Editor’s note: One of a series of articles on managing cancer-related symptoms from the Oncology Nursing Society.
Dana Jennings, in his New York Times blog on his battle with cancer, described depression during his illness:
This isn’t about sadness or melancholy. It’s more profound than that. Broadly, I have a keen sense of being oppressed, as if I were trapped, wrapped up in some thick fog coming in off the North Atlantic. To be more specific, I’m exhausted, unfocused and tap my left foot a lot in agitation. I don’t much want to go anywhere — especially anyplace that’s crowded — and some days I can’t even bear the thought of picking up the phone or changing a light bulb. All of this is often topped off by an aspirin-proof headache.
As patients and healthcare providers work hard to combat the physical effects of cancer and its treatment, even as they celebrate milestones in recovery and survivorship, they can fail to notice, assess, or address the emotional effects of cancer.
Depression is significantly higher in patients with cancer than in the general population (Holland, 2002)—at least 25% of oncology patients experience it (Martin & Jackson, 2000). Many studies have indicated that depression affects recovery, perhaps survival, and certainly quality of life. Therefore, healthcare professionals must be alert for signs of depression, screen for symptoms regularly (see Table 1), and intervene. This article describes treatments for depression supported by strong evidence.
Table 1. Assessment of Depression (Based on information from Eaton & Tipton, 2009)Clinical measurement tools
- Hospital Anxiety and Depression Scale
- Beck Depression Inventory
- Zung Self-Rating Depression Scale
Physical symptoms to assess
- Changes in appetite, weight, sleep, or activity
- Decreased energy
Psychosocial symptoms to assess
- Feelings of worthlessness or guilt
- Recurrent thoughts of death or suicidal ideation
Cognitive changes to assess
- Difficulty thinking, concentrating, or making decisions
- Family history
- Certain medical conditions (e.g., endocrine or immune disorders, cardiovascular or neurologic conditions)
- History of substance abuse
Oncology Nursing Society Puts Evidence Into Practice
To promote nursing practice that is based on evidence, the Oncology Nursing Society (ONS) launched the Putting Evidence Into Practice (PEP) program in 2005. ONS PEP teams consisting of advanced practice nurses, staff nurses, and a nurse scientist were charged with reviewing the literature to determine what treatments and interventions are proven to alleviate many cancer-related problems that are sensitive to nursing interventions. Each team classified interventions under the following categories: recommended for practice, likely to be effective, benefits balanced with harms, effectiveness not established, effectiveness unlikely, and not recommended for practice. Interventions recommended for practice were those for which effectiveness was demonstrated by strong evidence from rigorous studies, meta-analysis, or systematic reviews, and for which any expectation of harm was small compared to benefits (Eaton & Tipton, 2009).
Recommended for Practice
Evidence at the highest level supports the benefit of psychoeducational and psychosocial interventions in the management of depressive symptoms during and following cancer treatment in patients with different types of cancer (Eaton & Tipton, 2009). The most evidence relates to cognitive behavioral therapy, defined as any specific psychological or psychosocial intervention that is brief, goal oriented, based on learning principles of behavior change, and directed at effecting change in a specific clinical outcome (Osborn, Democada, & Feuerstein, 2006). It teaches problem-solving skills and helps people reframe attitudes. Other effective approaches are patient education and information, counseling and psychotherapy, behavioral therapy, and social support. Although some of the approaches require advanced training, others are essential nursing responsibilities. Additional study is needed to establish the most effective frequency and duration of such treatments.
Also recommended for practice is pharmacologic intervention with antidepressant medications. Studies have supported tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs), as well as others. Although no specific medication has been proven to be more effective than another, the lower incidence of side effects with SSRIs makes them preferable in patients with cancer (Eaton & Tipton, 2009).
Likely To Be Effective
The ONS PEP team found that methylphenidate, a central nervous system stimulant in doses of 10–40 mg daily, is effective in treating depression in a variety of advanced cancers. The drug also is used to address opioid-induced somnolence, to augment opioid effects, and to improve cognitive function.
Relaxation therapy also was found to reduce effects of cancer treatment, including depression. The techniques included progressive muscle relaxation, guided imagery, and autogenic training.
Other interventions that have been studied with regard to depression in patients with cancer are exercise, hypnotherapy, and massage. The ONS PEP team classified those interventions as “effectiveness not established” because of insufficient data, conflicting study results, or poor quality of studies.
Table 2. Interventions for Depression (Based on information from Eaton & Tipton, 2009)Recommended for practice: psychoeducational and psychosocial interventions such as cognitive behavioral therapy, patient education and information, counseling and psychotherapy, behavioral therapy, and social support; pharmacologic intervention with antidepressant medicationsLikely to be effective: methylphenidate (Ritalin®), relaxation therapyEffectiveness not established: exercise, hypnotherapy, massage therapy, and other complementary and alternative approachesExpert opinion: assessment at every encounter, a combination of antidepressant medication and psychoeducational or psychosocial therapy
Experts (National Comprehensive Cancer Network, 2006; Sadock & Sadock, 2003) encourage healthcare providers to assess patients and families for depression and depressive symptoms at every encounter, evaluate patients’ and families’ understanding of depression and its role in cancer recovery, and provide education about depression and it management.
And the evidence, as examined by the ONS PEP team, provides several effective treatment options for what Jennings (2009) described as a “dark waltz with cancer” common in patients with cancer.
At the time this article was written, Keightley Amen was a staff editor on the Publishing Team at the Oncology Nursing Society.
Find Evidence-Based Interventions for 15 Other Symptoms
Learn more about ONS’s PEP resources for other symptoms at http://www.ons.org/Research/PEP.
Need More Symptom Management Information? There’s an App for That!
The new ONS PEP app for iPhones and the iPod Touch gives you evidence-based symptom management information with the click of a button. Available through the iTunes Store, the 16 apps offer interventions for 16 common side effects of cancer and its treatment, including depression, CINV, pain, mucositis, and fatigue. Simply go to the iTunes Store and search for ONS PEP.
Eaton, L.H., & Tipton, J.M. (Eds.). (2009). Putting Evidence Into Practice: Improving oncology patient outcomes. Pittsburgh, PA: Oncology Nursing Society.
Holland, J.C. (2002). History of psycho-oncology: Overcoming attitudinal and conceptual barriers. Psychosomatic Medicine, 64, 206–221.
Jennings, D. (2009). After cancer, ambushed by depression. Retrieved from http://www.nccn.org/professionals/physician_gls/PDF/distress.pdf
Osborn, R.L., Democada, A.C., & Feuerstein, M. (2006). Psychosocial interventions for depression, anxiety, and quality of life in cancer survivors: Meta-analyses. International Journal of Psychiatry in Medicine, 36(1), 13–34.
Sadock, B.J., & Sadock, V.A. (2003). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (9th ed.). Philadelphia, PA: Lippincott Williams and Wilkins.