The Danger of Doubling: Depression’s Impact on a Cancer Diagnosis

Posted on May 28, 2012 by

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According to the National Institute of Mental Health, an astounding 1 in 4 cancer patients will experience depression some time throughout the course of their experience.

And certain cancers are even harder hit. According to Derek Hopko, Ph.D, associate professor at The University of Tennessee and co-author of A Cancer Patient’s Guide to Overcoming Depression and Anxiety: Getting Through Treatment and Getting Back to Your Life, and quoted by PsychCentral, depression rates average, for the following cancers:

  •  oropharyngeal: 22–57%
  •  pancreatic: 33–50%
  •  breast: 2–46%, and
  •  lung cancers: 11–44%

Honestly, it’s no surprise. From the fear of pain, illness and death that accompanies the diagnosis, to changes in body image, social roles, and lifestyle, to debilitating treatments, to mounting medical bills. . .well, depression has ripe breeding ground.

But it is urgent that cancer patients with depression get treatment for the mood lability, as it turns out that depression can interfere with one’s best efforts to get well.

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Research has recently been peeking a suspicious eye at depression’s impact on cancer progression and mortality–and it hasn’t liked much what it’s found.

For example, authors Statin, Linden and Phillips (2009) ran a meta-analysis (I’m a softie for a good meta-analysis–and you never even have to get your hands dirty in the lab!) to assess whether and how much depressive symptoms and major depressive disorder (MDD) impact disease progression and mortality in cancer patients.

The authors analyzed studies from 1990 through 2009.

  • 5 studies analyzed the effect of depression on cancer recurrence.
  • 5 articles examined the effect of depression on cancer progression (4 of these dealt with breast cancer, 1 with patients with melanoma).
  • 25 paper studied the effect of depression on mortality.

Their findings were somewhat mixed. Write the authors,

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]

Another study, “Depression — An independent predictor of early death in patients with advanced cancer,” took a look at the toll depression takes on patients with late-stage cancer, specifically.

In this study, 88 patients’ levels of depression were analyzed using the 10 item Edinburgh Depression Scale (EDS)-first at the time of recruitment and then at four and eight weeks following.

The findings were, well, depressing:

Even after adjusting for patient age, EDS raw score at baseline is significantly associated with shorter patient survival. A one-point increase in EDS score [remember--that's out of 10] raises risk of outcome (death) by 7%. [emphasis mine]

The researchers were concerned about their findings, ane suggested that further work was needed to determine precisely why depression had such a ‘profound effect’ on patients with late-stage cancer. One theory they suggest is that

It may be that patients who are depressed have an increased sense of helplessness and lose the will to live compared to other non-depressed patients which may impact on their survival.

Whether that is the definitive answer or not, it is clearly urgent that further work be done in this area, to determine why depression increased mortality so radically in this group of cancer patients.

And these studies are not alone.

In “Role of Depression as a predictor of mortality among cancer patients after stem-cell  transplantation,” Preito et al (2005) studied 199 cancer patients after stem-cell transplantation. Major Depressive Disorder predicted increased 1- and 3-year death rates.

Pasquini and Biondi (2007) quote an 8-year follow-up study of 10,000 pages run by Onitilo et al in 2006, which demonstrated that depression in the cancer patient was correlated with increased risk of death.

But, multiple as they are, these studies are not explanatory.

A recent, 2011 study, however, sheds some light on why depression may increase mortality.

Ann Bettencourt, professor of psychological sciences at University of Missouri, spent some time studying why depression appears to be so deadly in cancer.

She found that depression was correlated both with “intentions to adhere to treatment plans, and [with] lack of adherence to medication regimens.”

Bettencourt comments on her work, as quoted in ScienceDaily,

Depression can interfere with patients’ willingness to adhere to medication regimens. Deviating from the prescribed course of treatment may complicate patient outcomes and threaten prognosis.

That at least provides some explanatory power to the frightening statistics.

But still not a way out.

Along comes Janine Giese-Davis, from the Stanford University School of Medicine, and, with her colleagues, took a look to see whether changes in depressive symptoms might be correlated with better survival rates.

They analyzed 125 women with metastatic or recurrent breast cancer, and all completed the Center for Epidemiologic Studies–Depression Scale (CES-D), first before they were randomly assigned to groups, and then at  4, 8, and 12 months. The treatment group was given supportive-expressive group therapy (SET) for 1 year; this was not offered to the control group.

Their results were interesting–both in what they did find, and in what they couldn’t find.

The researchers did determine that improved depression correlated significantly with better median survival rates.

For women with decreasing CES-D scores [and thus improving depression] over 1 year, overall median survival time was 53.6 months compared with 25.1 months for women with increasing scores. A decrease in CES-D score over 1 year was significantly associated with  longer survival over 14 years.

Clearly, treating and alleviating cancer-related depression becomes a matter of nothing less than life-and-death.

What the study didn’t show, perhaps disappointingly, was that the therapy helped with survival, as would have been assumed. Write the authors,

 . . .we could not demonstrate any significant interaction effect of treatment condition by CES-D decrease on survival.

Hands somewhat tied by their findings, they were forced to conclude:

for all women in the study, the more they decreased depression symptoms, the longer their survival, suggesting that any effective intervention may enhance this result.

Their research is highly relevant, even if their randomized controlled trial didn’t pan out.Decreasing depression symptoms yields increased survival in cancer patients. Period. Thus it’s incumbent upon any of us, whether we’re friends, in the medical system, family, what have you, to work to get the cancer patient treatment for their depression.

And it looks like we’ve got a lot of options open to us, since any effective intervention can be lifesaving.

We have recourse to antidepressants, to CBT, to supportive psychotherapy–all proven ways to treat depression.

It’s always incumbent upon us to help those we love manage and emerge from a depressive episode. But if we do it for a cancer patient, we have the privilege of knowing we’re also adding years to their lives. Not bad for a day’s work.

REFERENCES

Giese-Davis J, et al. Decrease in Depression Symptoms Is Associated With Longer Survival in Patients With Metastatic Breast Cancer: A Secondary  Analysis. Journal of Clinical Oncology 2011; 29(4):413-20.

Lloyd-Williams M, Shiels C, Taylor F, Dennis M.  Depression — An independent predictor of early death in patients with advanced cancer. Journal of Affective Disorders 2009; 113(1-2):127-132.

Pasquini M, Biondi M. Depression in cancer patients: a critical review. Clinical Practice and Epidemiology in Mental Health 2007; 3:21–30.

Prieto JM,  Atala J,  Blanch J,  Carreras E,  Rovira M,  Cirera E,  Espinal A,  Gasto C.  Role of Depression as a predictor of mortality among cancer patients after stem-cell transplantation. Journal of Clinical Oncology 2005,  23:6063-6071.

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.

University of Missouri-Columbia. “Depression linked to breast cancer outcomes.” ScienceDaily, 2 Nov. 2011. Web. 28 May 2012.