Peg Esper
DEFINITION AND INCIDENCE
The term “depression” can be used to describe an emotional state that may be as simple as minor mood alterations or as major as a pathological inability to function or cope with life (Breitbart, Dickerson, Shuster et al., 2002). Reactive, or situational, depression is a common and expected response to a life-threatening disease. Reactive depression is generally self-limiting and resolves as the individual uses education, support, and other coping resources to face the threat against well-being.
A depressed mood becomes a problem for patients when it is prolonged or severe and interferes with daily functioning. Depressed mood related to an identifiable psychosocial stressor that exceeds what would be normally expected or that impairs social or occupational functioning may fit the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for an Adjustment Disorder with Depressed Mood (Strain, 1998). Although less specific than the criteria for Major Depressive Disorder, this diagnosis does allow for identification of early or temporary depressed states and can assist in obtaining appropriate treatment.
Major Depressive Disorder is a serious medical condition that disrupts an individual’s mood, behavior, thought processes, and physical health (American Psychiatric Association, 2000a). The DSM-IV criteria for this diagnosis are listed in Box 25-1.
Box 25-1
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At least five of the following symptoms have been present most of the day, or almost every day, for at least 2 weeks. At least one of the symptoms must be item 1 or 2.
1. Depressed mood (feeling sad or empty; appears tearful)
2. Markedly decreased interest or pleasure in all, or almost all, activities
3. Significant weight loss
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness, or excessive or inappropriate guilt
8. Diminished ability to think or concentrate, or indecisiveness
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation, or suicide attempt
From American Psychiatric Association (2000a). Major depressive disorder: A patient and family guide. Washington, DC; Author: American Psychiatric Association (2000b). Practice guidelines for the treatment of patients with major depression (2nd ed.). Washington, DC: Author.
Many studies document the prevalence of depression in various populations. However, these studies are somewhat difficult to compare since the researchers do not always differentiate among reactive depression, adjustment disorders, and major depressive disorders. The incidence of depressive symptoms in cancer patients varies among studies, but it is thought to be as high as 25% for significant mood disturbance (Goy & Ganzini, 2003). Depression is seen in equal proportions in patients without cancer who have terminal diagnoses (Waller & Caroline, 2000).
The data on incidence of major depressive episodes in persons with advanced cancer show less variability than do the preceding studies, probably because the criteria for major depression are well defined. Approximately 5% to 15% of patients with advanced cancer have a major depressive disorder (Hinshaw, Carnahan, & Johnson, 2002).
ETIOLOGY AND PATHOPHYSIOLOGY
Recent research into the etiology of depression has found what appears to be complex bidirectional relationships among neural, endocrine, and immune systems (Illman, Corringham, Robinson et al., 2005). These data lend support for a theory of cytokine-mediated depression. Interleukin-6 has been specifically identified as higher in individuals with acute depressive conditions (Illman et al., 2005). Overactivity of the hypothalamic-pituitary-adrenal axis has also been implicated in the development of depression. This combination is believed to have an overall immunosuppressive effect on the patient (Hinshaw et al., 2002).
There are a number of risk factors associated with a diagnosis of depression (Goldberg, 2004; Hinshaw et al., 2002; Paice, 2002):
▪ Older age
▪ Diagnosis with a chronic or life-threatening illness
▪ Unmanaged symptoms, especially pain
▪ Lack of social support
▪ Self-concept disturbance, due to changes in body image or ability to carry out roles
▪ History of substance use
▪ Personal or family history of depression
▪ Difficulty in expressing emotions
▪ Spiritual or existential distress
▪ Use of medications with depressive side effects, including antihypertensives, benzodiazepines, corticosteroids, neuroleptics, amphotericin B, and certain chemotherapy agents
▪ Disease-related metabolic changes, nutritional deficiencies, systemic infections, hypercalcemia, the syndrome of inappropriate antidiuretic hormone, hypothyroidism or hyperthyroidism, and adrenal insufficiency
ASSESSMENT AND MEASUREMENT
As individuals face end-of-life, the emotions that accompany the dying process can be overwhelming. The terminally ill experience multiple losses and naturally grieve these losses. Although reactive depression is normal, it is nonetheless distressing and should not be ignored. It is extremely important that the clinician assess for signs of a depressed mood and determine the severity of the patient’s depression—from mood change to adjustment disorder to major depression—and provide for the appropriate management for all levels of depression.
Assessment of Depression
The problem often cited when assessing major depression in persons with advanced diseases is that many of the somatic symptoms of depression (e.g., weight loss, fatigue, sleeping alterations) overlap with the symptoms of the disease process itself. Thus, the clinician must focus on the psychological symptoms of depressed mood, decreased interest in activities, inability to concentrate, feelings of worthlessness or excessive guilt, and recurrent death wishes as potential signs of depression (Goldberg, 2004; Nelson, 2002). In a major depression, these symptoms are present every day or almost every day for at least 2 weeks.
Major depression may be classified as mild, moderate, or severe on the basis of the severity of the symptoms. Mild depressive episodes have minimal symptoms and minor functional impairment. Moderate depression is characterized by symptoms that exceed the minimum and a greater degree of functional impairment. Severe episodes of depression involve the presence of several symptoms in excess of the minimum, and these symptoms markedly interfere with social or occupational functioning (American Psychiatric Association, 2000b).
It is often helpful to use a screening tool to assist in identifying the presence and, to some degree, the severity of depressed mood states. Information from one of the following assessment tools assists the clinician in identifying those persons who require a more detailed evaluation of their depressed mood and incorporating an instrument that best fits the practice setting.
▪ Beck Depression Inventory: The patient is asked a series of 21 questions that are scored to determine depression (Beck & Steer, 1987). This tool is based on the DSM criteria for depression.
▪ Hospital Anxiety and Depression (HAD) scale: This 14-item self-report tool excludes most of the somatic symptoms of depression that are often symptoms of advanced disease and takes about 5 to 7 minutes to complete (Zabora, 1998). This tool cannot distinguish between depression and sadness (Carroll, Callies, & Noyes, 1993).
▪ Geriatric Depression Scale: This tool is designed specifically for assessing depression in the elderly. It is a 30-item subjective questionnaire that excludes somatic complaints, focusing on the psychosocial symptoms of depression (Koenig, Meador, & Cohen, 1988).
▪ In evaluating effectiveness of measurement tools to screen for and evaluate ongoing depression, the measure with the best sensitivity, specificity, and positive predictive value in a study conducted by Lloyd-Williams, Spiller, and Ward (2003) was identified to be the act of asking the patient, “Are you depressed?” (Nelson, 2002).
▪ Distress Thermometer: The National Comprehensive Cancer Network (NCCN) recommends use of a symptom distress thermometer that includes a 0-to-10 rating scale for any kind of distress that the individual is feeling. The patient places a mark on the thermometer in response to the question, “How distressed have you been in the past week?” A mark of 5 or higher should be further evaluated by the clinician (NCCN, 2005).
Assessment of Suicide Risk
Although suicide is relatively uncommon among cancer patients, this population has a risk of committing suicide twice that of the general population (Hinshaw et al., 2002). Essentially all persons in palliative care programs have one of the risk factors for suicide: advanced disease and poor prognosis; a suicide assessment is essential for all persons with depressed mood states.
The clinician must assess for additional factors associated with a higher risk for suicide (Goldberg, 2004; Waller & Caroline, 2000):
▪ Uncontrolled symptoms, including pain, fatigue, and emotional suffering
▪ Feelings of hopelessness and despair
▪ Men are at greater risk than women
▪ Higher incidence in oral, pharyngeal, or lung cancer or AIDS
▪ Delirium
▪ History of substance abuse, psychiatric disorder, or suicide attempt
▪ Familial history of suicide
▪ Social isolation
▪ Recent death of a loved one
It is essential that the clinician assess the seriousness of suicidal intent by asking patients whether they have ever considered taking their own lives. Further questioning is then necessary to determine whether the individual has a plan for self-harm, to establish the specificity of the plan, and to determine whether the patient has the means to carry it out. Mental health experts emphasize that any patient who has devised a plan and a means to commit suicide should be immediately referred for a thorough psychiatric evaluation. The assessment for suicide risk is ongoing. It is especially important to reevaluate the severely depressed patient who is frequently undergoing treatment for depression. A patient without the energy to follow through on a suicidal act while severely depressed may indeed have the energy as the depression lessens.
HISTORY AND PHYSICAL EXAMINATION
The patient’s feelings of hopelessness, worthlessness, or suicidal ideation must be fully explored along with a thorough physical assessment of the somatic responses to depression (Breitbart et al., 2002; Goldberg, 2004; Hinshaw et al., 2002; Mystakidou, Rosenfeld, Parpa et al., 2005). Changes in heart rate and respiratory rate may indicate anxiety, which often accompanies depression.
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