Depression and anxiety in cancer care

Dr Kerry-Ann Louw informs us of the likelihood of depression and anxiety in cancer care.

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High levels of mental distress for long periods of time can lead to depression and anxiety and these disorders are common in cancer patients.¹ The prevalence rates of anxiety and depression in patients with cancer living in low- and lower-middle income countries have been found to be 18% and 21% respectively, which may be higher than upper-income countries.² A person’s ability to manage a cancer diagnosis and treatment, changes over the course of the illness and depends on several factors:

• Medical factors: cancer site, symptoms, clinical course, prognosis, treatment
• Prior level of adjustment
• Pre-existing mental illness
• Personality and coping style
• Threat of illness to attaining developmental tasks and goals
• Cultural, spiritual and religious attitudes
• Level of support
• Previous experience with loss

Depression

Depressive symptoms can occur as part of the adjustment to different phases of the illness, including diagnosis, initiation and completion of treatment, survivorship, recurrence, and palliation. Depression can be caused by the cancer itself (primary and secondary tumours) or by treatments, such as steroids. Depression is often underdiagnosed and undertreated. Emotional distress may not be recognised or be normalised. There is still stigma towards mental illness and people may fear the repercussions of expressing negativity. There are also social and cultural differences in how people express their distress. On the other hand, medical conditions such as hypoactive delirium, poorly controlled pain and fatigue can be mistakenly diagnosed as depression.

Signs and symptoms of depression³

• Depressed mood most of the day, nearly every day.
• Decreased interest and pleasure in most activities most of the day, nearly every day.
• Weight loss or weight gain or increase or decrease in appetite.
• Insomnia or hypersomnia.
• Psychomotor agitation or retardation.
• Fatigue or loss of energy.
• Feelings of worthlessness or excessive guilt.
• Poor concentration, reduced ability to think or indecisiveness.
• Recurrent thoughts of death, suicidal ideation, suicide plan, suicide attempt.

There is an overlap between the physical symptoms of depression and physical symptoms caused by cancer and its treatment. Clinicians should explore what is causing the symptom when making a diagnosis of depression.⁴ Physical conditions, such as pain, that can be mistaken for depression must also be excluded, or adequately treated before a diagnosis of depression is made.

Anxiety

Anxiety is a normal response to threat, uncertainty and loss of control, and anxiety and irritability are common following the shock of a cancer diagnosis. This acute anxiety may resolve as a treatment plan is made and prognosis is clarified. Anxiety is also common at crisis points such as starting treatment and diagnosis of recurrence. Anxiety disorders such as generalised anxiety disorder, panic disorder and specific phobia may also be diagnosed in patients with cancer. 

Medication side effects and medical causes, such as uncontrolled pain and hypoxia (low levels of oxygen in your body tissues), must be excluded before making a diagnosis of an anxiety disorder. Symptoms of anxiety may affect adherence to treatments, such as radiotherapy. 

Important need to be diagnosed

It’s important to diagnose depression and anxiety because untreated depression and anxiety can lead to non-adherence to treatment, increased treatment side effects, increased length of hospital stay, reduced quality of life, poorer outcomes, and increased risk for suicide.^5-7

Anxiety and depression must be treated to reduce suffering and improve quality of life in cancer patients. Referral to a mental health specialist may be needed. There are psychological and pharmacological treatment options for the management of depression and anxiety. Management options include counselling, psychotherapy, mindfulness practices, exercise, lifestyle interventions and medications, such as antidepressants.^4,8 It’s important to challenge stigma towards mental illness, these are diagnosable and treatable conditions and people living with cancer shouldn’t suffer with untreated anxiety and depression.

References

1. Linden W, Vodermaier A, MacKenzie R, Greig D. Anxiety and depression after cancer diagnosis: Prevalence rates by cancer type, gender, and age. J Affect Disorders. 2012;141(2–3):343–51.
2. Walker ZJ, Xue S, Jones MP, Ravindran AV. Depression, Anxiety, and Other Mental Disorders in Patients With Cancer in Low- and Lower-Middle–Income Countries: A Systematic Review and Meta-Analysis. Jco Global Oncol. 2021;7(7):GO.21.00056.
3. Association AP. Diagnostic and Statistical Manual of Mental Disorders, DSM-5-TR. 2022;
4. Lang-Rollin I, Berberich G. Psycho-oncology. Dialogues Clin Neurosci. 2018;20(1):13–22.
5. Wang YH, Li JQ, Shi JF, Que JY, Liu JJ, Lappin JM, et al. Depression and anxiety in relation to cancer incidence and mortality: a systematic review and meta-analysis of cohort studies. Mol Psychiatr. 2020;25(7):1487–99.
6. Satin JR, Linden W, Phillips MJ. Depression as a predictor of disease progression and mortality in cancer patients. Cancer. 2009;115(22):5349–61.
7. SMITH HR. Depression in cancer patients: Pathogenesis, implications and treatment (Review). Oncol Lett. 2015;9(4):1509–14.
8. Rodin G, Lloyd N, Katz M, Green E, Mackay JA, Wong RKS, et al. The treatment of depression in cancer patients: a systematic review. Support Care Cancer. 2007;15(2):123–36.

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