Canterbury DHB

Context

Depression in Cancer Patients

Depressive symptoms are relatively common in patients with malignant disease, and probably 20–30% experience significant depressive symptoms.

Clinical depression is generally under-detected in oncology/haematology settings. While severity of these depressive symptoms is generally less than in psychiatric patients without malignant illness, nonetheless they can have significant consequences.

Cancer patients with a history of depression are at risk of a worse clinical outcome, have deceased treatment compliance, quality of life, and longer stays in hospital.

Under-recognition is caused by multiple factors but include the complication of overlapping symptoms of depression and cancer, overlapping treatment side effects, especially fatigue and nausea, and because feeling upset or sad could be viewed as simply a natural reaction to illness.

Given the consequences of under-treating depression, the recommended diagnostic approach is to be inclusive of all symptoms even if there is a likelihood that these are secondary to medical illness or treatment.

There are few well-controlled trials of antidepressants in people with cancer, but most available data shows that most people will show a response to antidepressant medication. There is considerable data to show that psychological treatments also alleviate symptoms. Evidence suggests that combining psychological and pharmacological approaches can have an additive beneficial effect.

Unless the situation is urgent, in the first instance referral for a fuller assessment of symptoms and diagnostic work-up can be made to the Clinical Psychologist (part-time, pager 8928).

When considering the need for antidepressant treatment, the initiation of antidepressants needs to take into account that the patient is usually on multiple other medications, and they may be more sensitive to anti-depressant-related adverse effects.

In This Section

Drug Treatment of Depression in Patients with Cancer

Drug Treatment of Depression in Patients with Cancer

Antidepressants may be effective in treating major depressive disorder irrespective of whether the mood disturbance is “understandable”. There have been relatively few trials of antidepressants in patients who are also physically unwell and even fewer in patients with cancer. A recent Cochrane review reported that antidepressants are effective in patients with medical illness. It noted that response rates may be lower than in non-medically ill patients and that discontinuation due to side effects is more common.

There are four major classes of antidepressant:

  1. Tricyclic antidepressants.
  2. Selective serotonin reuptake inhibitors.
  3. Monoamine oxidase inhibitors.
  4. Others (e.g. nefazodone, venlafaxine).

There is no consistent evidence that one class of antidepressant is superior to others. Despite clinicians’ beliefs, systematic reviews show that differences in overall tolerability between different preparations are minimal.

Patients are slightly less likely to drop out of trials because of unacceptable side effects when taking an SSRI but are slightly less likely to drop out because of treatment inefficacy when taking a TCA.

Currently, SSRIs are generally preferred in patients with cancer, largely because of fewer anticholinergic, antihistaminic, sedative, and hypotensive side effects. Citalopram is the preferred SSRI due to its probable lower rate of pharmacokinetic interactions with other drugs. The evidence for this practice is based on open trials, case reports, and clinical consensus.

About this Canterbury DHB document (5049):

Document Owner:

Sean Macpherson (see Who's Who)

Issue Date:

January 2019

Next Review:

January 2022

Keywords:

Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer

Topic Code: 5049