Depressive disorders

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Sadness and grieving for loss of health and well being are normal responses in cancer patients. (3) A continuum is seen, beginning with these normal responses, and increasing intensity reaching the level of subsyndromal symptoms, adjustment disorder with depressed mood, and major depression and mood disorder related to medical condition. These are the most common depressive disorders encountered in patients seen at our counselling centre. A special diagnostic problem exists in cancer. Vegetative symptoms of depression are the same as many physical symptoms seen in patients with cancer, especially fatigue, slowed psychomotor activity, insomnia, absent libido, anorexia, and weight loss. The clinician must focus on the psychological symptoms of depression to make a diagnosis: persistent depressed, dysphoric mood, feeling of worthlessness, guilt, anhedonia, and preoccupation with hopelessness and death ( Tab.l.§... , 2).

Table 2 Diagnosis of depression

Patients with cancer report thoughts of suicide, even at early stages of illness. The incidence of suicide in patients with cancer exceeds that in the general population only slightly; however, many patients with advanced disease who commit suicide are probably not reported. (89) In general, patients use the thought as a way of asserting ultimate control: 'I will kill myself when the cancer becomes intolerable'. That time usually does not come but the control issue remains.

Patients who are in remission and who have a good prognosis should be evaluated for depression in the same way that you would evaluate physically healthy persons (Table 3). Suicidal ideation should be a cause for concern and be promptly evaluated and treated. Patients in advanced stages of illness may express suicidal thoughts which are viewed by others as 'rational' because of their level of illness. The debate on rational physician-assisted suicide hinges in part on this issue. However, in studies of the wish for hastened death in patients with advanced cancer and AIDS, presence of depression is the greatest predictor of experiencing a wish for hastened death, exceeding presence of pain as a factor. There is great need to teach physicians to evaluate patients with cancer for symptoms of depression, especially teaching them that asking about suicide does not increase the risk (Iable.3). The dearth of psychiatrists working in palliative care is a problem in bringing these concepts more prominently into end-of-life care.

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Table 3 Evaluation of suicidal patient

The factors for suicidal risk in patients with cancer are several. They can be elicited by taking a good medical or psychiatric history. Medically, the most important problems are uncontrolled pain, delirium in which impulse control is reduced, and advanced disease with poor prognosis. Medication review is important since steroids and interferon produce depressive symptoms. Psychiatrically, history of prior depression or suicide attempt, substance abuse, poor social support, and present depressive symptoms are predictors. In Scandinavia, the highest incidence of suicide was found in patients who were told they had no further treatment options, and who lost contact with their physicians, underscoring the need for continued support. (l0,i1> Thus, physician's availability, continued support, and control of symptoms, especially pain and depression, are essential.

In evaluating depression and suicide risk, neither can be adequately assessed in the presence of poorly controlled pain. The first step is to assure pain control is achieved and then reassess mental status. Management of pain and psychiatric symptoms is intimately related, particularly in advanced cancer where both are common. The psychiatrist working in oncology must be familiar with the basics of pain management. Factors associated with increased risk of suicide are listed in Table 4.(12>

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Table 4 Suicide vulnerability variables

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