiety can cause a patient with cancer to feel emotionally paralyzed (Stein, 2004; Wolman, 1994). The physical symptoms of anxiety are associated with the autonomic response, and the psychological symptoms are associated with feelings of apprehension and impending doom (Box 8-2). Individuals with a history of generalized anxiety disorder may experience a re-emergence or intensification of symptoms with the development of cancer. If the person has a history of post-traumatic stress disorder, that condition also may be reactivated, and specific phobias and claustrophobia (i.e., fear of enclosed places) may interfere with cancer treatment (Marrs, 2006; Noyes et al., 1998).
BOX 8-2
SYMPTOMS OF GENERALIZED ANXIETY DISORDER
Apprehension: Excessive and uncontrolled worry about a real or perceived threat to personal safety.
Motor tension: Muscle tension, aches or soreness, restlessness, trembling or feeling shaky, easily fatigued.
Autonomic hyperactivity: Palpitations, shortness of breath or feeling smothered, sweating, dizziness, dry mouth, gastrointestinal distress, flushing, trouble swallowing or lump in throat.
Vigilance: Scanning the environment, exaggerated startle response, difficulty concentrating or going blank, difficulty falling asleep or staying asleep, and irritability.
Data from American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders. (4th ed., text rev.). Washington, D.C.: The Association; and Noyes et al., (1998). Anxiety disorders. In J. C. Holland (Ed.). Psycho-oncology (pp. 548-563). New York: Oxford University Press.
EPIDEMIOLOGY AND ETIOLOGY
Emotional distress is a normal response to the threat of cancer at the time of diagnosis, relapse, treatment failure, and other transitional points along the cancer continuum. According to surveys of the cancer population, 20% to 40% of patients show a significant level of distress, such as depression and anxiety; however, significantly, fewer than 10% of patients with these conditions are identified and referred for psychosocial assistance (NCCN, 2007). Characteristic emotional responses to cancer and its treatment may include initial shock and disbelief, periods of turmoil with mixed symptoms of anxiety and depression, irritability, and disruption of daily patterns such as appetite and sleep. Most patients with cancer have fears about a painful death, changes in body image and function, and becoming disabled and dependent. However, the level of psychological distress that accompanies these fears depends on a number of factors.
The incidence of cancer-related depression increases with the acuity and chronicity of the illness (Albright & Valente, 2006; Lovejoy et al., 2000b). Depression is strongly correlated with unmanaged pain in the cancer population (Breitbart & Payne, 1998; Massie & Popkin, 1998). Patients with cancer have a higher than average risk for depression, and the incidence of depression in these patients is significantly higher than in the general population (Albright & Valente, 2006). Anxiety is closely associated with other psychiatric states and may also occur as a response to pain, fatigue, or metabolic side effects, heightening the patient’s feelings of helplessness and hopelessness, which contribute to depression (Bush, 2006b; Noyes et al., 1998).
Depression and anxiety may also be caused by specific medications (e.g., corticosteroids), and certain cancer diagnoses (e.g., pancreatic carcinoma) have been associated with depressive symptoms. Organic factors, such as tumor involvement of the central nervous system, may also contribute to cognitive deficits and mood disorders such as depression (Massie & Popkin, 1998). The phase, duration, and intensity of cancer treatment may challenge the patient’s ability to cope and diminish the person’s quality of life (Schreier & Williams, 2004).
The risk of psychiatric illness in response to cancer is greater if the patient has a personal or family history of depression or anxiety before diagnosis. Individuals who have had a major depressive episode are at increased risk of recurrent depression, and the risk of suicide is higher for a person who has made a previous attempt (Albright & Valente, 2006; APA, 2000). Other variables that may increase the patient’s risk for depression and anxiety are the individual’s normal personality traits and coping styles before diagnosis. Individuals who have a negative or pessimistic outlook on life are more prone to depressive states; the cancer validates their negative world view (Albright & Valente, 2006) . Research has shown that avoidant and passive styles of coping, such as helplessness and hopelessness, also correlate with poor disease outcomes (Bush, 2006a). If a person has a history of pre-existing trait anxiety (a personality characteristic), the normal fear and anxiety associated with the disease and treatment may be heightened and may manifest more frequently (state anxiety) (Gorman et al., 2002; Noyes et al., 1998). Patients with trait anxiety are more prone to developing anticipatory nausea and vomiting before chemotherapy, and patients with a history of generalized anxiety disorder, such as panic attacks, may suffer more intense anxiety with the cancer experience than the general population (Bush, 2006b; Noyes et al., 1998).
Other contributing factors for psychological distress during the cancer experience include gender, developmental life stage, cultural and socioeconomic dimensions, and social support. In the general population, rates of depression vary across the life span, and the rates demonstrate gender differences. The lifetime prevalence of clinical depression is approximately twice as high in women as in men (Kornstein & McEnany, 2000). Various theories have proposed both a biologic and a social basis for this gender difference. Women have differences in brain structure and function, different genetic factors, and hormonal fluctuations across the reproductive life span that increase their vulnerability to depression. Cancer treatments, such as certain chemotherapeutic agents, may also contribute to depression by placing a woman in premature, unnatural menopause. Psychosocial factors that increase a woman’s risk for depression include gender differences in socialization, roles, coping styles, and economic and social status (Kornstein & McEnany, 2000).
Men experience symptoms of depression similar to those seen in women, but they are less likely to identify or report depressive moods because they fear stigmatization, loss of job security, or loss of health insurance benefits (Porche, 2005). It also is important to note that depression in men manifests differently; men are more apt to engage in coping efforts such as using alcohol and drugs, submerging themselves in work-related activities, or acting out reckless and risky behaviors. A grave concern is that suicide can be either a symptom or a consequence of depression, and in the United States, men are four times more likely than women to succeed at committing suicide (Porche, 2005) (see Chapter 45).
Geriatric depression is a widespread health problem in the United States, affecting at least 1 in 6 patients seen in general medical practice. This is an important problem that must be addressed, particularly in the cancer population, because cancer is the second leading cause of death in individuals over age 55 (Itano & Taoka, 2005; Reynolds & Kupfer, 1999; Boyle et al., 1992;). The incidence of significant depression in later life increases to about 25% for those with chronic illnesses such as cancer, especially if the person suffers from cognitive impairment (Albright & Valente, 2006; Reynolds & Kupfer, 1999) (see Chapter 7). The elderly also have the highest suicide rate of any age group because of rising rates among Caucasian men age 85 or older (Reynolds & Kupfer, 1999).
Depression rates differ among females and males and among the young and the elderly. Therefore the developmental life stage, cultural and socioeconomic factors, and social support all affect the risk and rates of depressive episodes. Cancer may strike at any point in the life cycle, be treated and stay in remission for years, and then recur unexpectedly. Childhood survivors live with the fear of possible secondary malignancies related to their primary treatments (e.g., female survivors of Hodgkin’s disease may develop breast cancer as a result of mantle radiation). At each stage of psychological growth a person must resolve inherent developmental tasks or challenges, and cancer can disrupt emotional development and the resolution of life goals (Bush, 2006a; Barry, 2002). Studies have found that with regard to fertility, threats to physical health, finances, and employment, young people with cancer have greater adjustment problems and a poorer quality of life than older persons with the disease (Bush, 2006a; Barsevick et al., 2000). Yet the elderly may be less apt to recognize and report depressive symptoms because of the physical and social losses that have accumulated throughout their life span; for example, bereavement grief in the elderly increases their risk of chronic depression. Also, signs among the elderly are more complex because many in this age group have co-morbid diseases, and telltale symptoms may be mixed with dementia, anxiety, and alcohol or benzodiazepine use or may manifest in psychotic forms (Reynolds & Kupfer, 1999).
Social support is a significant variable believed to be positively associated with a patient’s ability to cope and adapt to the stress of cancer (Bush, 2006a). Social support includes the community of family, friends, church, and larger social systems, such as culture. Social support can provide emotional support by helping the patient evaluate the cancer experience as less threatening, by helping the patient problem solve and make decisions, and by assisting with physical supportive measures. Social support includes the health care professionals who care for the patient through diagnosis, inpatient hospitalization, ambulatory outpatient clinics, and in the home. In evaluating social support, it is important to determine how the patient perceives his or her social support; that is, is communication between the patient and significant others open and supportive or closed and restricted (Hudek-Knezevic et al., 2002)? Special populations, such as minorities and the elderly, have less access to continuity of care and social support systems; this contributes to feelings of isolation and powerlessness, which ultimately can lead to depression and anxiety. Depression can also be undiagnosed or misdiagnosed in certain cultural and ethnic groups as a result of stereotypes about the groups’ expected behaviors and because of language barriers between health care providers and the patient (Albright & Valente, 2006; Faysman & Oseguera, 2002).
RISK PROFILE
• Personal or family history of psychological illness
• Inadequate symptom management, particularly pain
• Severity of illness and poor prognosis
• Prolonged, intensive treatment modalities
• Medications, including specific chemotherapeutic agents
• Co-morbid medical conditions, especially organic CNS disease
• Developmental life stage, gender, and family and social roles
• Personality characteristics of pessimism, perceived loss of personal control
• Concurrent or cumulative personal and family crises and loss
• Perceived or actual loss of social support systems
PROGNOSIS
Depression and anxiety are common mood states in patients confronting the stress of cancer and its treatment. These symptoms of distress are responsive to pharmacologic, psychological, and social treatments aimed at reduce the patient’s emotional suffering. This suffering should not be viewed as an unavoidable consequence of cancer (Massie & Popkin, 1998) but should be evaluated and treated promptly to bring about relief. Depression worsens the prognosis for medical illnesses such as cancer, and the worst consequence of untreated major depressive disorder (MDD) is suicide (Albright & Valente, 2006; Ballenger et al., 1999). Patients with a history of previous suicidal attempts are at higher risk for repeated attempts (Albright & Valente, 2006).
PROFESSIONAL ASSESSMENT CRITERIA (PAC)
1. Ensure the patient’s physical safety. Patients with depression and other mood disorders can develop suicidal tendencies (see Chapter 45). Ask the patient if there is a personal or family history of depression and suicide attempts. Ask the patient, “Have you ever had thoughts about hurting yourself?” All depressed patients should be assessed for the risk of suicide by direct questioning about suicidal thinking and impulses. If the patient has an active plan for suicide or if significant risk factors exist, refer the patient immediately to a mental health specialist such as a psychiatric nurse practitioner, psychologist, or psychiatrist (Sharp, 2005).
2. All patients experiencing cancer should be assessed for depressed mood and co-existing anxiety. The assessment should include a thorough consideration of the medical, endocrinologic, neurologic, situational, and developmental risk factors (Itano & Taoka, 2005; Massie & Popkin, 1998). Simple, straightforward questions can be used to identify a patient’s emotional outlook, such as, “Are you feeling sad, blue, or depressed?” “Are you sleeping poorly?” “Have you lost energy or do you suffer from unexplained fatigue?’ “Do you worry too much?” and “Have you lost interest and pleasure in activities that you usually enjoy?” (Ballenger et al., 1999; Reynolds & Kupfer, 1999).
3. Differential diagnosis for depression and anxiety must include a thorough assessment of medical conditions that may contribute to or exacerbate psychosocial distress (Albright & Valente, 2006). This includes uncontrolled symptoms related to the disease and treatment such as unmanaged pain and unrelenting fatigue. Metabolic status (e.g., electrolyte imbalances) can contribute to confusional states such as delirium and must be differentiated from depression and anxiety. Depression may be an outcome of chronic alcohol intake or substance abuse, and anxiety may reflect withdrawal of both (Albright & Valente, 2006). Other medical factors may include anemia, hypothyroidism or hyperthyroidism, and nutritional deficiencies of vitamin B12 and folate (Van Fleet, 2006). The differential diagnosis must consider organic central nervous system involvement (e.g., brain metastasis) and medications, including chemotherapeutic agents that can contribute to depression (e.g., corticosteroids, vinblastine, vincristine, interferon, procarbazine, and asparaginase).
4. The standard for diagnosing psychopathology is the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) (APA, 2000). The primary DSM-IV-TR symptoms for major depression are depressed mood and/or loss of interest or pleasure in almost all activities most of the day, nearly every day, persisting for a 2-week period and associated with physical and psychological symptoms. Differentiating the many physical manifestations of cancer and treatment-related symptoms from the DSM-IV-TR diagnostic criteria for clinical depression make the assessment challenging, (e.g., fatigue, weight loss or gain, anorexia, insomnia or hypersomnia). Therefore use of the DSM-IV-TR criteria for diagnosing depression in patients with cancer is controversial (Van Fleet, 2006; Bowers & Boyle, 2003). Assessment for depression in the patient with cancer should focus on risk factors for depression and psychological symptoms that affect appearance, behavior, and cognition, which are a change from the patient’s previous level of functioning (e.g., flat affect, slowed speech, crying, labile emotions, pessimism, guilt, hopelessness, and problems with concentrating and decision making). Depending on the major symptoms present, the common disorders classified by the DSM-IV-TR are adjustment disorders with depressed mood, anxiety or mixed anxiety and depressed mood, and mood disorder with depressive features due to cancer (Itano & Taoka, 2005; Massie & Popkin, 1998).
5. Symptoms of distress that require further evaluation in the patient with cancer include excessive worries and fears, excessive sadness, unclear thinking, despair and hopelessness, severe family problems, and spiritual crises (NCCN, 2007). The NCCN has formulated standards of care for psychosocial management of the patient with cancer (see the section Evidence-Based Practice Updates), as well as algorithms outlining assessment, treatment, and management guidelines. Creative approaches to psychosocial distress have been discussed in the literature and can be implemented across settings. At the Johns Hopkins Cancer Center, a trained volunteer administers the Brief Symptom Inventory (BSI) to all new patients in the waiting room. At the University of Wisconsin Comprehensive Cancer Center in Madison, patients undergoing chemotherapy are screened for common psychiatric disorders and then referred to a cancer psychologist or psychiatric nurse practitioner for further evaluation and counseling. At Memorial Sloan-Kettering, a “distress thermometer,” similar to the 0 to 10 graphic rating scale for pain, has been implemented. The patient is shown the visual thermometer and asked, “How would you rate your feelings of distress today, on a scale of 0 to 10?” Studies have shown that patients who indicate a mark or verbalize a score above 5 have symptoms in need of intervention (NCCN, 2007; Madden, 2006; NCCN, 1999).
6. The Agency for Health Care Policy and Research (AHCPR) (1993) has developed a practical guide for the management of depression in adults. This guide provides an overview of both the general population and the medically ill patient. It is an excellent resource for health care practitioners across all care settings. Other diagnostic tools for evaluating mood disorders are available for clinical and research use. Common examples include the Brief Symptom Inventory (BSI), the Common Problems Checklist (CPCL), the Profile of Mood States (POMS), the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), the Hospital Anxiety and Depression Scale, and the Hamilton Rating Scale for Depression (Madden, 2006; Bowers & Boyle, 2003; Zabora et al., 2003). For initial diagnosis in the clinical setting, a thorough intake history, physical examination, and psychosocial assessment are appropriate and effective. A single-item screening question, such as, “Do you feel low in mood or depressed?” has the benefit of being simple and efficient and begins a dialog that is nonthreatening to both the patient and the nurse (Bowers & Boyle, 2003; Chochinov et al., 1997).
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
