Mrs. A. is a 61-year-old, married woman diagnosed approximately 1 year ago with small cell carcinoma of the lung. She has undergone multiple treatments, including several chemotherapy regimens.
She presents to hospital with some mild confusion and inability to cope at home. She has become virtually immobile and complains of severe weakness and fatigue. She has lost a significant amount of weight over the months just before hospitalization. On investigation, she is found to have diffuse bilateral brain metastases, for which she receives palliative radiotherapy. After this, Mrs. A. is told that there are no longer any curative treatments available. She becomes quite withdrawn, and staff and family note her spontaneously crying on several occasions. Her appetite diminishes significantly, and she refuses to take oral nutrition. Occasionally, she refuses her oral medications, believing that they are causing her to see things. Her energy level declines as the hospital admission progresses. She is noted to be sleeping most of the time. When she is able to converse, she has some difficulty retaining information over the short term. She wishes for the cancer to “take her quickly” but denies any intent to harm herself. She is noted to be fidgety and frequently pulls at her hair when speaking to physicians.
She has a history of anxiety treated with alprazolam for more than 20 years. Notably, 6 months before this admission she was started on bupropion 150 mg, which had reportedly lessened her crying episodes. In the past she cared for a sister who had bowel cancer.
She is seen by the Psychiatry Consultation Liaison service for assessment of her cognition and for possible depression.
As the clinical case highlights, the physical and psychological aspects of illness occur in tandem and are linked by a complex interplay of cause and effect. It frequently becomes difficult to separate the two. In fact, the act of trying to do so may result in missing some important links in treating the spectrum of suffering a person may experience when facing a life-threatening illness or the end of life.
A psychological response to the presence of stressors is the norm. We think about what is happening, and we draw on our past experience to direct us how to cope.
A discussion of what is meant by stress, distress, and coping is a necessary but often underappreciated and misunderstood step in understanding the possible genesis of clinical syndromes involving depression and anxiety.
“Psychological stress is a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being”. That is to say, distress occurs when the situation is thought by the person to exceed his or her ability to cope.
Cognitive appraisal is the process of “categorizing an encounter, and its various facets, with respect to its significance for well-being”. Appraisal in turn is affected by a person’s associations (real or imagined), which have been formed by their own history of contact with illness, death, and dying. For instance, in the clinical vignette, Mrs. A had watched her sister become more fatigued and withdrawn before her death, which Mrs. A described as “dreadful”; Mrs. A’s fears about her own death became amplified as she projected what was in store for her. In this case, the outcome of the appraisal process was anxiety, worry, and tension.
Anxiety may precede the appraisal process just as much as follow it. In the former case, anxiety serves as a signal of the presence of a stressor in the environment, such as being told that no further treatment is available. In the latter case, the presence of excessive amounts of anxiety is a sign of incomplete or maladaptive coping.
Coping is defined as a series of “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person”. Coping, then, is a process whereby a person manages stress, and thereby manages anxiety. Coping is the response to restore homeostasis—that is, to reduce or contain the feeling of anxiety.
Adaptation, or coping, can be categorized into three main streams:
- 1
Problem-based coping: In this type of coping, a problem is identified and a solution is sought to ease the distress. For example, “I am in pain, so I will take some morphine.”
- 2
Emotion-focused coping: Here the focus is not on solving the problem at hand; rather, it is to modulate the feelings that are caused by the problem; for example, “I am nervous about the results of the MRI scan, so I will distract myself by watching television.”
- 3
Meaning-based coping: In this method of coping, the focus is finding a meaning in the events that have taken place, to see things in a larger context. The meaning that one assigns to an event will be a reflection of one’s core beliefs about the world. For example, “I will put up with the pain so that I can attend my daughter’s wedding in 2 weeks.”
People may have developed any combination of these methods of coping. Typically people try to use what has worked in the past as their primary and first response. Difficulties may arise when, for example, a person typically utilizes a problem-solving approach and is told there is no further treatment available. Thus, there is no solution of curing the disease. The result may be a crisis because the person’s primary coping method has been taken away.
The awareness and articulation of underlying psychological processes is quite variable in different people. It is readily apparent that pain can consist of various dimensions, encompassing the physical, the psychological, and the spiritual. It is possible for psychological symptoms to be interpreted in the physical domain, resulting in complaints of increased physical pain.
Patients may be under the impression that psychological pain is always normal, that it must be endured, and that there is no method of addressing it. By believing that their suffering is normal, they may be afraid to bring up their psychological distress for fear of being labeled as weak. It is necessary for the clinician to broach these subjects, to explore and normalize the presence of psychological reactions, and to assess for the presence of distress as a result of incomplete coping, whether this takes the form of demoralization or as symptoms or syndromes of depression or anxiety.
This discussion now turns to the clinical syndromes of depression and anxiety. They are discussed together because their symptomatology often overlap; in fact, some see them as existing on the same emotional spectrum.
Depression
Depression is a commonly used word that has multiple meanings, frequently resulting in miscommunication and misunderstanding. Colloquially, it is often used a synonym for a feeling of sadness, the presence of tears, or to describe a multitude of more nuanced emotions for which the person has no vocabulary.
It is a common belief that sadness or “depression” is the natural reaction to the distressing events at the end of life, such as learning that one’s disease is progressing or that there is no longer any curative treatment; when one is suffering significant physical impairment or pain; or when one is reflecting on facing the end of life. “Who wouldn’t be depressed?” is the common phrase heard from the affected individual, from his or her support network, or even from within the interdisciplinary treatment team.
As previously discussed, the presence of distress, as manifested by sadness or anxiety, over the course of any chronic life-threatening illness is likely to be one of the normal reactions to either external or internal cues. Mrs. A, for example, cried more after the news of the absence of any further curative treatment. Her internal cue was the thought that she was going to die. The presence of distress needs to be differentiated from clinical depression, which has a much more precise definition.
The accurate and timely diagnosis of depression is critical. A recent meta-analysis has demonstrated that both depressive symptoms and clinical depression are small but statistically significant predictors of mortality in cancer patients, although not of disease progression.
Depression may lead to a lowered functional status. For instance, concentration problems may hamper adherence with treatments. Depression results in a lower ability to cope with either physical or psychological issues that arise as illness progresses, resulting in increased dysfunction and, ultimately, in increased suffering.
Diagnosis
Clinical depression is a syndrome consisting of the presence of five of nine possible symptoms, according to the Diagnostic and Statistical Manual of Mental Disorders, edition IV-TR (DSM IV-TR), the diagnostic manual of the American Psychiatric Association ( Box 10-1 ).
Depressed mood most of the day, nearly every day
Markedly diminished interest or pleasure in all, or almost all, activities of the day
Significant weight loss or gain
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropriate guilt
Diminished ability to think or concentrate, or indecisiveness
Recurrent thoughts of death (not just fear of dying), suicidal ideation, suicide attempt, or a specific plan for committing suicide
With respect to specific symptoms, there must be the presence of a depressed mood and / or markedly diminished interest or pleasure in all or almost all daily activities. These symptoms must cause clinically significant distress or impairment in the person’s function, and the symptoms must not be due to the direct physiologic effects of a substance or a general medical condition. Notably, these are usually assessed on the basis of self-report but also can be assessed by external observation.
In the physically ill person, there may be marked overlap between the symptoms of illness or side effects from medications and the physical manifestations of depression. Indeed, it may be very difficult or impossible to distinguish them. For instance, in the case of Mrs. A, her weakness, fatigue, sleep disturbance, change in appetite leading to weight loss, and cognitive difficulties may be symptoms of advanced disease and/or depression.
Therefore, there are multiple approaches one can take to try to solve this dilemma, each with its own implications. In an inclusive approach, the physical symptoms are taken as indicators of depression regardless of the cause. This will yield a higher rate of diagnosis of depression and potentially more false positives. One could exclude any physical symptoms from the diagnosis; however, the result would be many fewer diagnoses of depression and one would run the risk of missing a clinically significant issue.
Others have suggested a substitutive approach, where the physical symptoms have psychological analogues ( Table 10-1 ).
| Symptom | Substitution |
|---|---|
| Significant weight loss or gain | Depressed appearance |
| Insomnia or hypersomnia | Social withdrawal or decreased talkativeness |
| Fatigue or loss of energy | Brooding, self-pity, or pessimism |
| Diminished ability to think or concentrate, or indecisiveness | Lack of reactivity, cannot be cheered up |
There is some evidence that asking the single question “Are you depressed?” may provide an accurate assessment of the presence of the clinical syndrome of depression.
Depression is not a categorical diagnosis. That is, one does not either have or not have depression. More realistically, depression is experienced along a continuum, ranging from mild to extremely severe. It is important to rate the severity, as it affects the choice and efficacy of treatment. It has been shown that mild depression may respond to psychotherapeutic techniques alone, whereas moderate to severe depressive disorders respond best to a combination of psychotherapeutic and medication management strategies.
Depression, especially in severe cases, may present with psychotic symptoms. This may involve the presence of hallucinations in any sensory modality, although auditory and visual hallucinations are most likely. There may be the presence of delusions: fixed beliefs about something despite incontrovertible evidence to the contrary.
The differential diagnosis of depression can include other psychological/psychiatric illnesses such as bipolar disorder, substance abuse, anxiety disorders, schizophrenia, or delirium. One must rule out a bipolar disorder because starting an antidepressant medication may induce a manic episode. Ask about a previous history of mania or times when the mood has been elevated, expansive, or very irritable. Other symptoms of the manic phase of a bipolar disorder include the following:
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Inflated self-esteem or grandiosity
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Markedly decreased need for sleep
- •
More talkative than usual
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Flight of ideas or racing thoughts
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Distractibility
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Increase in goal-directed activity
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Excessive involvement in pleasurable activities that have high potential for painful consequences
From a medical perspective, one should be aware of common medical problems leading to depressive symptoms, such as hypothyroidism, low vitamin B 12 or folate levels, anemia, low testosterone levels in men, and substance abuse. The alleviation of physical pain is critical because uncontrolled pain may lead to feelings of helplessness and/or hopelessness around the future, resulting in poorer coping, and ultimately accelerate the onset of or worsen an already present depression. Conversely, the presence of depression may worsen existing physical pain.
Delirium may mimic the symptoms of depression. The major differentiation lies in the fluctuating level of consciousness seen in delirium (see Delirium for a more complete discussion). The connection between depression and anxiety is a strong one; each can fuel or cause the other. This connection is discussed in greater detail later in this chapter in the section on anxiety disorders.
Consideration must be given to the cultural context in which depression occurs. Some cultures do not have a word for depression, or it may be considered a weakness to have or show any such emotion. Cultural norms can greatly affect the expression of emotions, and knowledge of these norms aids in understanding the genesis and “normality” of a person’s reactions.
Clarke and Kissane have proposed a demoralization syndrome consisting of the core features of hopelessness, loss of meaning, and existential distress, but not necessarily accompanied by a feeling of sadness or anhedonia. There may exist the ability to enjoy a pleasurable experience, so-called consummatory pleasure, but it is difficult for the demoralized person to anticipate pleasure. Depression is thought to lack both consummatory and anticipatory pleasure. At the present, there is a lack of clinical data demonstrating the uniqueness of this syndrome from depression.
Screening Tools
Screening tools are not meant to make the diagnosis of depression, but they can be applied to rapidly assess for the likelihood of a clinically significant syndrome of depression, aid in assessing severity of depression, and be administered sequentially over time to monitor treatment response. Following are two commonly used scales:
- •
The Beck Depression Inventory-short form (BDI-sf)
- •
Hospital and Anxiety and Depression Scale (HADS)
The BDI-sf is a 13-item scale (compared with the standard BDI, which has 21 items) designed to screen for depression in medical patients. The HADS is a 14-item scale with the subscales of depression and anxiety. It places greater emphasis on cognitive symptoms than somatic symptoms.
Prevalence
Given the aforementioned issues in the diagnosis of depression, it is not surprising that the prevalence rates in individuals with cancer range anywhere from 3% to just under 50%. These studies are inconsistent with regard to stage of disease and prognosis; it is not completely clear if the risk of depression increases with disease progression. Certainly, there are points in the disease process that place the individual at greater risk of emotional distress, such as failing a specific treatment or therapy, learning that no further curative or disease-controlling treatments are available, and losses in functional status.
Risk Factors
The robust risk factors in depression include the following:
- •
Gender: Females have approximately a two times higher risk than males.
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History of depression: Individuals with previous episodes of depression are at higher risk for subsequent depression.
- •
Family history of depression: There is good evidence to indicate a genetic component to the transmission of depression.
- •
Lack of social support: The presence of a supportive network is a strong positive factor that helps bolster resilience to distress.
- •
Functional status: Declining functional status is associated with higher incidence of depression.
- •
Poorly controlled pain: Individuals with pain are at higher risk for depression than those whose pain is adequately controlled.
- •
Type of malignancy: Depression is more prevalent in those with pancreatic cancers than other intra-abdominal malignancies.
- •
Substance abuse: Be wary of abuse of painkillers, alcohol, or illicit substances.
- •
Poor adaptation to past life crisis: This will be discussed in detail in the anxiety section of this chapter.
Management
The biopsychosocial model provides a comprehensive, multidimensional way to think about treatment that considers the biological sphere, the persons’ inner psychology, and the social milieu.
Pharmacologic Treatment
In the biological sphere, the first action is to rule out physical causes and to correct them if possible. For instance, simple blood tests to check levels of vitamin B 12 , folate, thyroid-stimulating hormone, and hemoglobin can rule out correctable causes of fatigue. The treatment of fatigue can subjectively improve a person’s outlook tremendously. Steroids may cause depression or mood lability. Antineoplastic agents may do the same. Although it may not be possible to discontinue the medications that cause or contribute to depression, the simple act of informing patients of these effects may help them to cope by allowing them to attribute their symptoms to an external source instead of to themselves.
Because they are readily available and relatively easy to apply, pharmacologic agents are the mainstay in treating depression. They comprise antidepressants, psychostimulants, and mood stabilizers ( Table 10-2 ).
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