Depression (PDQ®): Supportive care - Health Professional Information [NCI] - Assessment and Diagnosis
Table 1. Suggested Questions for the Assessment of Depressive Symptoms in Adults With Cancera continued...
Possible Medical Causes of Depressive Symptoms in People With Cancer*
- Uncontrolled pain.[Level of evidence: II]
- Metabolic abnormalities:
- Sodium/potassium imbalance.
- Vitamin B12 or folate deficiency.
- Endocrine abnormalities:
- Hyperthyroidism or hypothyroidism.
- Adrenal insufficiency.
- Medications:[Level of evidence: I][39,40,41];[Level of evidence: II]
- Endogenous and exogenous cytokines, i.e., interferon-alfa and aldesleukin (interleukin-2 [IL-2]).
- Some antibiotics (e.g., amphotericin B).
- Some chemotherapeutic agents (e.g., procarbazine, L-asparaginase).
To make a diagnosis of depression, the clinician should confirm that these symptoms will have lasted a minimum of 2 weeks and are present on most days. The diagnosis of depression in people with cancer can be difficult due to the problems inherent in distinguishing biological or physical symptoms of depression from symptoms of illness or toxic side effects of treatment. This is particularly true of individuals who are receiving active treatment or those with advanced disease. Cognitive symptoms such as guilt, worthlessness, hopelessness, thoughts of suicide, and loss of pleasure in activities are probably the most useful in diagnosing depression in people with cancer. One German study comparing cancer patients who had a current affective disorder with those who had a single depressive symptom found loss of interest, followed by depressed mood, to yield the highest power of discrimination between the two groups on multivariate analysis.
The evaluation of depression in people with cancer should also include a careful assessment of the person's perception of the illness, medical history, personal or family history of depression or thoughts of suicide, current mental status, and physical status, as well as treatment and disease effects, concurrent life stressors, and availability of social supports. It is important to understand that more than 90% of patients indicate that they prefer to discuss emotional issues with their physician, but over one quarter of patients feel that the physician must initiate any discussion of that topic. Suicidal ideation, when it occurs, is frightening for the individual, the health professional, and the family. Suicidal statements may range from an offhand comment resulting from frustration or disgust with a treatment course: "If I have to have one more bone marrow aspiration this year, I'll jump out the window," to a reflection of significant despair and an emergent situation: "I can no longer bear what this disease is doing to all of us, and I am going to kill myself." Exploring the seriousness of the thoughts is imperative. If the suicidal thoughts are believed to be serious, a referral to a psychiatrist or psychologist should be made immediately and attention should be given to the patient's safety. Additional information on suicide can be found in the Suicide Risk in Cancer Patients section.