Positive findings also have been reported by the CCSS for young adults who are survivors of leukemias and lymphomas. Follow-up questionnaires about psychological adjustment were administered to 5,736 young adult survivors of leukemia, non-Hodgkin lymphoma, and Hodgkin disease and to 2,565 adult siblings. Survivors reported higher levels of depressive symptoms and somatic distress than did siblings, but scores for neither group fell within the clinically significant range for the general population. Sociodemographic factors such as gender and socioeconomic status were associated with reports of depressive symptoms, regardless of treatment status. The only disease-related factor associated with psychological distress was intensive chemotherapy, which was associated with an increase in somatic complaints.[Level of evidence: II] Similar outcomes were reported for survivors of brain cancers. Brain tumor survivors reported higher levels of depressive symptomatology than did siblings, but the rates for both groups were similar to rates for the general population.[Level of evidence: II] A summary of the main psychosocial outcomes reported by the CCSS is available.[Level of evidence: II] Other reports from the CCSS address alcohol consumption, the role of physical limitations on HRQL,[Level of evidence: II] fatigue, and sleep.
Depression and Suicide
Young adult survivors of childhood cancer may have an elevated risk for suicidality. A report from Eastern Europe compared the responses of 228 long-term survivors of childhood cancer with those of 127 controls to the Center for Epidemiologic Studies Depression Scale (CES-D) and the Suicidal Ideation and Behaviour Questionnaire. The rates of depressive symptoms reported by the childhood cancer survivors were three times the rates reported by the controls, with 13% indicating some level of suicidal ideation. Similarly, 226 adult survivors of childhood cancer seen in a survivor clinic completed the Short Form-36 (SF-36), the Beck Depression Inventory (BDI), and suicide items from the Symptom Checklist-90-Revised (SCL-90-R) and the Beck Scale for Suicide Ideation (BSS). The measures assessed whether the survivors had ever attempted suicide or whether they had experienced significant suicidal ideation within the past week; 29 participants (12.83%) reported suicidality. Suicidality was associated with younger age at diagnosis, longer time since diagnosis, cranial radiation therapy, a diagnosis of leukemia, pain, and concerns about physical appearance. Current physical condition, including pain, was associated with suicidality.[Level of evidence: II] These studies represent relatively small samples with small comparison groups and may reflect a reporting bias represented in individuals who actively attend follow-up clinics. Nonetheless, while these results are inconsistent with other findings related to psychological distress, they do suggest the need for ongoing monitoring and surveillance of adults who are survivors of childhood cancer.
Significant concern about the potential for suicide as a side effect of selective serotonin reuptake inhibitors (SSRIs) has led the U.S. Food and Drug Administration (FDA) to issue a caution about their use that includes the importance of careful monitoring of potential risks. Before this FDA Health Advisory was issued, clinical experience and the results of small clinical trials suggested that antidepressants can be safely administered to adult cancer patients, although there are no controlled clinical trials to support this position. The risk/benefit ratio for use of SSRIs may not be as favorable for children and adolescents. Several multicenter, double-blind, randomized, placebo-controlled clinical trials using SSRIs with children and adolescents with major depressive disorder but not cancer found modest improvements for fluoxetine,[28,29] paroxetine, and sertraline.[Level of evidence: I] Balancing these improvements were reports of serious adverse events that included worsening of psychiatric symptoms, increased suicidal ideation and gestures, increased conduct problems or hostility with paroxetine, and suicide and suicide attempts with sertraline.[Level of evidence: I]