Sunday, December 18, 2011

Challenges in identifying ‘Depression’ in Cancer Patients

Depression is the common cold in psychiatry. No body can escape from depression. At one point or other in everybody’s life time, depression occurs. The reason behind depression varies from individual to individual. One such reason is cancer. Important issues in the life of any person with cancer may
include the following:

  • Fear of death.
  •  Interruption of life plans.
  • Changes in body image and self-esteem.
  • Changes in social role and lifestyle.
  •  Money and legal concerns.
Everyone who is diagnosed with cancer will react to these issues in different ways and may not experience serious depression.

Why Depression is not given due importance in Cancer Care?
Even though observable symptoms of depression such as crying spells, social withdrawn and sad mood are present in many cancer patients, only few are recognized by the oncologists and referred for further assessment and treatment. There are many difficulties present that obstruct the patients getting appropriate treatment for depression and they will be discussed under the following headings.

ü      Related to Oncologists
Most of the oncologists think depressive symptoms are normal when facing a very serious illness like cancer. It is generally seen as sickness behavior. Except the symptoms of depressed mood, guilt/worthless and suicidal ideation, all the other symptoms of depression are similar to sickness behavior.

Since the number of oncologists is very less in India comparing with the actual requirement, they are burdened with so many patients. Their work is being shared by nurses. Nurses are usually given adequate training to understand and use the technical language of cancer but nurses are not trained to understand the psychological issues of cancer patients.

Most of the oncologists are not aware of the symptoms of psychological issues such as depression, anxiety and stress. Even if they are aware of the symptoms, they tend to ignore even they are presented to them since they have no expertise to address them.

Fatigue is a well known mental health issue in cancer. One of the symptoms of clinical depression is fatigue. With the increased awareness among cancer care professionals, depression is overlooked as fatigue. However many oncologists fail to refer to treat fatigue.

In deciding the treatment plan, the family members are given more importance rather than the patients. So the interactions between the patients and the oncologists are very less. Thus oncologists fail to recognize the patients’ mental health issues. Since the patients are not completely informed about the diagnosis and prognosis, the fear of unknown catches the patients and it may lead to depression.

The source of significant weight loss/gain and Insomnia/Hypersomnia are very difficult to find in case of cancer. There are various possibilities such as site and stage of cancer, side effects of treatment and psychological issues.

ü      Related to Patients
For cancer patients and their family members, the priority is cancer treatment. They give less importance to mental health. They themselves think the sad mood is normal irrespective of its intensity. Moreover most of the oncologists also think it is normal to undergo distress during the time of diagnosis and treatment.

The taboo to meet mental health professional is another significant challenge. People lack awareness about the mental health.

ü      Related to Psychologists
The next challenge is ‘lack of trained human resources in Psycho-oncology’. If the distress or depression is identified, it has to be addressed properly. Most of the cancer centers do not have psycho-oncology unit. Even if Psycho-oncology unit is present, the training and expertise of the unit have to be viewed seriously.

A research world wide done in the field of Psycho-oncology says the incidence of depression is 15-25% on an average. The widely used tool in hospital setting to diagnose depression is HADS. However the 7 items of HADS which measure depression are not adequately correlated with the symptoms of depression as given in DSM IV TR. Feelings of worthlessness or excessive and inappropriate guilt, significant weight loss or gain, Insomnia or hypersomnia are neglected.

In oncology setting, all the symptoms of depression may not be observable. The stage, site and type of cancer influence the behaviors of the patients. Thus it is better to develop new parameters according to the stage, site and type of the cancer. So that depression in cancer will not be left unrecognized.

ü      Related to System/Practices
The cancer treatment is packed with many procedures. Inserting Psychological tests may be regarded as a burden for the patient. There is no clear cut idea where to bring in the psychological tests whether at the time of screening or disclosing diagnosis or during the course of treatment. Even though NCCN guidelines state patients have to be screened for distress in the first visit itself, Indian oncology set up lack facilities to do it.

Sustained efforts to educate medical professionals involved in cancer care such as oncologists and nurses on identifying depression and techniques to intervene will be of great help to the cancer patients who undergo depression. Patients should also be given awareness about the psychological services available for them. Psycho-oncologists have to have strong research base to convince the oncology setting to take up depression as a serious issue since depression has the potential to affect the treatment outcome. New set of criteria to recognize depression according to site, type and stage of cancer has to be developed.