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Cancer is a leading
cause of death, but it turns from a terminal illness to more of a chronic
illness with periods of remission and exacerbation of symptoms. This
perspective has broadened the scope of care from treating the disease alone to
managing cancer-related symptoms including mental disorders. Among the
nosological forms of comorbid mental pathology in cancer patients, affective
disorders (depression and anxiety) predominate. This predomination is most
distinct in long-term cancer survivors. Receiving a fatal diagnosis, going
through treatment protocols, interruption of life plans, learning to live with
limitations, changes in lifestyle, social role, body image and self-esteem and
financial and legal concerns can cause depression in many patients, as can side
effects from the treatment itself. Still, not everyone with cancer becomes
depressed. Normally, a patient's initial emotional response to the crises faced
during cancer is brief, extending over several days to weeks, and may include
feelings of denial, disbelief, despair, sadness and grief. More severe symptoms
of depression are of clinical concern because of their association with marked
distress, more prolonged hospital stays, physical disorders, poorer treatment
compliance and adherence to therapy, disability, lower quality of life,
increased desire for hastened death and completed suicide. If untreated,
depression has been shown to negatively influence the underlying cellular and
molecular processes that facilitate the progression of cancer. Higher rates of
depressive symptoms in cancer have been found toward the end of life and in
specific cancers, such as lung, pancreatic, gastric and oropharyngeal ones.
Depressive symptoms occur on a continuum, with non-pathologic sadness at the milder
end, minor or sub threshold depression in the middle and major depression at
the more severe end of the spectrum. The most common form of depressive
symptomatology in people with cancer is an adjustment disorder with depressed
mood, sometimes referred to as reactive depression which may be
under-recognized and undertreated. Cancer-related depression can exist before
the diagnosis of cancer or may develop after the cancer is identified. While
there is no evidence to support a causal role for depression in cancer, it may
impact the course of the disease and a person's ability to participate in
treatment. Emergence of depression in cancer patients may be understood as a
final common pathway resulting from the interaction of multiple
disease-related, individual and psychosocial factors. There is mounting
evidence that tumor cell burden and treatment-induced tissue destruction, which
release pro-inflammatory cytokines that alter neurotransmitter and
neuroendocrine function, may contribute to depressive symptoms in cancer
patients with, captured under the rubric of cytokine-induced depression. The
diagnosis of depression is difficult due to the problems inherent in
distinguishing biological or physical symptoms from symptoms of illness or
toxic side effects of treatment. Suicidal statements may range from an off-hand
comment resulting from frustration or disgust with a treatment course to a
reflection of significant despair and an emergent situation. If the suicidal
thoughts are believed to be serious, a referral to a psychiatrist or
psychologist should be made immediately and attention should be given to the
patient's safety. A critical part of cancer care is the recognition of the
levels of depression present and determination of the appropriate level of
intervention, ranging from brief counseling or support groups to medication
and/or psychotherapy. At least one half of all people diagnosed with cancer
will successfully adapt. Pharmacotherapy for depression in patients with
advanced cancer should be guided by a focus on symptom reduction, irrespective
of whether the patient meets the diagnostic criteria for major depression. The
optimal antidepressant for specific patients can be determined by each
patient’s depressive symptom profile and potential dual benefit for depression
and cancer-related symptoms such as anorexia, insomnia, fatigue, neuropathic
pain and hot flashes. Because of both their adverse effect profiles and risk
for lethality in overdose, tricyclic/heterocyclic antidepressants, monoamine
oxidase inhibitors and reversible inhibitors of monoamine oxidase A are rarely
used in patients with cancer. Timely and precise diagnosis and appropriate
treatment of depression is required in an effort not only to increase quality
of life but also to reduce adverse effects on cancer course, length of hospital
stay, treatment adherence and efficacy and possibly prognosis and survival.
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