What you need to know

· Psychological, rather than biological, symptoms of depression, such as anhedonia and pronounced helplessness, hopelessness, guilt, and suicidal ideation, tend to be key diagnostic pointers to depression in patients with cancer

· Anxiety is regarded as pathological in a patient with cancer when it is disproportionate to the level of threat and disrupts usual functioning

· Investigate and address reversible causes, such as vitamin deficiency or hypercalcaemia, and perpetuating factors, such as pain

A 54 year old man asks his doctor for a sleeping tablet. He has recently been diagnosed with a Dukes B adenocarcinoma of the rectum and seems low in mood. Although he has been given a good prognosis, has completed neoadjuvant chemotherapy, and is booked for curative surgery shortly, he expresses doubts that he will live much longer. His doctor wonders if he might be depressed or anxious, and how best to address this.

  Depression and anxiety are more common in patients with cancer, and they are associated with poorer quality of life and cancer survival.1-2 This article offers advice on how to recognise these disorders, and when to offer referral for specialist advice.

During the assessment, form an impression about whether the patient has depression:

· Is this pathological low mood or anxiety, or is this a normal response to the threat posed by cancer?

· Could this be a direct effect of a medication or the disease?

  What you should cover

   History

   Explore current mood and difficulties with sleep. Facilitate disclosure by acknowledging that some patients may feel depressed or anxious after a cancer diagnosis, even when receiving lifesaving treatment.

    Ask about:

·         Specific psychological symptoms. These are the key diagnostic pointers of depression in patients with cancer. Ask about anhedonia (loss of pleasure or interest in previously enjoyable activities), and pronounced feelings of helplessness, hopelessness, guilt, or suicidal ideation causing severe distress or impairment, as these are likely to be diagnostic of depression. 3

·         Whether the patient feels very low in mood or reports panic symptoms. Has the patient ever experienced this before?

·        Specific biological symptoms. For example, is the problem specifically initial insomnia or early morning waking, or is sleep broken due to pain or recent use of high dose corticosteroids?

·         Check that depressive symptoms are not a result of the biologically mediated effects of the tumour or treatment (see infographic). 1For example, weight loss, low energy, and poor motivation may be a consequence of cancer cachexia or chemotherapy.

·         How these symptoms are affecting the patient’s life and ability to function. Are they likely to influence his or her cancer treatment decisions?

·         Current physical symptoms, including but not limited to pain and bowel habit. Is the patient anxious about other symptoms, fearing they represent cancer spread?

    Health anxiety describes a preoccupation with the fear of having a serious illness based on a misinterpretation of somatic symptoms. This may be understandable for patients in remission whose anxiety is reinforced by a past (and sometimes missed) cancer diagnosis.

    For patients with high levels of anxiety, it may be hard to distinguish between an anxiety disorder, an adjustment disorder, and a transient but normal response to a life-changing diagnosis. Anxiety is regarded as pathological where it is disproportionate to the level of threat (for example, still high more than 10 days after receiving bad news), persists or deteriorates without intervention, and disrupts usual functioning. ²

    Previous medical history—Does the patient have any other medical problems associated with depression? Take an alcohol history, especially as rectal cancer is associated with alcohol use. Hazardous alcohol use will worsen low mood or anxiety and render antidepressants ineffective.

    Previous psychiatric history—Is this a further relapse of a longstanding recurrent depressive disorder or bipolar mood disorder?

    Risk assessment

    There is no evidence that screening for suicidal thoughts induces suicidal ideation. ⁴ Explore suicidal thoughts, which may be passive (such as “I don’t care if I wake tomorrow or not,” “I wish I was dead”) or active (such as “I am thinking of ending my life”). Ask patients if they have begun to think of ways to end their life and whether they intend to act on this. If so, when are they planning to take action?

    Risk factors for suicide in cancer include tumour site, physical functioning, and cancer prognosis, in addition to the usual risk factors for completed suicide in the general population. ⁵  Patients with head and neck tumours, multiple myeloma, or lung cancer and those with limited treatment options are a particular concern, as are men with poor social support. ⁶  Suicide risk peaks during the first month after cancer diagnosis. ⁷  Such elevated risks are apparent despite the prevalence of suicidal ideation being no higher than that in the general population. ⁵  Suicidal thoughts may arise as a catastrophic reaction to a new diagnosis, during the intense phase of treatment, or in terminal illness (box 1). A past history of severe mental illness, previous self harm, and continuing alcohol or drug misuse are further important risk factors for completed suicide.

Box 1  “Desire for hastened death”

    “Desire for hastened death” is the term used to describe suicidal thoughts, requests for assisted suicide, and requests for euthanasia in terminally ill patients. It is reported by 17% of inpatients receiving end-of-life cancer care and is associated with major depression. ⁸  Commonly such patients report uncontrolled pain, burdensomeness, loss of dignity, and fear of a painful death. While healthcare staff might be asked to assist death at the end, this is illegal in the UK.

·        If a person asks about options for hastening their death, use their request to open up a conversation about their fears about death

·         Explore modifiable contributory factors, particularly pain

·         Clarify that assistance to die cannot be provided, document the discussion, and explain your obligation to share their feelings with senior professional colleagues

    Clinical examination

    Whether the aetiology is thought to be biopsychosocial or due to direct biological effects (for example, due to recent antifolate chemotherapy), a full physical screen will identify any reversible contributory causes.

    In this patient’s case, as for any assessment for depression, this should include:

·        Mental state examination, looking for signs of self neglect, poor eye contact, depressed posture, agitation or psychomotor retardation, depressive cognitions, suicidal thoughts or intent, and depressive delusions. Test concentration and memory (after recent chemotherapy).

·         Medical investigation may include reviewing full blood count and renal, thyroid, and liver function tests. The oncologists will have ruled out bone or brain metastases as part of the preoperative staging of the cancer.

    What you should do

    The general principle when assessing a patient with cancer for depression is that, if psychological symptoms reach the threshold for a depressive disorder, this should be diagnosed and treated. Similarly, when anxiety is noted to impair function significantly, it should be assessed against diagnostic criteria for an anxiety disorder and treated accordingly.

    Further details about management are found in the accompanying Clinical Update, but the basic approach would include:

    Address any underlying biological causes (such as hypothyroidism independent of the patient’s cancer). Colorectal cancers have few neuropsychiatric effects. If the patient’s low mood is thought to be an adverse effect of antifolate chemotherapy, administration of vitamin B12 may ameliorate this by correcting raised homocysteine levels, but this remains untrialled.

    Psychological approaches——Group or individual cognitive-behavioural strategies can be used to understand and cope with the patient’s depressive symptoms, and wider psychological therapy approaches used to explore existential issues. These may be available from a psychosocial support service embedded in local cancer services or from local psychological therapy services such as the Improving Access to Psychological Therapies (IAPT) programme. Where specialist services are not available, IAPT services may also have “long term conditions support” available to address depression and anxiety.

    Pharmacological approach——Assuming there is no alcohol misuse, sertraline or citalopram would usually be appropriate first line agents for such a patient, with a gastroprotective agent if he has previously had gastritis (see box in linked article on general prescribing pointers in patients with cancer). However, these selective serotonin reuptake inhibitors occasionally cause diarrhoea. In this patient’s case, choice of antidepressant should anticipate forthcoming stoma, and mirtazapine would be a better option due to its relatively neutral effect on bowel function.

    Psychosocial support——Local voluntary sector support groups for people with cancer and web based psychoeducation resources are likely to be of benefit in self management of distress.

    When to refer

    Referral for specialist counselling and specific psychological interventions is indicated where depression or anxiety seriously challenge coping mechanisms or give rise to persistent distress. Such interventions include anxiety management or cognitive-behavioural therapy tailored to cancer contexts, and are provided in specialist psychological support services, including specialist counsellors and clinical psychologists embedded in cancer services. ⁹ 

    Patients with cancer treated in primary care for major depression have better response rates to antidepressants after prescribing input from a psychiatrist. ¹⁰  Liaison psychiatrists have particular expertise in selecting antidepressants in the context of complex medical or surgical care, particularly in the case of treatment resistance. In hospitals where there is no specialist oncology liaison service, or where liaison psychiatry input is only available for inpatients, prescribing advice for outpatients may be sought from community based psychiatric services.

    Suicidal ideation, psychotic symptoms, mania, and confusion or severe depression of rapid onset after chemotherapy or corticosteroid administration are all indications for urgent psychiatric referral.

Education into practice

·         What questions might you include in a screen for depression and anxiety in patients with cancer exhibiting psychological distress?

·         How comfortable do you feel discussing suicidal ideation in a patient offered potentially curative treatment for cancer?

·        Are you aware of any local voluntary sector support groups for people with cancer or web based psychoeducation resources?

How patients were involved in the creation of this article

We interviewed a range of our patients with cancer to find out what they felt were the important aspects to address in an article about psychiatric problems in cancer. We invited a patient representative to give a personal perspective of her experiences and to review our article for its coverage of key points.

Contributors: AP and AH conceived the article and conducted literature searches. AP drafted the article, with contributions from SS, NH, and AH. SS devised the cognitive behavioural model. All authors approved the final version of the article and agree to be accountable for all aspects of the work. AP is the guarantor.

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare. Our employers and Macmillan had no role in the preparation, review, or approval of the manuscript. The views expressed are those of the authors and not necessarily those of their employing trusts or of Macmillan.

Provenance and peer review: Commissioned, based on an idea from the author; externally peer reviewed.

Alexandra Pitman, Macmillan consultant liaison psychiatrist, senior clinical lecturer in psychiatry^1-2,

Sahil Suleman, Macmillan consultant clinical psychologist, honorary research associate^1-2,

Nicholas Hyde, consultant head and neck surgeon¹,

Andrew Hodgkiss, consultant liaison psychiatrist, honorary clinical senior lecturer^3 - 5

¹St George’s University Hospitals NHS Foundation Trust, London, UK

²UCL Division of Psychiatry, London, UK

³Central & North West London NHS Foundation Trust, London, UK

⁴The Royal Marsden NHS Foundation Trust, London, UK

⁵Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, UK

Correspondence to: A Pitman [email protected]