Current Management of Depression in Cancer Patients Published on Physicians Practice (http://www.physicianspractice.com)

Current Management of Depression in Cancer Patients Review Article [1] | August 01, 2002 By Leonard Schwartz, LLB, LLM, MD [2], Mark Lander, MD, FRCPC [3], and Harvey Max Chochinov, MD, PhD, FRCPC [4] Depression is a common but treatable condition among cancer patients. Screening for depression can be done simply and effectively, and a variety of practical treatment strategies are available. Numerous factors should be

epression is a relatively common but regrettably underdiagnosed condition among cancer patients. Comprehensive care should, however, encompass not only a good understanding of the physical domains of patient care, but include attentiveness to the psychological, spiritual, and existential concerns of patients facing malignant illness. Depression can influence a patient’s will to live, as well as diminish the quality and perceived meaning of life. Therefore, health-care staff who care for patients with cancer—particularly patients nearing the terminal phase of their cancer—must be aware of the impact of depression on the patient’s sense of meaning and desire to go on living in the face of a life-threatening illness. D

The underdiagnosis of depression in a cancer treatment or palliative care setting occurs for a variety of related reasons. These include uncertainty as to how to make a diagnosis of depression in medically ill patients, the false assumption that all cancer patients are "understandably depressed," physician discomfort with probing too deeply into the psychological distress of patients, and discomfort in using, or lack of familiarity with, the treatment options available to treat depression.[1,2] All patients with a life-threatening condition and particularly those with a terminal prognosis will understandably experience some periods of profound sadness. Such a reaction to vulnerability and loss is inherently human. Clinical depression or depressive syndrome, however, may complicate a patient’s cancer illness and is marked by a persistent, prominent sad mood, loss of interest in almost all activities, overwhelming helplessness, hopelessness, worthlessness, feelings of guilt, and preoccupation with thoughts of suicide or death. In addition to these psychological symptoms, people with major depression also experience a variety of physical symptoms including fatigue, poor concentration, anorexia, weight loss, and insomnia. Not surprisingly, clinical depression may lead some patients to a heightened desire for hastened death. Studies of terminally ill patients and ambulatory AIDS patients have demonstrated that the most significant predictor of support for physician-assisted suicide was depression and psychological distress.[3,4] Patients with cancer or other terminal illnesses are at increased risk of suicide, compared to the general population.[5] Suicide risk factors include poorly controlled pain, depression, delirium, and various disabilities resulting from advanced illness. In one study of psychiatric disorders in suicidal cancer patients, 39% were thought to have a major depression, 54% were diagnosed with an adjustment disorder with anxious and/or depressed features, and 20% were delirious.[6] The elderly are at greater risk for both depression and suicide, due to numerous losses they may experience—loss of good health, financial losses, loss of spouse or friends, and so forth. Depressed elderly patients may not describe themselves as depressed, but instead may complain of loss of interest in activities, or problems with memory or concentration. Careful history-taking will demonstrate that depressive features often antedate these changes.[7] Depressive symptoms may occur in many patients with advanced cancer, and 10% to 20% of these patients meet diagnostic criteria for major depression.[6,8] One study suggested that the greater the physical disability suffered by the patient, the more likely they were to present with significant depressive symptoms.[9] Physicians must be aware of the possible existence of depression in seriously ill patients, and the effect this may have on their desire for death. Ambivalence or apathy about continued treatment may, in fact, be due to feelings of hopelessness engendered by a clinical depression. As such, there is the risk that these patients will receive less than optimal care, should depression be misperceived as a "normal reaction" to serious physical illness. It is therefore essential for physicians to screen for and treat depression in this patient population. Page 1 of 10

Current Management of Depression in Cancer Patients Published on Physicians Practice (http://www.physicianspractice.com) In this article, we will examine techniques for the assessment of depression in cancer patients, as well as current strategies for the treatment of depression in these patients. A combination of supportive psychotherapy and appropriate pharmacotherapy is the most effective treatment for severe depression; both approaches are discussed, with particular emphasis on their application in the cancer care setting.

Assessment of Depression in Cancer Patients Case Presentation Ms. J. is a 48-year-old woman with stage IV breast cancer. She has been married for 17 years and has a 12-year-old daughter. Several months after starting on paclitaxel and tamoxifen, she discloses the fact that she has been feeling profoundly depressed for nearly a year. She reports feeling depressed most of the time, along with decreased interest in many activities and an avoidance of all social contact. She thinks constantly about death, and no longer sees a point in living. She denies suicidal ideation but states that going to sleep and not waking up would be a welcome relief. She reports significant difficulty with sleep, libido, energy, memory, and concentration. Upon examination, she cries throughout the consultation, endorsing feelings of helplessness, hopelessness, and worthlessness. She feels she has become a burden to everyone that has contact with her. There is no evidence of delusions or psychosis, but she does seem to have psychomotor retardation. There is also a significant family history of depression (mother, several siblings, and a paternal aunt). This case presentation illustrates one particular reaction to a diagnosis of advanced cancer. Is this a normal response? While emotional distress is a normal reaction to a cancer diagnosis, profound and unremitting depressed mood, excessive guilt, anhedonia (an inability to experience pleasure), and loss of interest in all activities are not. Patients who are newly diagnosed with cancer and those who learn of a relapse, or that treatment has failed, frequently demonstrate a response marked by a period of initial shock or disbelief. This is often followed by a period of turmoil, marked by symptoms of anxiety and depression, irritability, and sleep and appetite disruption. After a period of several weeks, a tolerable degree of resolution usually occurs.[10] Symptoms Depression, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV),[11] is characterized by a constellation of symptoms, which must occur at a certain level of severity, for a defined duration, and result in impairment in functional and social roles. There are two core criterion symptoms for major depression in the DSM-IV: depressed mood and anhedonia (a marked loss of interest or pleasure in all activities). In order to qualify for the diagnosis, one of these core symptoms must be consistently present for a minimum of 2 weeks, along with at least four other symptoms from the DSM-IV depression symptom list. In the severely ill, however, symptoms such as fatigue, reduced appetite, weight loss, sleep problems, and poor concentration may not be helpful in making the diagnosis of major depression, as these symptoms can be caused by the patient’s underlying medical illness.[12] Screening Despite the nonspecificity of these somatic symptoms, we have reported that asking patients if they are feeling depressed "most of the time" is a very simple and effective way to screen for clinical depression. Recent work has compared various brief screening measures for depression in terminally ill patients. A single-item screening approach, which essentially asked patients if they felt depressed most of the time, correctly identified the eventual diagnostic outcome of every patient and was superior to other self-report measures for assessing depression. Inclusion of questions concerning loss of interest or pleasure in activities did not improve diagnostic accuracy but might be appropriate in a brief screening interview, as it provides for complete coverage of core depressive symptoms and reduces the possibility of missing the diagnosis.[13] Organic Causes Physicians should also consider the possibility of organic mental disorders, which are prevalent in patients with advanced disease and may play a role in the patient’s presentation. Delirium, dementia, anxiety disorders, and organic mood syndromes are easy to mistake for a (functional) psychiatric disturbance. Symptoms such as disbelief, denial, numbness, irritability, hopelessness, and suicidal ideation are found in major depression, anxiety disorders, and adjustment disorders. However, in progressive dementias, the organic nature of the presenting symptoms usually becomes more obvious. Neuropsychological testing may help distinguish dementia from a depression or an adjustment Page 2 of 10

Current Management of Depression in Cancer Patients Published on Physicians Practice (http://www.physicianspractice.com) disorder. Other issues, such as the potential duration of the organic mental syndrome and its effect on competency should also be considered. It has been estimated that approximately 25% of hospitalized medical and surgical patients suffer from dementia, and that the prevalence of delirium in dying patients approaches 80%. Indeed, the magnitude of this problem is compelling.[14] Risk Factors Risk factors for depression in patients suffering from cancer include a past personal or family history of depression and/or previous suicide attempts by the patient. Other risk factors include increasing physical disability, which appears to correlate with measures of depression and distress in cancer patients, as well as physical pain. Numerous studies have found an association between increased pain and reports of depression or other psychiatric complications. Spiegel et al found that patients with the highest pain levels were two to four times more likely to be diagnosed with a depressive disorder than patients with lower pain levels.[15] Of note, chronically discomforting pain may cause some patients to become depressed, and conversely, depression may result in an amplification of the pain experience.[6] However, a strong social network has been shown to be a protective factor against depression.[16] Disease processes that directly affect the central nervous system cause depressive symptoms, although organic mood disorders can also result from disorders with no direct neurologic involvement (eg, Cushing’s syndrome due to pituitary tumors has been linked with depression). Hypercalcemia, which is often associated with breast or lung cancer, has also been associated with depression.[17,18] In addition, patients with oral, pharyngeal, and lung cancers are at increased risk of suicide, possibly because these diseases are often associated with premorbid alcohol and substance abuse and may result in profound facial disfigurement and associated impairments. Pancreatic cancer has been associated with a high prevalence of depressive and suicidal states,[19] ostensibly because of tumor-induced changes in the neuroendocrine system. However, pain, which is common with pancreatic cancer, may also be a causative factor.[20] In addition, the grave prognosis that this illness carries may give rise to depressive illness. Numerous anticancer drugs—including corticosteroids, procarbazine (Matulane), -asparaginase (Elspar), interferon, vinblastine, vincristine, tamoxifen, and cyproterone (Androcur)—have also been associated with depression. Poorly controlled severe nausea and vomiting may also contribute to depression.[10] A Treatable Illness Some sadness is inevitable in all patients facing a life-threatening or terminal condition. Clinical depression, on the other hand, is a treatable illness, and physician awareness and assistance can help patients to recover their ability to enjoy social interactions, and sometimes prior interests. Physical symptoms of depression such as poor energy, sleep, and appetite may be relieved. Finally, proper treatment of clinical depression can result in a renewed ability to find meaning in life, despite the uncertain or dire medical circumstances. Practical treatment strategies, and the considerations that underlie these approaches, will be discussed in the next section. L

Treatment of Depression in Cancer Patients Case Presentation An elderly man with metastatic lung cancer presented to the palliative care service with a request to die. He had become wheelchair bound and was no longer able to enjoy many previously pleasurable and meaningful activities. A person who previously was "always in control," he now found himself constantly crying and thinking about the futility of living and a wish for death. He was burdened with feelings of guilt—specifically that he had become a burden to his family and care providers. Within 3 weeks of antidepressant therapy and supportive counseling, his depressive symptoms remitted entirely, allowing him to enjoy spending time with his wife, who helped nurse him through his final days. Somatic Therapies Many antidepressant medications are available (see Table 1),[7] and a number of factors should be considered when choosing a medication. For example, antidepressants that may take 4 to 8 weeks to achieve a therapeutic effect are a poor choice for patients with days or weeks to live. In such cases, psychostimulants, which are more rapidly acting, may be a better alternative. Overall side-effect profile and tolerability are essential considerations. If the patient has been successfully treated for depression in the past, first consideration should be given to using the same medication for treatment of the current episode. When treating older patients, changes in drug metabolism, such as reduced gut absorption, altered drug distribution (loss of lean body mass with increased half-life of lipophilic medication), and reduced metabolism and excretion, should be kept in Page 3 of 10

Current Management of Depression in Cancer Patients Published on Physicians Practice (http://www.physicianspractice.com) mind. Poor nutritional status can cause reduced albumin levels, which will increase the proportion of unbound (active) antidepressant medication.[21] For patients who are antidepressant-naive, it is worthwhile to determine whether there is a first-degree relative who has been successfully treated with a particular antidepressant. That same medication should be given first consideration, other things being equal. When psychotic features such as hallucinations, delusions, or grossly disorganized thinking are present, patients should be treated with both an antidepressant and antipsychotic. Although there is less experience with the new-generation (atypical) antipsychotics, low doses of this class of medication, such as risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon), have a preferable side-effect profile compared to the older neuroleptics. Olanzapine may also stimulate appetite in cachectic patients. Among older medications, higher-potency neuroleptics such as haloperidol, trifluoperazine, or fluphenazine are usually preferable, as they have a lower incidence of anticholinergic side effects (eg, delirium, cardiac arrhythmias, constipation, urinary retention, and blurred vision). These drugs also tend to have less of an effect on the seizure threshold than lower-potency antipsychotics such as chlorpromazine and thioridazine.[10] Finally, if there is a history of bipolar disorder, mood stabilizers (such as lithium, sodium valproate, or carbamazepine) may be needed.[7,10] Selective Serotonin-Reuptake Inhibitors Selective serotonin-reuptake inhibitors (SSRIs) are generally well tolerated, effective, and preferred over tricyclic antidepressants (TCAs) in the cancer setting. Compared with TCAs, SSRIs are associated with a decreased incidence of anticholinergic side effects including orthostatic hypotension, and are less likely to cause tachycardia or arrhythmias. They appear to be relatively safe in overdose, although there are rare case reports of hyponatrenia due to syndrome of inappropriate diuretic hormone (SIADH) in geriatric patients,[22] as well as occasional reports of hypomania. More common side effects include transient gastrointestinal upset, insomnia, headaches, sexual dysfunction, and occasional agitation or anxiety. Side effects are dose-related, supporting the clinical adage "start low and go slow." SSRIs have a variable ability to inhibit the hepatic cytochrome P450 enzyme system, which is responsible for metabolizing numerous medications including the SSRIs themselves (see Table 2).[23] In this regard, citalopram (Celexa) is the "cleanest" of the SSRIs. Serotonin Norepinephrine-Reuptake Inhibitors Venlafaxine Venlafaxine (Effexor) is a potent inhibitor of both serontonin and norepinephrine reuptake, with a minor impact on muscarinic, histaminic, or alpha-adrenergic receptors. It may increase systolic blood pressure in some patients but is associated with few protein binding-induced drug interactions. Venlafaxine may cause nausea if the dose is started too high or increased too rapidly; other potential side effects include headache, dry mouth, sedation, and tremors. The appropriate dose varies according to studies, ranging from 18.75 to 300 mg/d. Serotonin Antagonist-Reuptake Inhibitors Nefazodone Nefazodone (Serzone) is associated with less sexual dysfunction than the SSRIs. Its sedating effect may also be helpful in depression-related sleep problems. The drug has a short half-life, minimal anticholinergic activity, and no apparent cardiotoxicity. Side effects include dry mouth, dizziness, sedation, gastrointestinal upset, and postural hypotension. The starting dose is 50 mg once or twice daily, with a therapeutic range of 200 to 600 mg/d. Trazodone The effective dose of trazodone—200 to 600 mg/d—is often so sedating as to preclude its usefulness. The drug may be used as a sedative hypnotic in doses of 25 to 100 mg, but it has been shown to be associated with arrhythmias in patients in the acute phase (ie, within 6 weeks) of a myocardial infarction.[24] There have been rare reports of priapism, so male patients must be warned about this possible side effect.[25] Norepinephrine Dopamine Modulators Bupropion A generally well tolerated drug, bupropion (Wellbutrin) has minimal interactions with other medications. Common side effects include dry mouth, headache, gastrointestinal upset, agitation, and insomnia. It has minimal effect on cardiac function but may cause small increases in blood pressure. Bupropion can slightly increase the risk of seizures (0.4%) in doses above 300 mg and should be used cautiously in patients with seizure disorders or central nervous system disorders. It has a stimulant-like effect, which is useful when significant psychomotor retardation is present. Page 4 of 10

Current Management of Depression in Cancer Patients Published on Physicians Practice (http://www.physicianspractice.com) Monoamine Oxidase Inhibitors Monoamine oxidase inhibitors (MAOIs) are generally avoided, unless the patient has had a previous good response to these drugs predating their cancer treatment. They are associated with numerous problems. For instance, consumption of foods rich in tyramine or the use of sympathomimetic drugs such as pseudoephedrine or psychostimulants with MAOIs can cause a potentially fatal hypertensive crisis.[26] In combination with opioid analgesics, they may cause myoclonus and delirium.[27] When combined with meperidine, MAOIs have been associated with death. Hence, they are rarely used in the depressed cancer patient. Reversible Inhibitors of Monoamine Oxidase Type A Moclobemide The most common side effects of moclobemide (not commercially available in the United States but available in Canada as Manerix) include dizziness, gastrointestinal upset, constipation, dry mouth, and headaches.[28] An initial dose of 100 mg/d and gradual titration to the maximum dose of 600 mg/d are recommended. Unlike the MAOIs, no dietary restrictions are necessary with moclobemide. Due to inhibited metabolism, the dosage of this drug should be reduced by 50% if the patient is also taking cimetidine. It should also not be combined with clomipramine, dextromethorphan, meperidine, and sympathomimetics such as over-the-counter cold preparations. Tricyclic Antidepressants As a class, TCAs have varying degrees of anticholinergic effects, increasing the risk of urinary retention, constipation, dry mouth, blurred vision, and cognitive impairment.[29] These agents may interact with antihypertensives, anticholinergics, anticoagulants, and anticonvulsants. Patients taking TCAs in addition to other anticholinergic medications are at risk for developing anticholinergic delirium. They are also associated with postural hypotension and dizziness, increasing the risks of falls and fractures, and should not be used in patients with narrow-angle glaucoma. TCAs are highly cardiotoxic in overdose and known to occasionally cause hyponatremia through SIADH[30]; they can also cause tachycardia. The quinidine-like effects of these drugs can lead to arrhythmias. Therefore, extreme caution is advised in patients with preexisting conduction defects, precluding consideration if second- or third-degree heart block is present. Desipramine Of the tricyclic antidepressants, desipramine is thought to be the least likely to cause anticholinergic side effects. It can be started at 25 mg/d and increased to a maximum of 300 mg/d. (The geriatric dosage is usually 50 to 150 mg/d.) Nortriptyline This TCA causes sedation due to its H1-histamine-receptor blockade. For patients using a number of sedating medications (ie, narcotic analgesics, antiemetics, anxiolytics), the cumulative sedating effects of these drugs may become problematic. Nortriptyline has least propensity for orthostatic, postural blood pressure changes. Dosing should start at 25 to 75 mg/d.[31] Psychostimulants For patients whose life expectancy is limited, psychostimulants (eg, dextroamphetamine, methylphenidate, pemoline) offer an effective alternative due to their more rapid response rate.[32,33] In some patients, benefits may be seen within 48 hours. Psychostimulants have been shown to improve attention, concentration, and overall performance on neuropsychological testing in the medically ill.[34] They may even be beneficial in patients with mild cognitive impairment, and, when added to antipsychotics, can produce significant benefits in lethargic delirium. They can reduce the sedating effect of opioid analgesics, and may even provide some adjuvant analgesia themselves.[35] Stimulants can increase appetite, promote a sense of well-being, and improve feelings of weakness in cancer patients. Side effects of psychostimulants include rare agitation, insomnia, or anxiety. If given within 6 to 8 hours of bedtime, insomnia can result, but this is easily avoided. They are generally well tolerated and rarely cause major problems. Mild increases in blood pressure, pulse rate, or tremor may be seen. Rarely, dyskinesias, paranoid psychosis, or exacerbation of an underlying confusional state may occur. Dextroamphetamine or Methylphenidate These medications can be initiated at a dose of 2.5 mg in the morning and at noon, and increased over several days to doses of 20 to 40 mg/d. If there is a good response, they may be continued for 1 or 2 months. Two-thirds of patients will be able to be withdrawn without a recurrence of depressive symptoms.[36] Should depression recur, one may continue their use for a year or more without significant abuse problems. In the event that tolerance develops, some dose adjustment may be Page 5 of 10

Current Management of Depression in Cancer Patients Published on Physicians Practice (http://www.physicianspractice.com) required. Pemoline Compared to other psychostimulants, pemoline may be somewhat less potent and appears to have little abuse potential.[37] It also is not subject to the federal triplicate prescription regulation of other stimulants. The drug comes in a chewable tablet form that can be absorbed through the buccal mucosa, which is especially helpful if the patient has problems with swallowing. Dosing can begin at 18.75 mg in the morning and at noon, and increased gradually over several days, with most patients ultimately requiring 75 mg or less per day. Caution should be exercised in patients with liver impairment, and liver function tests monitored if treatment is to be continued over a prolonged period.[38] Electroconvulsive Therapy It is necessary to consider electroconvulsive therapy (ECT) in the following cases: (1) the treatment-resistant patient, (2) the patient who is psychotic or dangerously suicidal, and (3) the patient who is refusing to eat or drink. ECT has been shown to be a safe and effective treatment alternative, and may achieve more favorable responses than pharmacotherapy in medically compromised patients.[39] Supportive Psychotherapy Probably the most important aspect of psychotherapy is the therapeutic alliance (ie, the relationship between the patient and the caregiver). Fear of abandonment is common in severely ill patients; this fear is often based on the reality of seeing a social support network drop away over time. Psychotherapeutic relationships work best if they are based on mutual trust, respect, and sensitivity. Doctor and patient work together toward mutually agreed upon goals. Tailoring psychotherapy to the individual patient—considering personal style and unique needs—works best. Supportive psychotherapy attempts to support adaptive coping mechanisms, minimize maladaptive ones, and decrease adverse psychological reactions such as fear, shame, self-loathing, and withdrawal.[40] The aim of such treatment is to bolster psychological equilibrium via the physician’s empathic posture in the context of a stable therapeutic relationship. Reassurance is useful when it is based on a specific understanding of the individual’s needs and is not clinically unrealistic. Psychoeducation is an important part of supportive psychotherapy. The caregiver should not adopt a stance that is overly solemn or emotionally restrained, because the patient may experience this as distancing. Moreover, patients should be encouraged to freely talk or ask questions about their prognosis (if they would like to), with the therapist taking an interested and interactive stance.[7] Group Psychotherapy Supportive group therapy is often helpful for patients to regain a sense of mastery and control by allowing patients to share common experiences, thereby reducing the sense of individual emotional isolation. Supportive/expressive group psychotherapy has been shown to improve mood, reduce maladaptive coping responses, and reduce pain in breast cancer patients.[41] Goals of supportive expressive groups include encouraging mutual support, detoxifying dying, enhancing communication with family and physicians, improving social networks, and examining life priorities. Structured Cognitive Therapies Cognitive-behavioral therapy and interpersonal therapy are systems of short-term individual and group psychotherapy that were developed specifically for the treatment of depression. Interpersonal therapy focuses on discrete manageable psychological and interpersonal issues and has shown promise in research pertaining to patients with human immunodeficiency virus (HIV) or breast cancer. Cognitive-behavioral therapy has been well established as a treatment for depression.[42] It has also been used to help with symptom management in terminally ill patients.[43] This type of intervention focuses on cognitive distortions that negatively affect mood. Improvement in such distortions often helps patients to better cope with or adapt to the vicissitudes of their illness. Existential Psychotherapy Existential psychotherapy involves the evaluation of one’s relationship to life, with the goal of helping patients live more fully in the moment. It is an appropriate intervention for some terminally ill persons, who confront daily choices that affect quality of life and often have questions concerning the meaning, purpose, and value of life. The way in which seriously ill patients cope influences both their emotional state and their ability to adjust. It has been demonstrated that avoidance of feelings, denial of concerns, ongoing feelings of helplessness, a stance of passive compliance, and social isolation all result in decreased quality of life, and possibly an increased risk of disease or mortality. However, open and honest expression of both feelings and thoughts corresponds to a higher quality of life and, indeed, may bolster one’s physical health.[44] Group existential psychotherapy allows the patient to hear about the experience of others, thereby Page 6 of 10

Current Management of Depression in Cancer Patients Published on Physicians Practice (http://www.physicianspractice.com) providing "lateral experience" from which the patient may consider alternative ways of understanding and action. Moreover, the perspective of other patients can challenge one’s own conclusions about life, facilitate an adjustment to one’s current circumstances, and assist in choosing actions that are truly meaningful. The group has the potential to help the patient realize that he or she is not alone, and that others have different perspectives that may bear consideration.[45,46] The Therapeutic Life Narrative Patient distress may not be directly related to the fear of death itself, but to concerns regarding missed opportunities, loss of autonomy and control, and regret for decisions not taken. All of these feelings may be examined through use of the psychodynamic life narrative (or life review). This form of therapy is particularly useful in patients whose previously successful adaptation has been disrupted by a crisis or a specific life event. It permits patients to understand their present experience in the context of their life history and to view their current reaction as the logical product of previous experience, rather than as an arbitrary response to illness. This may offer a reassuring sense of coherence, order, and logic in a situation that is largely beyond the patient’s individual control. The patient is also provided with a protective therapist/physician who can offer reassurance, while attempting to capture the life narrative. The therapy gradually assumes the quality of a shared experience.[47] For example, we recently counseled an elderly gentleman with an advanced oral malignancy. This patient gained considerable comfort in being able to review his life as a successful musician. He found that the therapeutic task of sharing this history provided a context within which to understand his current existential distress and helped give him a much needed sense of life’s continued meaning and purpose.

Conclusions Depression is a treatable condition, even in the cancer care setting. Recognizing and treating depression in severely ill patients is as important in this population as in the physically healthy, if not more so. Quality-of-life issues are never more germane than they are for patients whose lives are in jeopardy, facing the physical, psychological, and spiritual challenges that a cancer illness inevitably brings. Screening for depression can be done simply and effectively, and treatment initiated with any of various appropriate interventions, as previously described. Moderating the level of specific neurotransmitters is only a small part of treating depression in cancer patients. The physician-patient relationship is of critical importance and should be characterized by warmth, caring, honesty, and recognition, not simply of the physical domains of patient care, but of the psychological and spiritual dimensions as well. The judicious use of medication and supportive therapies should significantly alleviate depression and enable the patient to navigate the cancer course with dignity, purpose, and the best quality of life possible.

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46. Greenstein M, Breitbart W: Cancer and the experience of meaning: A group psychotherapy program for people with cancer. Am J Psychotherapy (in press). 47. Viederman M: The supportive relationship, the psychodynamic life narrative and the dying patient, in Chochinov HM, Breitbart W (eds): Handbook of Psychiatry in Palliative Medicine. New York, Oxford University Press, 2000.

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