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Depression

Chapter 20 - Psychological Problems in Older Cancer Patients

Despite the high prevalence rates and deleterious effects of depression, elderly patients are far less likely to be diagnosed with major depression or dysthymia than any other age group. Moreover, when depression is present, it is frequently undertreated.

Depressive symptoms manifest themselves differently in both later adult- hood and in patients with cancer. For example, the symptoms of cancer and the side effects of treatment such as pain, fatigue, insomnia, changes in appetite, anxiety, or adjustment to the cancer diagnosis often overlap with many symptoms of depression. Older depressed adults often present with more somatic complaints (such as body aches and malaise) as opposed to affective complaints (i.e., sadness, guilt, and self-criticism). The prevalence of depression in patients with cancer ranges from 6% to 25%.

Many cancer centres now screen patients for general psychological distress using the distress thermometer, a brief self-administered visual analogue scale that has been used extensively and well validated in patients with cancer. This tool may be a good gateway for more elaborate screening for anxiety and depression.

Depression in Geriatric Patients with Cancer

Exploration of the two gateway symptoms of depression is important (i.e., depressed mood and loss of interest). It is important to elicit information about other potential symptoms of depression in older patients. These would include “general malaise” as opposed to being depressed or having loss of interest due to pain or fatigue, or “general” aches and pains or stomach aches as opposed to specific tumour site pain or specific side effect of cancer treatment. Hopelessness is also an important aspect to investigate; many patients with cancer express some hope for a meaningful future regardless of prognosis, or a cure of their cancer; thus reporting little or no hope for either may be a sign of depression. Sleep may be problematic for both patients with cancer and older patients; however, it is important to ask if the patient wakes up in the middle of the night (middle insomnia) and has difficulty getting back to sleep because they worry or feel anxious or wake up too early in the morning. An older depressed patient may also report mood variation during the day.

Treatment for Depressed Patients with Cancer

While there is evidence about the efficacy of treatments for geriatric depression, there is minimal evidence specifically demonstrating the effectiveness of psychological and pharmacological treatments in depressed patients with cancer. The level and duration of distress, the inability to carry out daily activities, and the response to psychotherapeutic interventions are the signs used to determine when a psychotropic medication is needed.

  • Medications that are typically used to treat depression in patients with cancer are those that are used in treating depression in general. Most commonly, serotonin-specific reuptake inhibitors (SSRIs) and seroto- nin-norepinephrine reuptake inhibitors (SNRIs) are prescribed for older patients with cancer. All antidepressants now carry a ‘Black Box’ warning for possibly causing suicidal ideation.
    • The SSRIs do not have the same risks of cardiac arrhythmias, hypotension, and troublesome anticholinergic effects such as urinary retention, memory impairment, sedation, and reduced awareness as older antidepressants, such as the tricyclic antidepressants (TCAs) do. The most common side effects of the SSRIs include gastric distress, nausea, brief periods of increased headache, and insomnia (and sometimes hypersomnia). Some patients may experience anxiety, tremour, restlessness, and akathisia, while others may feel sluggish. SSRIs can cause sexual dysfunction in men and women, a side effect that often leads to cessation of the medication even in older adults. Consideration must be given to interactions with other medications such as coumadin, digoxin, and cisplatin.
      All the SSRIs have the ability to inhibit the hepatic isoenzyme P450 2D6. It is important to consider additional drug-drug interactions especially in the elderly who may be on multiple medication regimens and have various physicians. This has been elucidated as many anti- depressants decrease effective levels of tamoxifen, a hormonal agent used in breast cancer. It appears that venlafaxine and mirtazapine are least interactive with tamoxifen, though further research is needed. SSRIs should be avoided with the chemotherapeutic agent procarbazine, which has monoamine oxidase inhibitor (MAOI)-like properties.
    • SNRIs are potent inhibitors of neuronal serotonin and nor- epinephrine reuptake. They are similar to TCAs in terms of efficacy, without the same problematic side effects. These antidepressants should also not be used in patients receiving MAOIs. Mirtazapine is a sedating antidepressant, useful in depressed patients with associated anxiety and insomnia. It has few gastrointestinal and sexual side effects and may induce weight gain. It is usually dosed at bedtime because it can be sedating.
  • Bupropion has an activating side effect profile that makes it useful in lethargic medically ill patients, yet it should be avoided in patients with a history of seizure disorders and in those who are malnourished; it may cause anxiety or restlessness in some patients.
  • TCAs may be used when patients have severe, treatment-resistant depression or have concomitant neuropathic pain syndromes; however, they are difficult for the elderly to tolerate at therapeutic doses. The anticholinergic actions of TCAs can cause confusion as well as serious tachycardia, and the quinidine-like effects of TCAs can lead to arrhythmias. Postural hypotension and dizziness may also occur; these are of particular concern for the frail, volume-depleted patient who is at risk for falls and possible osteoporosis-related fractures. Urinary retention and constipation are also problematic side effects for the elderly.
  • Psychostimulants may be used when there is coexisting fatigue or malaise. There is growing experience for supporting the use of these medications to treat depressive symptoms in patients with cancer, on the basis of their quick response time and its alleviation of concomitant symptoms of fatigue, sedation, and poor concentration. They may be useful early in the treatment of depression until an antidepressant has a chance to become therapeutic.

Choosing an antidepressant in the elderly cancer population may be based on whether a patient or a family member has responded well to an anti- depressant in the past. Other factors that should be considered include the patient’s overall health and cognitive abilities; the social and financial resources, which are often limited in this patient population; and any other existing psychiatric conditions (i.e. substance abuse, psychosis, or anxiety disorders). Additionally, it is useful to note if there is a need for physical symptom control (i.e. neuropathic pain, fatigue, and insomnia) as well as management of the psychiatric symptoms. It is helpful to consider the side effect profiles of different antidepressants that may be useful as well as those that should be avoided. For example, if a patient presents with fatigue or sedation, the most appropriate agent may be an energising antidepressant or a psychostimulant. Consider mirtazapine in a patient who is experiencing anxiety or insomnia, gastric upset, or loss of appetite.

Patients who are unable to swallow pills may be able to take an antidepressant in an elixir or mirtazapine, which comes in a soluble tablet preparation. Patients with Stomatitis secondary to chemotherapy or radiotherapy or those who have slow intestinal motility or urinary retention should receive an antidepressant with the least anticholinergic side effects such as sertraline.

Psychotherapy, including supportive therapy, psychoeducational interventions, cognitive behavioural therapy (CBT), interpersonal therapy (IPT), and problem-solving therapy also appear to help older depressed patients with cancer. Supportive techniques such as active listening with supportive comments can be readily applied by oncologists and oncology nurses. Cognitive therapy, which focuses on how an individual’s inaccurate thoughts or assessments of his/her situation lead to anxious and depressed feelings, can be used to help a patient develop an adaptive perspective on his/her circumstances.

  • CBT has been found to help depressed patients with cancer, in particular by combining behavioural activation with cognitive techniques.
  • Group therapy for patients with cancer, caregivers, and families may be advantageous, allowing individuals to receive support from others facing similar problems.

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