Depressed Older Cancer Patients–What Prevents Better Care?

Posted on June 13, 2012 by

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“From 2010 to 2030, the total projected cancer incidence will increase by approximately 45%, from 1.6 million in 2010 to 2.3 million in 2030. This increase is driven by cancer diagnosed in older adults and minorities. A 67% increase in cancer incidence is anticipated for older adults, compared with an 11% increase for younger adults.” ~ Smith et al

Clearly, efforts to improve cancer care for older adults must begin–now. And there’s a lot of room for improvement, but maybe not in the oncology arena, as much as the psychological one. For older cancer patients are suffering in large numbers from depression–and the care they’re getting is anything but satisfactory.

Prevalence of Cancer and Depression in the Elderly

Depression is a debilitating, at times unbearable illness in its own right, and deserves prompt and appropriate treatment wherever it might be found.

To make a difficult situation worse, the disorder is quite prevalent among cancer patients.

Estimated percentages of depression and cancer vary widely based on the study, but Pirl’s 2004 study has gained credibility–although it suggests quite a range. After analyzing 350 studies published between 1966-2011, Pirl determined the occurrence of depression to be between 10-25%.

However, when we look at depression in the elderly, the lower end of the range is much higher, with prevalence of depression ranging from 17 to 25% (Weinberger et al, 2009).

Dangers of Untreated Depression in Cancer Patients

Treating depression in cancer patients becomes quite a serious matter.

In the 2007 article, “Depression and Barriers to Mental Health Care in Older Cancer Patients,” the authors highlight a host of reasons why treating depression must be a treatment priority.

Depression has been correlated with decreased quality of life, difficulties with relationships, sleep problems, more rapid progress of symptoms, and grater pain. In fact,  research has indicated that depression can actually increase a patient’s risk of succumbing to the illness.

In my post, “The Danger of Doubling: Depression’s Impact on a Cancer Diagnosis,” I point out some of the proofs that support such an assertion. Just to quote one strong metaanalysis, synthesized in 2009:

The current meta-analysis presents fairly consistent evidence that depression is a small but significant predictor of mortality in cancer patients. Estimates were as high as a 26% greater mortality rate among patients endorsing depressive symptoms and a 39% higher mortality rate among those diagnosed with major depression. There is no evidence that the effect weakens when adjustments are made for other known risk factors, suggesting that depression may be an independent risk factor in cancer mortality, rather than merely correlating with biological factors associated with a poor prognosis. [emphasis mine] [Statin, Linden and Phillips (2009)]

Lead author Statin was confident enough in her findings to release the following statement:

We found an increased risk of death in patients who report more depressive symptoms than others and also in patients who have been diagnosed with a depressive disorder compared to patients who have not.

In short, treating depression in cancer patients becomes a matter of life and death–but that urgency actually increases in the elderly.

Another consequence of depression in cancer patients [as in all depressed patients] is higher suicide rates. As it is, adults over 65 have the highest suicide rate compared to any other age group, according to the Center for Disease Control, and those 85+ have rates twice the national average.

People with severe medical illnesses are also at risk of suicide. Therefore older, depressed cancer patients–besides having all the adverse effects of depression that all ages have–are at a double-high risk for suicide.

Miller, from the Harvard School of Public Health, studied 1,408 New Jersey residents age 65 years or older enrolled in Medicare and in a pharmaceutical insurance program in their 2008 article, “Cancer and the risk of suicide in older Americans.” Their goal was to determine if the risk of suicide was greater among patients with cancer than among those with other medical illnesses. The answer was a resounding yes, as they found,

In adjusted analyses, the only medical condition that remained associated with suicide was cancer.. . . The risk of suicide in older adults is higher among patients with cancer than among patients with other medical illnesses, even after psychiatric illness and the risk of dying within a year were accounted for.

Between decreased quality of life, sleep issues, poor prognosis, increased mortality–and higher risk for suicide–depression in elderly cancer patients clearly needs to be addressed promptly and efficiently.

However, treating the mood disorder is not at all as simple as it would sound. A number of factors complicate the issue, beginning with the difficulty in properly assessing and diagnosing the depression.

WHAT PREVENTS BETTER CARE?

  • Difficulty Diagnosing Depression

Diagnosis and assessment of depression in cancer patients pose very real difficulties.

As Weinberger et al point out, because the symptoms of cancer and its treatments can mimic those of depression, distinguishing normal treatment responses from an affective disorder is quite the challenge.

Symptoms such as

  • significant weight loss
  • difficulty sleeping
  • fatigue
  • difficulty concentrating, and
  • thoughts of dying

could be signs of depression–but could just as easily by symptoms of cancer and its treatment.

And the diagnostic situation is further complicated when dealing with the elderly.

To start with, in general, old people tend to under-report or deny depression.

Then symptomatology becomes quite confusing, as the depressed elderly often fail to exhibit ‘classic symptoms of depression,’ particularly sad mood and loss of pleasure or interest (Evans and Mottram 2000), as indicated in the chart below:

Depressive Symptoms in Later Adulthood (Alexopoulos, 2005)

COMMON UNCOMMON
**  ● Sleep problems (insomnia or hypersomnia),   ● “Classic symptoms of depression”
  ● Stomach aches   ● Dysphoria (sad mood)
  ● General aches and pains   ● Anhedonia (lack of interest in activities)
  ● Diffuse somatic complaints   ● Guilt
  ● Malaise   ● Self-criticism
  ● Hopeless about the future
 ** ● Pain
 ** ● Weight loss
  **● Cognitive impairment
  ● Peripheral body changes
**Note: Asterisks indicate symptoms that may overlap with symptoms of cancer or cancer treatment [emphasis mine]
In fact,  the very absence of depressed mood and anhedonia  in depressed older people is so unusual that diagnostic texts have adapted in order to still properly diagnose depression, without the patients meeting these usual symptom requirements.
Evans & Mottram point out:

Because of the importance of recognising the depressive illness in such patients, depressed mood is not an absolute requirement for the diagnosis in either DSMIV (American Psychiatric Association, 1994) or ICD-10 (World Health Organization, 1992). . . .ICD-10 10 also allows for the diagnosis of “masked depression” with mixtures of somatic depressive symptoms and persistent pain or fatigue not due to organic causes [as a common presentation of depression in the elderly is somatic complaints].

Reasons for Poor Care Post-Diagnosis

So it’s all well and good. Someone’s been able to tease out the depressive from the cancer symptoms, and to discover that an older cancer patient is suffering from depression.  Seems like the rest would be smooth sailing.

It’s anything but, as Weinberger et al (2011) point out.

Kadan-Lottick from the Department of Pediatrics, Section of Pediatric Hematology-Oncology, Yale University School of Medicine, notes that cancer patients underutilize resources to an alarming extent. Once diagnosis has been taken care of, well. . .little happens. Writes Kadan-Lottick:

Mental health services were not accessed by 55% of patients with major psychiatric disorders [which leads her to conclude that psychiatrically] affected individuals have a low rate of utilizing mental health services. [emphasis mine]

DB Greenberg in “Barriers to the treatment of depression in cancer patients” suggests that uncertainty and cost prevent cancer patients from getting themselves proper psychiatric care.

Given uncertainty about diagnosis and treatment, cancer physicians with limited time avoid questions about emotions.

Additionally, patients worry about cost. Mental illness is notoriously poorly covered by insurance, and cancer patients are already spending sometimes astronomical sums on their primary physical care. To add the extra cost burden of therapy and medication seems overwhelming.

And, as unfair as it may be, elderly cancer patients with depression are referred less frequently for psychological care.

Ellis et al studied the rate of referral for specialized psychosocial oncology care in 326 patients with metastatic cancer. They concluded that

Routine referral of patients with metastatic cancer for psychosocial oncology care was predicted by presence of more severe depressive symptoms, younger age, and unmarried status. The rate of referral progressively declined with each decade of age, even among those with significant distress. [emphasis mine]

old_race

And of course, as is so often the case in mental health, patients worry about medication side effects and stigma.

Whether due to side effect concerns or not, 40-70% of elderly depressed patients are noncompliant with their antidepressant medication regime (Neel 2002).

And then there are the general  problems with geriatric mental health care, which are severe in this country.

The number of elderly continues to increase, and is on a trajectory to do so at least through 2030.

Despite burgeoning numbers, however, only 6% of the National Institute of Mental Health’s new grants funds are awarded for geriatric health care research.

The American Geriatrics Society highlights another serious problem–the shortage of psychiatrists for the elderly. Currently there are only 1,751 geriatric psychiatrists. That’s one for every 10,865 older Americans.  Between the growing elderly population and decreasing numbers of psychiatrists for the them, that ratio is projected to decrease by 2030 to one for every 12,557 Americans 75 and older..

Numbers of first-year family medicine physician for the elderly are increasing, but internal medicine physicians and psychiatrists have taken a nose-dive. Just finding an available psychiatrist for depressed older cancer patients is quite the challenge.

In one of the few studies to analyze specifically why older cancer patients are undertreated, Endo, from the Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan, studied data from

a self-administered measure of 100 lung cancer patients in Japan (M age=65 years of age) . . . Results illustrated that patients reported that a lack of correct information or misunderstanding about treatments, negativity toward psychotropic medications, and more severe psychological distress were barriers to mental health care.

 *******************************************************************************************************

There is hope, once treatment is initiated. Cognitive Behavioral Therapy (CBT), interpersonal therapy, and antidepressant medications have solid research behind them (Weinberger 2009).

Thus there is the proverbial light at the end of the cancer/depression tunnel–but all health care providers must work at making the trip through the tunnel speedier, more accurate, more efficient, and more effective. It is enough to suffer through a cancer diagnosis and treatment; it is unacceptable to have to suffer through un-managed depression–needlessly–as well.

REFERENCES

Alexopoulos GS. Depression in the elderly. Lancet 2005; 365:1961–1970.

Ellis J, et al. Predictors of referral for specialized psychosocial oncology care in patients with metastatic cancer: the contributions of age, distress, and marital status. Journal of Clinical Oncology 2008; 27(5):699-705.

Evans M, Mottram P.  Diagnosis of depression in elderly patients. Advances in Psychiatric Treatment 2000; 6:49–56.

Greenberg DB. Barriers to the treatment of depression in cancer patients. Journal of the National Cancer Institute Monographs 2004; (32):127-35.

Kadan-Lottick NS. Psychiatric disorders and mental health service use in patients with advanced cancer: a report from the coping with cancer study. Cancer 2005; 104(12):2872-81.

Massie MJ. Prevalence of depression in patients with cancer. Journal of the National Cancer Institute Monographs 2004; 32:57-71.

Miller M, et al. Cancer and the risk of suicide in older Americans. Journal of Clinical Oncology 2008; 26(29):4720-4.

Neel J. Treatment of Depression in the Elderly 2002.

Pirl WF. Evidence report on the occurrence, assessment, and treatment of depression in cancer patients. Journal of the National Cancer Institute Monographs 2004; (32):32-9.

Satin JR, Linden W, Phillips MJ. Depression as a predictor of disease progression and mortality in cancer patients: A meta-analysis. Cancer 2009; 115(22):5349-5361.

Smith BD, et al. Future of cancer incidence in the United States: burdens upon an aging, changing nation. Journal of Clinical Oncology 2009; 27(17):2758-65.

Weinberger MI, et al. Depression and Barriers to Mental Health Care in Older Cancer PatientsInternational Journal of Geriatric Psychiatry 2011; 26(1): 21–26.*

[*This is the article that offered the structure for this post.]

Weinberger MI, Roth AJ, Nelson CJ. Untangling the Complexities of Depression Diagnosis in Older Cancer Patients. Oncologist 2009; 14(1): 60–66.