Tailoring Depression Treatment for Women with Breast Cancer: Factors Unique to These Patients Help Determine Treatment Strategies
Agarwala, Prachi, Riba, Michelle B., Current Psychiatry
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.
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 al (5) 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)
Self-blame for developing breast cancer can affect mood. In 2007, Friedman et a1 (9) 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)
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 al (11) 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.
Risk factors for psychiatric distress related to breast cancer
Past psychiatric illness
Family history of psychiatric illness
Younger age (<45 years)
Having young children
Limited social support
Poor family coherence
Source: Adapted from reference 10
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 (Figure, page 45). …