Abstract
Depression is a common comorbidity in cancer cases, affecting >10% of patients. A cancer diagnosis is life-changing, and is a source of considerable psychological and emotional stress. Non-pathological sadness may be a normal response to a cancer diagnosis, however, stress beyond the coping mechanisms of patients may result in major depressive disorder. The current review, in addition to the obvious psychosocial elements of depression, explores its biological mechanisms, including tissue damage, inflammatory mediators and the chronic stress response, and how these immune and endocrine pathways may underlie depression in cancer. Possible iatrogenic causes of depression in cancer are also explored. There is a strong need to identify and treat depression in cancer patients in order to increase quality of life and reduce mortality. The most popular clinical and potential future biochemical screening tools for depression in cancer are briefly discussed. The interventions used will vary for every patient, but may include psychosocial therapies or pharmacotherapy; however, a paucity of research on the most effective management of depression in cancer means the optimal combination of therapies is unknown. Selection of antidepressants should be carefully considered, given the common side effects of chemotherapy (such as nausea), and the necessity to avoid serious interactions, including reducing the effectiveness of chemotherapeutic drugs. The possible link between the chronic stress response, which may predispose patients to depression, and the risk of mortality from cancer is also explored. The complex interactions between the endocrine, nervous and immune systems, which continue to be elucidated, may offer the opportunity for the development of more rapid and efficacious treatments for depression in cancer in the future.
Highlights
Depression is a common comorbidity in cancer cases, affecting >10% of patients
The prevalence of depression in patients with high levels of pain compared with low pain levels is significantly higher; one study observed that depression occurred in 33% of those in high amounts of pain, compared with 13% in those with low levels of pain, suggesting that pain may be a causative factor in depression [16]
A study measuring interleukin‐6 (IL‐6) levels and relative diurnal cortisol variation in depressed cancer patients revealed that IL‐6 levels are increased by a factor of seven (18.7 pg/ml vs. 2.7 pg/ml), whilst relative diurnal cortisol variation is decreased by a factor of six (11.7% vs. 60.6%) among cancer patients with depression compared with those without depression
Summary
For the diagnosis of MDD according to the DSM, the patient must have either a depressed mood or a diminished level of interest or pleasure in activities for at least two weeks. The somatic presentations of depression, including fatigue, loss of appetite, weight change and poor cognition, can be dismissed by clinicians as symptoms of cancer or side effects of treatment, which leads to decreased detection of the disorder. Appetite changes and reduced cognitive ability were found to be positively associated with anhedonia, whereas fatigue and sleep difficulties were not, even after adjusting for cancer pain and physical functioning. This suggests that reduced appetite and poor cognition may be more useful symptoms in diagnosing depression in cancer [17]. Screening tests for depression in cancer patients using diurnal cortisol variation, at a cut‐off value of 35%, provided the highest specificity and sensitivity, at 88% and 81%, respectively; these tests may be useful in detecting depression in cancer patients [22]
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