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Geriatric Oncology

Untangling the Complexities of Depression Diagnosis in Older Cancer Patients

^aDepartment of Psychiatry, Weill Cornell Medical College, White Plains, New York, USA; ^bDepartment of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, New York, USA

Key Words. Depression diagnosis • Cancer • Geriatrics

Correspondence: Christian J. Nelson, Ph.D., Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, 641 Lexington Avenue, 7th Floor, New York, New York 10022, USA. Telephone: 646-888-0030; Fax: 212-888-2356; e-mail: nelsonc{at}mskcc.org

Received July 8, 2008; accepted for publication December 14, 2008; first published online in THE ONCOLOGIST Express on January 14, 2009.

Disclosures

Mark I. Weinberger: None; Andrew J. Roth: None; Christian J. Nelson: None

Section editors Matti S. Aapro and Arti Hurria have disclosed no financial relationships relevant to the content of this article.

The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias.

Target audience: Physicians who wish to advance their current knowledge of clinical cancer medicine in geriatric oncology.

	Learning Objectives

Top Learning Objectives Abstract Introduction Diagnostic Criteria for Major... Depression in Cancer Patients Depression in Geriatric Patients Depression in Geriatric Cancer... Treatment of Geriatric... Treatment for Depressed Cancer... Summary and Conclusion Author Contributions References

 

1. Identify the two "gateway" symptoms of depression.
   
2. Describe and differentiate symptoms of depression in cancer patients.
   
3. Analyze the most common symptoms of depression in geriatric cancer patients in order to determine best care management.
   

	ABSTRACT

Top Learning Objectives Abstract Introduction Diagnostic Criteria for Major... Depression in Cancer Patients Depression in Geriatric Patients Depression in Geriatric Cancer... Treatment of Geriatric... Treatment for Depressed Cancer... Summary and Conclusion Author Contributions References

 
This review article discusses the complexities of diagnosing depression in older, geriatric cancer patients. There has been little research conducted with this population on the assessment, recognition, and treatment of depression, and thus increased attention is required to improve care for these individuals. Depressive symptoms often manifest themselves differently in both cancer patients and older patients, and therefore a modified and adapted way of assessment must be employed when thinking about diagnosing and treating these patients.

	INTRODUCTION

Top Learning Objectives Abstract Introduction Diagnostic Criteria for Major... Depression in Cancer Patients Depression in Geriatric Patients Depression in Geriatric Cancer... Treatment of Geriatric... Treatment for Depressed Cancer... Summary and Conclusion Author Contributions References

 
The prevalence of depression in the elderly with cancer is in the range of 17%–25% [1]. When considering psychiatric symptoms in cancer, depression receives the most attention because of its high prevalence, cost, and enormous impact on the individual and family [1]. Yet, despite the existing 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 [2], and significant depression is thus frequently left underdiagnosed and undertreated in older cancer patients [3–4].

One reason depression is often underdiagnosed in older cancer patients is that depressive symptoms manifest themselves differently both in later adulthood and in cancer patients. For example, the symptoms of cancer and the side effects of treatment often overlap with many symptoms of depression. Therefore, depressive symptoms may be difficult to separate from other problems associated with cancer, such as pain, anxiety, or difficulty in adjusting to the cancer diagnosis [1]. Depression in older adults is also difficult to diagnose. Symptom profiles may differ from those of younger adults because older adults often present with more somatic complaints as opposed to affective complaints (i.e., sadness, guilt, and self-criticism). Taken together, diagnosing depression in older cancer patients is specifically challenging [5].

This review focuses on depression assessment in cancer patients, in geriatric patients, and lastly, in geriatric cancer patients. This paper suggests a novel way of conceptualizing and diagnosing depression in older cancer patients that requires a modified and adapted way of assessment. Current treatment options are also discussed.

	DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSIVE DISORDER

Top Learning Objectives Abstract Introduction Diagnostic Criteria for Major... Depression in Cancer Patients Depression in Geriatric Patients Depression in Geriatric Cancer... Treatment of Geriatric... Treatment for Depressed Cancer... Summary and Conclusion Author Contributions References

 
Like all psychiatric disorders, a diagnosis of major depressive disorder has specific criteria. The two most important symptoms are a depressed mood and loss of interest or pleasure. These are generally referred to as the "gateway" symptoms of depression. Table 1 shows a list of all criteria. At least five of the symptoms of depression in Table 1, including one gateway symptom, need to be endorsed by the patient to qualify for a diagnosis of major depression.

	DEPRESSION IN CANCER PATIENTS

Top Learning Objectives Abstract Introduction Diagnostic Criteria for Major... Depression in Cancer Patients Depression in Geriatric Patients Depression in Geriatric Cancer... Treatment of Geriatric... Treatment for Depressed Cancer... Summary and Conclusion Author Contributions References

The ability to appropriately identify, assess, and treat depression in cancer patients is becoming increasingly important. Depression is associated with decreased quality of life, significant deterioration in recreational and physical activities, relationship difficulties, sleep problems, more rapidly progressing cancer symptoms, and more metastasis and pain than in nondepressed cancer patients [9]. Depression may not cause these issues, but the presence of depression typically worsens the distress experienced from these physical and psychosocial symptoms, and can interfere with effective coping. In a recent study, depression was found to be an independent predictor of poor survival in patients with advanced cancer [10], and suicide risk in cancer patients is higher than in patients with other medical illnesses [11]. This emphasizes the point that the proper assessment of depressive symptoms in cancer patients is critical, so that appropriate interventions can be offered in a timely fashion [10].

Unfortunately, depression is one of the most difficult psychiatric problems to diagnosis in cancer patients [12]. The primary difficulty is that many symptoms of cancer and side effects of treatment overlap with the symptoms of depression. For example, significant weight loss, sleep problems, fatigue/anergia, difficulty concentrating, and thoughts of suicide may be either symptoms of depression or symptoms of cancer and/or its accompanying treatment side effects. The symptoms in Table 1 highlighted with shading are all symptoms that overlap with depression and cancer or side effects of treatment, leaving only the gateway symptoms of depressed mood and loss of interest or pleasure as the two "pure" symptoms of depression in cancer patients.

This difficulty in diagnosing depression in cancer patients has led to the development of several diagnostic approaches used for the assessment of depression in this group including inclusive, etiologic, substitutive, and exclusive approaches. Overall, these categories differ on the symptoms used for the diagnosis of depression and/or whether or not it incorporates the origin or etiology of the depression. For example, the etiologic approach determines whether a somatic symptom is either illness or treatment related or a result of depression, whereas the exclusive approach excludes the somatic symptoms such as fatigue and appetite/weight change that can be seen in many cancer patients [12].

For the oncologist, busy clinics and a lack of specific training in identifying depression make it unrealistic to conduct a complete diagnostic interview for depression. To screen cancer patients for depression (Table 2), we suggest asking the two gateway questions of depressed mood and loss of interest or pleasure because these are the two "pure" symptoms of depression in cancer patients. In fact, in a recent review of the literature, Mitchell [13] examined data from 17 studies to determine whether or not using these one or two questions in the detection of depression in cancer settings is valid. The findings showed that the use of both questions assessing, respectively, "sad mood" and "loss of interest" had a sensitivity of 91% and a specificity of 86%, with a positive predictive value of 57% and a negative predictive value of 98%. Therefore, screening patients for depression using these two symptoms—depressed mood and anhedonia—may indicate to a busy clinician the patients who require more in-depth psychiatric assessment and possible intervention. To help distinguish between the somatic symptoms of depression and the side effects of disease, it may also be helpful to discuss symptoms suggested by Guo et al. [14], such as late insomnia, mood variation, anxiety, and loss of sexual interest, which offer succinct and specific evidence for a diagnosis of depression in cancer patients.

	DEPRESSION IN GERIATRIC PATIENTS

Top Learning Objectives Abstract Introduction Diagnostic Criteria for Major... Depression in Cancer Patients Depression in Geriatric Patients Depression in Geriatric Cancer... Treatment of Geriatric... Treatment for Depressed Cancer... Summary and Conclusion Author Contributions References

 
Late-life depression is becoming an increasing public health concern based on the burgeoning aging population and the association among depression and many comorbidities experienced by older adults. The high prevalence rates of geriatric depression are not surprising given that geriatric depression often affects individuals with chronic medical illnesses, cognitive impairment, or disability [15], and typically is associated with functional impairment, disability, increased economic costs, and mortality. For example, late-life depression is often associated with peripheral body changes such as hypercortisolemia, increased abdominal fat and risk for type 2 diabetes, hypertension, decreased bone density, and cognitive impairment [16, 17].

There has been a great deal of attention in the literature directed at the proper recognition and assessment of depression in later adulthood. The recognition and assessment of depression in this population are difficult because older adults are less likely than younger adults to report the two "gateway" symptoms of sad mood or loss of pleasure or interest [15, 18]. Table 3 shows the common and uncommon symptoms of depression in older adults. When compared with younger adults, older adults also tend to report fewer cognitive/mood symptoms such as self-criticism, guilt, and sense of failure [18–20]. Older adults are more likely to endorse somatic symptoms of depression such as sleep problems and stomach aches [18–20]. However, the somatic symptoms of depression are a particular source of concern when assessing mood, because these symptoms may be confounded with general aging issues or physical health problems.

Suicide is also a major concern in older adults, and is almost twice as likely as in younger populations [24], making assessment and recognition of geriatric depression even more important. In fact, many older adults who commit suicide are reported to have visited a primary care physician shortly before suiciding [25]. The issue of suicide is of even more relevance in older adults with cancer who are at higher risk for suicide than older adults with other medical illnesses, even after controlling for psychiatric illness and risk of dying within the year [26].

	DEPRESSION IN GERIATRIC CANCER PATIENTS

Top Learning Objectives Abstract Introduction Diagnostic Criteria for Major... Depression in Cancer Patients Depression in Geriatric Patients Depression in Geriatric Cancer... Treatment of Geriatric... Treatment for Depressed Cancer... Summary and Conclusion Author Contributions References

 
Identifying depression in older cancer patients presents a unique challenge to clinicians and researchers because it combines the difficulty of diagnosing depression in cancer patients with the complexities of detecting depression in older adults. As discussed, the two gateway symptoms of depressed mood and loss of pleasure or interest are crucial for assessing depression in cancer patients, yet older depressed patients are less likely to endorse these questions. Of interest, the somatic symptoms tend to be more relevant for older patients; however, as in depression in younger cancer patients, many symptoms of the disease and side effects of the treatment overlap with common somatic symptoms of depression in older adults (Table 3, shaded items).

Despite these difficulties, the research in this area provides a guide for specific suggestions for identifying depression in older cancer patients (Table 4). A screen of the two gateway symptoms of depression should be administered first (i.e., depressed mood and loss of interest). Even though it is less common for older adults to endorse the two gateway symptoms, a proper and thorough assessment of depression should still begin with asking about these two symptoms. Even if the patient denies these gateway questions, it is important to elicit information about other potential symptoms of depression in this sample including "general malaise," as opposed to being depressed or loss of interest, or "general" aches and pains or stomach aches, as opposed to specific tumor site pain or a specific side effect of the cancer treatment. Hopelessness may also be an important aspect to discuss; many cancer patients express some hope for the future, so reporting little or no hope may be a sign of depression. Sleep is difficult for both cancer patients 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. An older depressed patient may also report mood variation during the day. For example, the patient may report that during part of the day their mood is normal (i.e., euthymic); however, they may spend most of the day with a general malaise. Research also suggests that establishing a good rapport in a more open-ended manner with older patients is essential, so that the patient feels comfortable reporting depressive symptoms.

	TREATMENT OF GERIATRIC DEPRESSION

Top Learning Objectives Abstract Introduction Diagnostic Criteria for Major... Depression in Cancer Patients Depression in Geriatric Patients Depression in Geriatric Cancer... Treatment of Geriatric... Treatment for Depressed Cancer... Summary and Conclusion Author Contributions References

Despite these concerns, there is sound evidence supporting the use of medications in treating late-life depression, especially at moderate to severe levels [28]. Based on expert consensus guidelines for unipolar nonpsychotic major depression, the first-line treatment for late-life depression is an antidepressant (selective serotonin reuptake inhibitor [SSRI] or venlafaxine extended release are preferred) plus psychotherapy [27]. In a more recent review of late-life depression, Alexopoulos [15] summarizes that SSRIs and serotonin-norepinephrine reuptake inhibitor are the first-line antidepressants, followed by bupropion and mirtazapine. While often started at low doses, optimal antidepressant doses are usually similar to doses seen in younger adults.

There have been a number of studies that have also demonstrated the effectiveness of structured psychotherapy with older patients. Behavior therapy [29], cognitive behavioral therapy (CBT) [30], and interpersonal psychotherapy [31, 32] have all been shown to be effective with healthy, older adults in treating depression. In a recent review of recommendations for treating late-life depression, Steinman et al. [33] found CBT to be effective with older depressed adults. CBT is a psychotherapy that focuses on symptoms of depression and examines thoughts, patterns, and behaviors that exacerbate the symptoms. In one study, dialectical behavior therapy (DBT) was found to effectively bolster the effects of antidepressant medication in depressed older adults [34]. Specifically, the DBT skills training and telephone coaching were found to be helpful.

Regardless of the evidence for effective treatments, several studies suggest that older adults tend to receive suboptimal treatment [35] and generally demonstrate poor antidepressant medication adherence [36, 37]. For example, Wei et al. [38] found that psychotherapy is underused among older adults with depression and that geographic restrictions to mental health professionals represent a significant barrier to receiving appropriate care. In a qualitative study, Givens et al. [39] investigated antidepressant adherence among older adults and found four themes that emerged to explain resistance to antidepressants. These themes were the fear of dependence, the resistance to viewing depressive symptoms as a medical illness, the concern that antidepressants would prevent natural sadness, and prior negative experiences with medications for depression.

Given the complexities of treating late-life depression in the community, it is not surprising that a multimodality approach may be needed to effectively treat geriatric depression [37, 38]. Frederick et al. [40] reviewed different community-based treatment modalities for late-life depression and concluded that a collaborative care model may be the most effective at managing geriatric depression. Collaborative care models for the treatment of depression usually involve primary care physicians, psychiatrists, therapists, psychologists, nurses, and social workers who work closely to actively manage the patient. This model appears to be superior to education and skills training, geriatric health evaluation and management, or physical rehabilitation and occupational therapy. In sum, Frederick and colleagues [40] concluded that treating depression in this population may " ... require a multifaceted approach to ensure effectiveness" (p. 33).

	TREATMENT FOR DEPRESSED CANCER PATIENTS

Top Learning Objectives Abstract Introduction Diagnostic Criteria for Major... Depression in Cancer Patients Depression in Geriatric Patients Depression in Geriatric Cancer... Treatment of Geriatric... Treatment for Depressed Cancer... Summary and Conclusion Author Contributions References

 
While there is evidence on the efficacy of treatments for geriatric depression, there is minimal evidence specifically demonstrating the effectiveness of psychological and pharmacologic treatments in cancer patients with depression [41]. Medications that are typically used to treat depression in cancer patients are those that are used to treat depression in general, including SSRIs, newer antidepressants, tricyclic antidepressants, and psychostimulants. There is growing evidence supporting the use of methylphenidate (Ritalin®; Novartis Pharmaceuticals Corp., East Hanover, NJ) to treat depression in cancer patients based on its quick response time and its alleviation of concomitant symptoms including fatigue, sedation, and poor concentration.

Like treatments for depression in noncancer populations, psychotherapies also appear to help depressed cancer patients, including psychoeducational interventions, CBT, interpersonal therapy, and problem-solving therapy. CBT has been found to help depressed cancer patients, in particular, combining behavioral activation with cognitive techniques. While electroconvulsive therapy has been widely used in treating severe depression, it is rarely used in treating depression in a cancer setting. When focusing on older cancer patients, there appears to be no gold standard treatment for depression, and thus further research is warranted in this area. Using evidence from research on community-based treatment for older adults, a combined treatment including both pharmacologic and psychotherapeutic techniques is likely the best option.

	SUMMARY AND CONCLUSION

Top Learning Objectives Abstract Introduction Diagnostic Criteria for Major... Depression in Cancer Patients Depression in Geriatric Patients Depression in Geriatric Cancer... Treatment of Geriatric... Treatment for Depressed Cancer... Summary and Conclusion Author Contributions References

 
Based on this review, it is clear that diagnosing depression in older cancer patients is difficult because symptoms of cancer and depression have distinct but overlapping symptom profiles (e.g., fatigue, lethargy, suicidal ideation). In addition, older adults often present with depressive symptoms that differ from those of younger adults (e.g., more somatic than affective symptoms). Therefore, clinicians need to be able to recognize symptoms of depression in older cancer patients in order to improve recognition, diagnosis, and treatment. This is particularly important given the high suicide rates in both older adults and older cancer patients.

Diagnosing depression in older cancer patients should focus on first assessing the two gateway symptoms of depression, although less commonly reported (i.e., anhedonia and sad mood), attempting to separate out symptoms of depression and cancer based on onset of symptoms, and focusing on subtle but nuanced symptoms in older cancer patients. In older cancer patients, there should be a greater focus on symptoms of general malaise, general aches and pains, hopelessness, late insomnia, and daily changes in mood. Increased awareness and attention are warranted in this population to determine the most suitable ways to treat this growing population. In sum, we suggest a modified and adapted way of diagnosing depression in geriatric cancer patients.

	AUTHOR CONTRIBUTIONS

Top Learning Objectives Abstract Introduction Diagnostic Criteria for Major... Depression in Cancer Patients Depression in Geriatric Patients Depression in Geriatric Cancer... Treatment of Geriatric... Treatment for Depressed Cancer... Summary and Conclusion Author Contributions References

 
Conception/design: Christian J. Nelson, Mark I. Weinberger

Administrative support: Christian J. Nelson, Andrew J. Roth

Manuscript writing: Christian J. Nelson, Mark I. Weinberger, Andrew J. Roth

Final approval of manuscript: Christian J. Nelson, Mark I. Weinberger, Andrew J. Roth

	REFERENCES

Top Learning Objectives Abstract Introduction Diagnostic Criteria for Major... Depression in Cancer Patients Depression in Geriatric Patients Depression in Geriatric Cancer... Treatment of Geriatric... Treatment for Depressed Cancer... Summary and Conclusion Author Contributions References

 

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This Article Abstract Full Text (PDF) All Versions of this Article: theoncologist.2008-0147v1 14/1/60    most recent eLetters: Submit a response to this article Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services E-mail this article link to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Reprints/Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Weinberger, M. I. Articles by Nelson, C. J. Search for Related Content PubMed PubMed Citation Articles by Weinberger, M. I. Articles by Nelson, C. J.