In 2000, Michael Sharpe, a psychiatrist and senior lecturer at the University of Edinburgh Cancer Research UK Centre in Scotland, was interviewing cancer survivors to confirm a diagnosis of clinical depression for a research study, when he noticed a disturbing trend. “It seemed to me that while they had very good cancer treatment, the job was often not finished,” Sharpe recalls. “Many of them came through their cancer treatments, and one notably said to me, ‘I went through that treatment and they say I’m cured, but I wish I’d died.’ ”
Clinical depression, characterized by a persistent lack of interest in all activities or a feeling of hopelessness that lasts two weeks or more, affects an estimated 10 percent of cancer survivors, which is two times the rate in the general population, according to Sharpe, who is now a professor of psychological medicine at the University of Oxford in England. Symptoms of depression are often overlooked or dismissed, he says. “Even if patients and doctors pick up that the patient is feeling very low, they see this as normal for having cancer,” Sharpe says. “Rather than thinking, ‘I should treat that,’ they say, ‘Well, they’ve got cancer—that’s what you’d expect.’ ”
Initiatives that emphasize treating the whole cancer patient, including addressing the patient’s emotional health and financial well-being, may help to identify more patients with depression. Starting in 2015, the American College of Surgeons Commission on Cancer, a consortium that sets quality care standards and accreditation for hospitals, will require cancer centers to screen patients for psychosocial distress, including depression.
Sharpe says these screening methods need to be followed by collaborative and systematic treatment in order to ensure survivors with depression get the help they need. He and colleagues published research in the Sept. 20, 2014, issue of the Lancet that validates an approach that provides survivors who have signs of depression with one-on-one support from nurses who are trained and indirectly supervised by psychiatrists.
Sharpe spoke with Cancer Today about better ways to identify and treat depression in cancer patients.
CT: How would you describe the current standard in identifying patients with cancer who may also have depression?
SHARPE: The good news is this issue has really moved up the agenda. In 2007, the Institute of Medicine released a report, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, which examined how the health care system copes with cancer patients’ psychological and social problems. And beginning in 2015, the American College of Surgeons is mandating that comprehensive cancer services use a basic questionnaire for what they call psychosocial distress. However, what we do with that survey is important. It’s only really worth screening if you’ve got a very good system for treating.
We know there’s a lot of evidence, from cancer and from other conditions, that it’s wishful thinking to think if you screen and tell the primary care doctor that the patient has depression, that the patient will get an adequate level of help to improve their condition. You get a bit of an increase in prescribing antidepressants, but it doesn’t really improve patient outcomes.
CT: What did your research show in this area?
SHARPE: In our most recently published study in the Lancet, we used screening to identify 500 cancer patients with major depression. Half the patients were given usual care, and half were allocated to our new intervention, “Depression Care for People with Cancer” (DCPC). In the usual care group, we told the patients that they had depression, informed their oncologists and primary care doctors, and encouraged them all to do something about it. The outcome for that usual care group was terrible. Six months after the intervention, only 17 percent of these survivors responded to the usual care. This really suggests, and there are similar findings from others studies, that screening and informing on their own aren’t enough.
CT: In your study, 62 percent of patients who received DCPC reported feeling better and responded to treatment for their depression. What made the difference?
SHARPE: These survivors didn’t have to go to a separate clinic; they saw a cancer nurse for their depression. We spent a lot of time at the beginning explaining to the patient what depression was and how it was treated, and listening to survivors’ concerns about taking antidepressants and having a diagnosis of depression. This enabled survivors to come to the view that it actually was worth getting treatment for their depression, which linked treatment and engagement.
The second bit that’s critical is that we gave them intensive treatments for depression. People who have been through cancer treatment particularly are often made very passive. They’ve had huge changes in their life; they often become very inactive. We combined the use of antidepressants with two non-pharmacological treatments. One non-pharmacological treatment was behavioral activation, which was to help them get going again in their lives. The other was problem-solving therapy to help them feel more in control of things and to address some of the challenges.
CT: How does one distinguish between clinical depression and normal emotional adjustment to cancer?
SHARPE: There are some basic red flags: if someone is clearly feeling very low or down most of the time for a minimum of two weeks, but usually longer, or if they seem to have lost interest in everything and seem very withdrawn. Other things like having poor sleep, poor appetite and feeling tired are all part and parcel of the cancer and the treatment, so it’s a persistent low mood or loss of interest in things, particularly after treatment’s finished, that is a sign that there’s something more going on than a normal emotional adjustment.
CT: Why do some people with cancer become depressed while others do not?
SHARPE: Obviously some people are just more vulnerable to depression than others. That may reflect their genes, childhood experience, situation or social support. But there are cancer factors as well. We know that some cancers, like lung cancer, have a higher rate of depression than other cancers, like prostate cancer. Some of the less treatable and more disabling cancers, not surprisingly, have high rates of depression.
CT: For patients who suspect they have depression, what do you recommend?
SHARPE: Depression does occur commonly with cancer and its treatment, so don’t just dismiss the symptoms as a part of cancer. Depression is not a sign of weakness or failing in the fight against cancer. It is understandable, and it is also treatable. If a patient’s mood stays low most of the time or he or she loses the ability to enjoy things for two weeks or more, it may be time to seek someone to treat symptoms. For treatment, consider both medication and behavioral therapy—it is often best to have both. Most people get better from depression, although they may need to take medication to stay well. So above all, don’t give up hope of feeling better.
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