Depression

What can nurses do to assist people with cancer who also have depression or depressive symptoms?

Recommended for Practice

Interventions for which effectiveness has been demonstrated by strong evidence from rigorously conducted studies, meta-analyses, or systematic reviews, and for which expectation of harms is small compared with the benefits

Psychoeducational or Psychosocial Interventions

Psychoeducational or psychosocial interventions include cognitive-behavioral therapy, patient education and information, counseling or psychotherapy, behavioral therapy, and social support. Cognitive-behavioral therapy is defined as any specific psychological or psychosocial intervention that is relatively brief, goal oriented, based on learning principles of behavior change, and directed at effecting change in a specific clinical outcome.⁵ Patient education and information are defined as sensory, procedural, or medical information about cancer or cancer therapy regarding illness or symptom(s), symptom management, and/or discussion of treatment options; may include the use of booklets, videos, or other education materials; and do not include active rehearsal of new behaviors.^1,5 Counseling or psychotherapy is defined as interactive verbal interventions, including nondirective, psychodynamic, existential, supportive, general, or crisis interventions; no specific behavioral or coping skills, including social support, are taught by professionals.¹ Social support is defined as supportive interventions provided by patients with cancer, family members, or laypeople but not professionals.¹ With the exception of patient education and information, the other types of intervention require advanced education and training.

Evidence at the highest level^1-8 supports the benefit of psychoeducational or psychosocial interventions in the management of depressive symptoms during and following cancer treatment in patients with different types of cancer. Although variability in frequency and duration of the interventions is considerable, most studies support that such interventions are effective for reducing depressive symptoms; fewer studies support that such interventions are effective for a diagnosis of depression.⁸ A small study²⁵ concluded that nurses could be trained to provide problem-solving therapy to outpatients with cancer that resulted in reduced symptoms of a major depressive disorder. Of the psychosocial interventions studied, the strongest evidence is for cognitive-behavioral therapy. More research is needed to systematically examine the intervention “dosage” (frequency, duration) required for effectiveness among the different types of psychoeducational or psychosocial interventions for diverse cancer subpopulations.

Pharmacologic Interventions

Antidepressant Medications

Articles describing the effectiveness of antidepressant medications in the treatment of depression abound. However, fewer randomized, controlled trials (RCTs) are available describing the medications’ effectiveness in patients with cancer and depression. Four reviews were identified that supported the benefits of antidepressant medication in patients with cancer,^6,11 other comorbid medical illness,⁹ and palliative care.¹⁰ Treatment studies of depression in patients with cancer have been completed using tricyclic antidepressants (TCAs) as well as selective serotonin reuptake inhibitors (SSRIs) and Mianserin*. Studies measuring depression at less than five weeks showed less benefit, perhaps because the time to reach therapeutic effect may be four to eight weeks. No differences were found in the effectiveness between TCAs and SSRIs; however, the lower incidence of side effects in the SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs) makes them preferable in patients with cancer. No studies have specifically examined the newer SNRI, duloxetine, in patients with depression and cancer, but its similarity to venlafaxine makes it likely to be similarly effective.

Patients with malignant melanoma, traditionally treated with interferon alfa, are well known to experience depression as a side effect of their treatment. In a double-bind study,¹² 40 patients were prescribed paroxetine two weeks prior to the initiation of interferon alfa and continued for the first 12 weeks of therapy. Dosages ranged from 10–40 mg daily. Major depression developed in only 2 of the 18 patients in the paroxetine group as opposed to 9 of the 20 on placebo. Paroxetine treatment also significantly decreased the likelihood that interferon would have to be discontinued because of severe depression.

Clinical practice guidelines are another comprehensive, evidence-based tool to assist healthcare professionals in providing optimal care. The National Health and Medical Research Council¹³ published Clinical Practice Guidelines for the Psychosocial Care of Adults With Cancer, concluding that the treatment of depression should incorporate psychotherapeutic and medication interventions. The guidelines state that evidence clearly indicates the efficacy of antidepressant medication in treating depression in patients with cancer, but no evidence suggests that any one antidepressant is superior to another. The sedating properties of the tricyclics and the potentiation of opiod analgesia in those with pain may be beneficial to some patients. The guidelines also state that patients with cancer may respond to a lower dose of tricyclic antidepressants. The long half-life of fluoxetine makes it less desirable in patients with hepatic or renal dysfunction; in such cases, sertraline or paroxetine is preferable. Other guidelines for the treatment of depression exist and provide useful information about medication management in the treatment of depression in adults.^15,16 Provided information includes antidepressant selection, dose adjustment, response assessments, switching medications, continuation and maintenance phases of antidepressant treatment, and discontinuation of treatment. The guidelines are not specific to depression in patients with cancer, and although they recognize that depression can coexist with medical conditions, they do not take into consideration the physical impairments of many patients with cancer; therefore, they must be applied with caution. The National Comprehensive Cancer Network¹⁴ published guidelines for distress management that contain algorithms describing the care of patients with cancer and mood disorders as well as adjustment disorders with depressed mood. Pharmacology is recommended as an effective intervention.

Antidepressant Medications Used in Patients With Cancer

Selective Serotonin Reuptake Inhibitors

Fluoxetine (Prozac^®)

Fluvoxamine (Luvox^®)

Sertraline (Zoloft^®)

Paroxetine (Paxil^®)

Citalopram (Celexa^®)

Escitalopram (Lexapro^®)

Tricyclic Antidepressants

Amitriptyline (Elavil^®)

Imipramine (Tofranil^®)

Desipramine (Norpramin^®)

Nortriptyline (Pamelor^®)

Doxepin (Sinequan^®)

Serotonin-Norepinephrine Reuptake Inhibitors

Venlafaxine (Effexor^®)

Duloxetine (Cymbalta^®)

Other Antidepressants

Mirtrazapine (Remeron^®)

Bupropion (Wellbutrin^®)

Trazodone (Desyrel^®)

Mianserin* (This drug has not been approved by the U.S. Food and Drug Administration for use in the United States.)

Likely to Be Effective

Interventions for which effectiveness has been demonstrated by supportive evidence from a single rigorously conducted controlled trial, consistent supportive evidence from well-designed controlled trials using small samples, or guidelines developed from evidence and supported by expert opinion

Methylphenidate (Ritalin^®)

One phase II study¹⁷ and one systematic review¹⁸ explored methylphenidate in patients with depression in advanced cancer. The advantage of this central nervous system stimulant is its reported safety and rapid onset of action. It is used more often in advanced cancer and palliative situations. Doses are typically prescribed twice daily starting at 5 mg and titrated until response is obtained or side effects dictate discontinuance. Administering methylphenidate before breakfast and lunch is recommended because food increases the absorption rate and early administration lessens insomnia. Various cancer sites studied include breast, esophagus, pancreas, and colorectal. The maximum daily dose needed to resolve depression was 20 mg in a study of 40 patients.¹⁷ In a review of nine studies, methylphenidate was concluded useful in treating depression in a variety of malignancies, with more than 80% of patients responding favorably and less than 20% reporting side effects.¹⁸ Methylphenidate also is used to address opioid-induced somnolence, augment opioid effects, and improve cognitive functioning in patients with cancer; in addition, some have found a decrease in pain scores. These benefits may contribute to mood improvement.

Complementary and Alternative Therapy

Relaxation Therapy

Techniques that focus on inducing a relaxed physical and mental state include progressive muscle relaxation with or without guided imagery, hypnosis, and autogenic training.^19,20 A meta-analysis¹⁹ evaluated 15 RCTs that were conducted from 1980–1995. Relaxation training was found to have a significant impact on reducing cancer treatment-related side effects, including emotional adjustment variables (depression, anxiety, and hostility). In a study of 56 people with advanced cancer, progressive muscle relaxation and guided imagery techniques were taught to patients as single techniques or as a combined technique. Patients in the three treatment groups showed a reduction in depression as measured by the Hospital Anxiety and Depression Scale (HADS) three weeks later; those randomized to the control group did not.²⁰

Effectiveness Not Established

Interventions for which there are currently insufficient or conflicting data or data of inadequate quality, with no clear indication of harm

Complementary and Alternative Therapy

Massage Therapy

Massage is the manipulation of soft tissue areas of the body, offered to assist relaxation, aid in sleep, and relieve muscle tension and pain.²¹ One systematic review²² evaluated 8 RCTs and 10 reports from 1966–2002 regarding the effect of massage for symptom relief in patients with cancer. Approximately one of three studies in the review found a beneficial effect on cancer-related depression. The patients with cancer experienced the most consistent relief on postintervention anxiety.²² Two studies evaluated the effect of massage therapy. A randomized study²³ evaluated 34 female participants with breast cancer who were at least three months post treatment. They received massage three times weekly for five weeks and depressed mood was reduced at pre- and post-session and first-last days.²³ In a nonrandomized study of 1,290 patients looking at symptoms relief from massage therapy, patients chose one of three types of massage treatments in which sessions lasted 20–60 minutes.²¹ Baseline scores were self-rated for common symptoms: pain, fatigue, stress or anxiety, nausea, depression, and “other.” The rating scale was 0 (not at all bothersome) to 10 (extremely bothersome). Patients again self-rated 5–15 minutes after massage therapy. Symptoms scores were reduced by approximately 50%, with those reporting depression demonstrating 48.9% improvement in their scores.²¹ The researchers attempted to follow some of the patients up to 48 hours post treatment; even so, the results reflect only short-term benefit.

Hypnotherapy

Hypnotherapy is a behavioral therapy that uses hypnosis to induce heightened concentration, receptivity, and relaxation. One systematic review²⁴ reported results of 27 studies conducted from 1974–2003 using hypnotherapy in terminally ill adult patients with cancer for symptom relief. Of the 27 studies reported, most were of poor quality and only one was a randomized control study involving 50 subjects. In that study, a statistically significant reduction in depression and anxiety scores was demonstrated for patients’ assigned hypnotherapy compared with the standard group.²⁴ Overall, few adverse effects were reported; however, reports indicated that patients were unable to enter a deep trance or were frightened by the treatment.²⁴

Special Consideration: The use of other complementary methods such as St. John’s wort, nutritional and herbal supplements, yoga, acupuncture, aromatherapy, exercise, and meditation has not been studied specifically in the setting of patients with cancer and depression. Although some promising studies show benefit of the methods on stress, pain, and other symptoms, at this time, effectiveness for depression in patients with cancer has not been established.

Expert Opinion

Low-risk interventions that are (1) consistent with sound clinical practice, (2) suggested by an expert in a peer-reviewed publication (journal or book chapter), and (3) for which limited evidence exists. An expert is an individual with peer-reviewed journal publications in the domain of interest.

Experts^26-28 have recommended the following interventions for patients experiencing depressive symptoms and/or depression during and following cancer treatment.

• Assess patients and family members for depression and depressive symptoms at every encounter.

• Assess patient’s and family’s understanding of depression and its role in cancer recovery, as well as the meaning of depression to the patient and his or her family.

• Provide education and information to patients and families about depression and its management.

Although no evidence exists on combination of antidepressant medication plus psychoeducational or psychosocial therapy in patients with cancer and depression, clinical practice guidelines for the treatment of depression do recommend combined therapy for severe and chronic depression, finding it more effective than either alone.^15,16

Authors: Terry A. Badger, PhD, APRN, BC, FAAN, Caryl D. Fulcher, MSN, APRN-BC, Ashley K. Gunter, RN, BSN, OCN^®, Joyce Marrs, MS, APRN-BC, AOCNP, and Jill Reese, RN, BSN, OCN^®

Definitions of the interventions and full citations: www.ons.org/outcomes

Literature search completed through September 2006.

This card, published by the Oncology Nursing Society (ONS), reflects a scientific literature review. There is no representation nor guarantee that the practices described herein will, if followed, ensure safe and effective patient care. The descriptions reflect the state of general knowledge and practice in the field as described in the literature as of the date of the scientific literature review. The descriptions may not be appropriate for use in all circumstances. Those who use this card should make their own determinations regarding safe and appropriate patient care practices, taking into account the personnel, equipment, and practices available at their healthcare facility. ONS does not endorse the practices described herein. The editors and publisher cannot be held responsible for any liability incurred as a consequence of the use or application of any of the contents of this card.