Evidence-Based Reviews

Tailoring depression treatment for women with breast cancer

Current Psychiatry. 2010 November;9(11):39-49

Factors unique to these patients help determine treatment strategies

References

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4. Fann JR, Thomas-Rich AM, Katon WJ, et al. Major depression after breast cancer: a review of epidemiology and treatment. Gen Hosp Psychiatry. 2008;30:112-126.

5. Waljee JF, Hu ES, Ubel PA, et al. Effect of esthetic outcome after breast-conserving surgery on psychosocial functioning and quality of life. J Clin Oncol. 2008;26(20):3331-3337.

6. Brandberg Y, Sandelin K, Erikson S, et al. Psychological reactions, quality of life, and body image after bilateral prophylactic mastectomy in women at high risk for breast cancer: a prospective 1-year follow-up study. J Clin Oncol. 2008;26(24):3943-3949.

7. Lee KC, Ray T, Hunkeler E, et al. Tamoxifen treatment and new onset depression in breast cancer patients. Psychosomatics. 2007;48:205-210.

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9. Friedman LC, Romero C, Elledge R, et al. Attribution of blame, self-forgiving attitude and psychological adjustment in women with breast cancer. J Behav Med. 2007;30:351-357.

10. Spiegel D, Riba M. Psychological aspects of cancer. In: DeVita VT, Lawrence TS, Rosenberg SA, eds. Principles and practice of oncology. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:2817–2826.

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19. Dolbreault S, Cayrou S, Bredart A, et al. The effectiveness of a psycho-educational group after early-stage breast cancer treatment: results of a randomized French study. Psychooncology. 2009;18:647-656.

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Dr. Riba discusses treatments for depressed breast cancer patients

Discuss this article at http://currentpsychiatry.blogspot.com/2010/11/depression-treatment-for-women-with.html#comments

Psychological distress among patients with breast cancer is common and is linked to worse clinical outcomes. Depressive and anxiety symptoms affect up to 40% of breast cancer patients,¹ and depression is associated with a higher relative risk of mortality in individuals with breast cancer.² Psychotropic medications and psychotherapy used to treat depression in patients without carcinoma also are appropriate and effective for breast cancer patients. However, some patients present distinct challenges to standard treatment. For example, growing evidence suggests that some selective serotonin reuptake inhibitors (SSRIs) may reduce the effectiveness of tamoxifen, a chemotherapeutic agent. This article discusses challenges in diagnosing and treating depression in breast cancer patients and reviews evidence supporting appropriate psychiatric care.

Increased vulnerability

In 10% to 30% of women, a breast cancer diagnosis may lead to increased vulnerability to depressive disorders, including adjustment disorders with depressed mood, major depressive disorder (MDD), and mood disorders related to general medical conditions.^3,4 The risk of developing a depressive disorder is highest in the year after receiving the breast cancer diagnosis.⁴

A woman’s risk of developing a depressive disorder may depend on the type of cancer treatment she receives. For example, breast asymmetry is common after breast conserving surgery. Waljee et al⁵ found that women with breast asymmetry had increased fears of cancer recurrence and more feelings of self-consciousness. More pronounced asymmetry led to a higher incidence of depressive symptoms. However, among 90 patients undergoing bilateral prophylactic mastectomy, the rate of depression had not changed 1 year after the procedure.⁶ Chemotherapy, particularly at high doses, is a risk factor for depression.^4,7,8

Clinical Point

Somatic symptoms of depression may be mistaken for side effects of breast cancer treatment

Self-blame for developing breast cancer can affect mood. In 2007, Friedman et al⁹ determined that higher levels of self-blame correlated with higher levels of depression and decreased quality of life. Women often blamed themselves for various reasons, including:

poor coping skills
anxiety about their health and treatments
inability to express emotions
delays in medical consultation.

Exacerbated symptoms and side effects. Women with depression often experience increased side effects from cancer treatments, and the subjective experience of these effects—including hot flashes, cognitive impairment, pain, and sexual dysfunction—likely is intensified.⁴ Somatic symptoms of depression may be exacerbated by cancer treatment side effects or mistaken for effects of the treatment. When somatic symptoms of depression are mistaken for treatment side effects, depression—and the opportunity to treat it—can be overlooked.¹⁰

Clinical Point

Depressive symptoms can create the impression that a patient is poorly adherent to cancer treatments

Depression may be a risk factor for poor adherence to cancer treatment. In a quantitative review of studies correlating depression and medical treatment noncompliance, DiMatteo et al¹¹ determined that compared with nondepressed patients, those with depression were 3 times more likely to not adhere to treatment recommendations; this review was not limited to cancer patients. Depressive symptoms—notably poor concentration and amotivation—can create the impression that a patient is poorly adherent. Women with comorbid depression and breast cancer may have difficulty understanding treatment recommendations or remembering daily treatment goals.⁴

Appropriate screening tools

Factors that may increase a breast cancer patient’s risk for developing a psychiatric disorder are listed in Table 1.¹⁰ Many depression screening tools are available; below we describe 3 commonly used for patients with breast cancer.

The National Comprehensive Cancer Center Distress Thermometer allows patients to rate their overall distress level over the past week on a scale from 0 to 10, using a visual analogue.¹² The Distress Thermometer has been validated for several cancer populations and in different parts of the world. A score of 7 has both good sensitivity and specificity for detecting depression in breast cancer patients. Consider a complete psychiatric evaluation for patients with scores ≥7.¹³

The Profile of Mood States questionnaire¹⁴ is a reliable, valid 65-item questionnaire often used in studies of mood dysregulation and breast cancer. Subscales include depression-dejection, tension-anxiety, anger-hostility, confusion-bewilderment, vigor-activity, and fatigue-inertia. Using a 5-point Likert scale, patients rate their symptoms over the past week. Subscale scores are then added to a total mood disturbance score.^14,15

The Hospital Anxiety and Depression Scale (HADS) is a sensitive, reliable 14-item scale that is commonly used to study depression and anxiety in patients with breast cancer.¹⁶ HADS includes two 7-item subscales—anxiety and depression—and answers are scored on a 4-point Likert scale. Patients are asked to respond quickly and avoid thinking too long about their answers.

Table 1

Risk factors for psychiatric distress related to breast cancer