Depression Increases With Advanced Cancer and May Influence Cancer Pain

NEW YORK--Depression is more common in patients with advancedcancer and can have an adverse effect on cancer pain. For example,in patients with advanced breast cancers, a study showed thatconcomitant depression and interpretation of pain influenced painmore than site of disease or presence of metastases, MemorialSloan-Kettering psychiatrist William S. Breitbart, MD, said ata conference sponsored by Cancer Care, Inc., a social work agencyfor cancer patients and their families.

The women who interpreted their pain as a progression of theirdisease reported more pain than those who had a more benign interpretation,Dr. Breitbart said. He noted that about half of all cancer patientswill develop a diagnosable psychiatric disorder during the courseof their disease. Adjustment disorder is the most common, makingup about 68% of all psychiatric disorders among cancer patients.About 15% develop depression, about 10% develop delirium, anda smaller percentage develop anxiety disorders, Dr. Breitbartsaid.

Half of the cancer patients who do not have a psychiatric disorderare still psychologically distressed. "They're anxious, tense,worried, and may have problems with sleep," he said.

About 50% of patients with advanced cancer develop depression,which can contribute to suicidal ideation.

"Some patients, because of symptoms related to their cancerand treatment, feel a loss of control that induces a sense ofhelplessness," Dr. Breitbart noted. "Suicidal ideationis sometimes a way of trying to control things, but, more often,it is a signal that someone is not coping and may be seriouslydepressed."

Patients who do commit suicide often have a family history ofsuicide or have attempted suicide before. They may be patientswho have a protracted terminal phase of their illness.

"We had a number of suicides in our home care program,"Dr. Breitbart said. "They were patients who took a very longtime to die, 9 months to a year. When the dying process becomesvery prolonged, it's extremely exhausting for patient and caregiveralike, and it makes people more likely to see suicide as a solution."

The patient's pain, physical symptoms, and functional limitationsall influence suicidal ideation, primarily through their impacton depression. "So depression is the important focus,"he said.

The treatment for depression involves supportive psychotherapyinterventions, Dr. Breitbart said, but for a severe depression,therapy with antidepressant medications is critical. "Weuse all of the antidepressant medications that we use with physicallyhealthy people. It may not make them 'happy', but it resolvesthe symptoms of depression, hopelessness, and suicidal ideation."

Some of the anticholinergic effects of certain antidepressants,such as dry mouth and constipation, should be avoided in somepatients, but in others may be helpful, such as in patients whohave diarrhea, he said.

Lower Antidepressant Doses

Patients generally are started on low doses and moved up slowly.In a physically healthy person, the ultimate daily dose of a commonantidepressant such as amitriptyline may be anywhere from 150mg to 300 mg. But in most cancer patients, the therapeutic dosetends to be a little lower, Dr. Breitbart pointed out. This isparticularly true, he said, of patients who weigh less, have liverdisease, or do not metabolize drugs well.

The serotonin-specific drugs such as fluoxetine (Prozac) are alsouseful because they are simple to take, he said. "You canstart with 20 mg/day and keep it there."

Another class of antidepressant drugs that are used frequentlyin the medical setting is the psychostimulants such as dextroamphetamineand methylphenidate (Ritalin). "These drugs are very effectiveto treat depression, and don't cause sedation or constipation."Dr. Breitbart said.

In fact, they make patients more alert, and are sometimes usedto counteract the sedative effects of opiate drugs or to potentiatetheir analgesic effects. Another advantage is that they work quicklycompared to traditional antidepressants, which often take 7 to10 days, he said.

"These drugs produce their stimulant and antidepressant effectswithin hours or days. Sometimes we'll use combinations of stimulantsto start with, and add an antidepressant at the same time. We'lluse the stimulants until the traditional antidepressant beginsto work," he said, adding that as with antidepressants, thedosages of stimulants used in cancer patients are generally slightlylower than those used in healthy people.

Occasionally, benzodiazepines such as alprazolam (Xanax) or lorazepam(Ativan) are used in combination with stimulants or antidepressants,particularly when treating anxiety associated with depression.But these agents are not effective treatments for depression bythemselves, Dr. Breitbart said.