Cancer and Depression

Introduction

Cancer has become the second highest cause of death and a major global public health issue. According to estimates by Siegel et al. (2023), cancer is projected to cause the death of 609,820 Americans, or 1670 people per day. Prostate, and lung cancers in men as well as breast, lung, and colorectal cancers in women cause the majority of deaths. Cancer is a chronic disease that has long-term effects for health and quality of life, and it is more common among older individuals. Cancer patients face a variety of stressing situations and emotional difficulties. The fear of an impending death, the disruption of personal aspirations, lifestyle adjustments and social roles changes present significant difficulties that must be addressed (Pasquini and Biondi, 2007).

Comorbid chronic disorders are frequent in cancer patients. Comorbidity prevalence has significant clinical, health-care, and research consequences (Ogle et al, 2000). In terms of psychological symptoms and disorders, the prevalence of depression is the most common among people living with and beyond cancer in its various types and stages. This paper presents and overviews cancer co-morbid depression, focusing on assessment, comorbidity, etiological mechanisms and evidence-based available treatment options.

Cancer and Depression

Depression is the most frequent psychological condition in cancer patients, and its degree of severity may vary from nonpathological sadness to clinical disorders linked with significant suffering (Li et al, 2012). All patients who receive a diagnosis like cancer naturally experience unpleasant emotional reactions, however a substantial minority will  present clinical depression. (Chochinov, 2001).  Depression in cancer patients often exists alongside with pain and distress. Untreated depression has a high morbidity and death rate. Depression prevalence in over 100 cancer patient studies vary from 0% to 58% and cancer is linked to a significant degree of depression regardless of place or stage of illness (Masie, 2004). More severe depressive symptoms are clinically significant since they are associated with longer stays in hospitals, physical suffering, lower treatment adherence, decreased quality of life, increased urge for suicide and hastened death (Katon, 2022). Depression diagnosis and depressive symptoms indicate increased mortality (Krebber et al, 2014).

Assessment

Depression has been investigated in cancer patients using a variety of assessment methods. The Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, and DSM criteria are the most frequently employed methods (Massie , 2004). Depression has been difficult to study because patient's mood might change when they are repeatedly threatened with death, are undergoing cancer treatments, are exhausted, or are in pain, and because symptoms range from sadness to major disorder (Massie, 2004). The reported prevalence of depression typically decreases the stricter the term's definition is. Diagnosis is often difficult to be conducted accurately since a change in mood is sometimes challenging to evaluate when an individual is presented with recurring threats to his or her life, receives cancer treatments, is exhausted and many times is in pain.

Comorbidity

            In some cases, other physical symptoms like pain and other disorders such as anxiety disorders coexist with depression. According to National Comorbidity Survey statistics, 51% of cancer patients with severe depressive disorders had an extra anxiety disorder in a 12-month period (Kessler, 2005). Individuals who have both depression and anxiety disorders concurrently, present more severe symptoms, require longer periods to recover, utilize additional medical resources, and do worse than the patients who only have one illness. (Grady-Weliky, 2002). Alexander et al (1993) suggested that psychological morbidity was much less likely to occur in people who were uninformed of their cancer or thought that their treatment was curative. When there were distant metastases, relapses, or progression,  depression and anxiety were more prevalent regardless of gender or age.

Etiological Mechanisms

Cancer patients' depression is examined within a biopsychosocial context. Being younger, having a background of depression, lower level of social support,  poor communication with healthcare professionals and using maladaptive coping mechanisms are individual and psychosocial factors that increase the risk of depression  (Li et al., 2011). One of the most significant and consistent predictors of depressive symptoms is the physical burden of cancer, as assessed by factors including limitations in function, disease stage, and the number and intensity of physical symptoms (Rodin et al., 2007).

Health and Psychological Impact of Depression

Depression, especially if it is not entirely related to cancer is possible to reduce self-motivated health behavior change and adherence to prescribed therapies through cognitive, motivational, and social factors. This noncompliance has the potential to jeopardize a patient's health and survival (Kissane, 2011).

Depression can be an obstacle to adherence to treatments for cancer because it impacts memory and thought processes, motivation and social support resources, all of which are critical for sustaining adherence.  Healthcare personnel would need to inquire about, and if necessary, assist the patient in seeking help for depressive symptoms , in order to maintain optimal treatment adherence levels (Kissane, 2011).

According to Rockett et al (2008), cancer patients are more likely than other medically ill individuals to experience suicidal thoughts and commit suicide. Depression is a documented element in 50% of all deaths by suicide, and people who are depressed are 25 times more likely to commit suicide (Breitbart et al., 2006).

Treatment

Depression treatments in the case of cancer patients aims at treating the symptoms, but also tackle biological and psychosocial factors which lead to the development of depression. Some of these factors may be physical pain, relationships with healthcare professionals and the social support system as well as the patient’s subjective understanding of their disease (Li et al, 2012). Psychotherapy treatment studies΄ results for depression in cancer patients have been inconsistent due to methodological errors, such as the inability to define the degree of depression, small sample sizes as well as differences in demographics, criteria for inclusion, treatment characteristics of the populations analyzed and follow-up duration (Williams and Dale, 2006).

 A variety of treatments have been utilized to address depression in cancer patients.  Interventions are mostly characterized as psychosocial and include psychoeducation, relaxation training, problem-solving training, cognitive behavioral therapy, interpersonal therapy and different supportive-expressive psychotherapies like meaning-centered group therapy and  dignity therapy (Li et al, 2012). Disease stage, depression symptoms, the patient's motivation and level of functioning  and interest in self-reflection are some criteria in the selection of a psychotherapeutic approach. Cognitive behavioral therapy (CBT), relaxation techniques and psychoeducation are better for newly diagnosed cancer patients with mild to moderate depression (Ell, 2007). For patients in later stages with an interest in self-reflection, supportive-expressive psychotherapy such as Dignity therapy and CALM (Managing Cancer And Living Meaningfully) is preferred and the focus in on more existential issues like fears about death (Kissane et al, 2011).

When it comes to the effectiveness of cancer-related depression psychological interventions of psychosocial approaches, different meta-analyses and systematic reviews produce small to large effects of different treatments  (Sheard and Maguire, 1999; Jacobsen and Jim, 2008). According to Rodin et al (2013), about half of psychosocial treatments studies showed substantial decreases in cancer related depressive symptoms in individuals who received a depression diagnosis based on a thorough diagnostic interview or a validated self-report assessment of depression.

Psychoeducational therapies offer cancer patients with information to help them adjust to new oncology conditions. Acquiring knowledge and information is critical to assisting cancer patients in navigating the healthcare system and the processes of cancer treatment, which can be rather stressful. A meta-analysis of 116 psychoeducational research by Devine (2003) indicated a moderate effect size for depression alleviation, while a comprehensive qualitative analysis reported positive outcomes in 63% of the psychoeducation studies analyzed (Barsevick et al, 2002).

Relaxation interventions are among the most commonly utilized psychosocial therapy provided to cancer patients, and they are especially beneficial for regulating  behaviors or emotions linked with cancer treatments. According to Luebbert's meta-analysis (2001), relaxation training has a moderate impact size on depression.

Interpersonal therapy (IPT) addresses problems with relationships, changing circumstances in life, bereavement  and isolation, which constitute relevant contextual difficulties for patients. Currently, relevant psycho-oncology studies are unavailable, although face validity and previous reference efficacy findings imply its utility (Kissane et al, 2011).

Problem solving therapy was developed using CBT principles and is based on the idea that more effective problem solving or enhanced coping leads to decreased psychological suffering.  Problem solving programs teach cancer patients to describe their problem, brainstorm and evaluate potential solutions, execute them, measure their success, and fine-tune them. In a RCT by Nezu et al (2003), problem solving was successful in reducing depression symptoms significantly, an outcome that was still evident after one year.

A RCT by Kissane et al (2007) showed that supportive-expressive group therapy ameliorated and prevented new depressive disorders, reduced hopelessness and helplessness as well as trauma symptoms and increased social functioning.

There is a lack of scientific evidence on the efficacy of psychosocial therapies to reduce depression in advanced-stages cancer patients and there is also a need to provide proof of efficacy in depression management based on intervention type and treatment status (Li et al, 2012).

CBT for Depression in Cancer

Cognitive-behavioral therapy (CBT)  originally developed by Beck in the 1960’s is based on the premise that it is how a person interprets a situation rather than the issue itself that creates an emotional reaction (Kissane et al, 2011).  Thus, a triggering condition activates an 'automatic thought,' which subsequently causes an emotional, behavioral, or physiological reaction. CBT's therapeutic approach includes the reframing of problematic automatic thoughts. The counselor’s goal is to lower the degree of such cognitive biases by directing the individual’s attention to more logical options.

CBT's core viewpoint is empiricism and that means that the therapist might create a hypothesis about particular factors (such as an interpersonal conflict) that are exacerbating depression symptomatology. Evidence for and against this hypothesis is examined, and actions to improve the particular factor (e.g. the relationship) are adopted. A great advantage of CBT in psychooncology is that it encourages autonomy and self-management, frequently sought in assisting patients cope better with long-term cancer (Kissane et al, 2011).

An example of the approach is Chambers et al (2018) trial of individualized CBT for young survivors of cancer during adolescence where ten cancer survivors received up to 15 sessions of customized CBT guided by behavioral case formulations and showed a decrease in psychological distress (P=.04), cancer-specific distress (P=.02), and unmet psychological care needs (P=.03) from baseline to 8 weeks as compared to the control group.

In a condensed version of CBT named behavioral activation (BA) where the crucial role of withdrawal and avoidance in the maintenance of depression is emphasized, scheduling, self-monitoring, measuring pleasure and achievement during daily tasks and exploring alternative behaviors with tools such as role-playing are examples of strategies used. Behavioral activation has shown to have equivalent to antidepressant treatment results in more severely depressed patients (Dimidjian et al, 2006).

Cognitive behavioral therapy is the most commonly used type of treatment for depression in health settings. Meta-analyses of many RCTs in cancer patients provide evidence supporting the efficacy of CBT for depression (Sheard and Maguire, 1999).

                                             Discussion

Depression increases suffering of the cancer patients. So far ,it has been difficult to study because symptoms occur on a spectrum and the assessment is a great challenge due to methodological errors and the interference of factors such as the impact of the cancer treatments to the patient. After providing a brief overview of cancer-comorbid depression and the main psychological approaches to treatment, we could conclude cancer patients suffering from depression may benefit from psychosocial treatment interventions that take into account the biopsychosocial context of the patient,  provide information and support and address any combination of emotional, cognitive, and behavioral symptoms.

 All the mentioned depression treatment approaches have had some impact with CBT interventions showing efficacy in many RCTs and being the first choice for treatment of depression especially in early-stage cancer patients. Additional research needs to be conducted for advanced-stage cancer where depression is more prevalent but it seems that supportive-expressive psychotherapy should be the preferred choice. At last, it seems that an eclectic selection from different approaches to best respond to the needs of the particular patient in the specific conditions, whether clinical, psychological or social is the best strategy for treating depression in cancer patients.