CLEVELANDSince sadness and anxiety are normal reactions
to serious illness such as cancer, the challenge for the physician
becomes determining which symptoms are appropriate to the situation
and which are pathologic and require treatment, Susan J. Stagno, MD,
said at a conference on palliative medicine at the Cleveland Clinic
The clinician must also keep in mind that psychiatric symptoms can be
caused by medication or by a medical condition. Poorly controlled
pain, for instance, will create anxiety, said Dr. Stagno, of the
Cleveland Clinic Foundations Harry R. Horvitz Center for
Studies show that about 25% of medically ill patients have a
depressive disorder that should be treated. In patients admitted to
palliative care, it is more than 25%, Dr. Stagno said. Yet major
depression is difficult to diagnose in medically ill patients.
Look for Nonphysical Symptoms
The problem with diagnosing depression in palliative care patients is
that many of the symptoms associated with depression in well patients
are common in patients with advanced cancer, including sleep and
appetite disturbance, memory and concentration difficulties, and
fatigue. For this reason, depression in patients with advanced
disease is best diagnosed by identifying symptoms that are cognitive
and nonphysical. These symptoms are known by the memory aid WART:
withdrawal, anhedonia, ruminations and tearfulness (see Table).
WART: Memory Aid to Identify Depression in Advanced Cancer Patients
Withdrawal (from family and caregivers)
Anhedonia (a lack of response to things that
Ruminations (excessive worry)
Tearfulness (or a generally depressed appearance)
Depressed patients will be withdrawn from their families and from
their caregivers in the hospital. They will exhibit anhedonia, or a
lack of response to what is good and pleasurable. To measure this,
Dr. Stagno asks patients whether receiving visitors or winning the
lottery would lift their mood.
Although terminally ill patients would seem to have enough to worry
about, depressed patients find even more to worry about, to the point
of paranoia, she said. Finally, depressed patients will typically be
tearful or have a generally depressed appearance.
Suicidal ideation alone, although signaling the need for evaluation,
is not necessarily a sign of psychiatric disorder. Just because
a patient says he is suicidal, does not necessarily mean he is
depressed, Dr. Stagno said.
Other issues must be considered when a patient expresses the desire
for suicide or asks for aid in dying. Inadequate pain control may
spur a desire for death. Patients who feel guilt for past deeds may
be expressing a desire for punishment. Advanced illness involves
losing a great deal of control, and patients with an interest in
suicide may be trying to stem the loss of control by managing the
circumstances of their death.
The loss of hope, however, is most often the reason for suicidal
thoughts. The people who kill themselves are the ones who
decide there is no hope, Dr. Stagno said. You can instill
hope by controlling their pain and by assuring them that they will
not die alone. Often physicians can help restore a sense of
hope to very sick patients just by listening to them express their
feelings. By doing this, the clinician demonstrates belief in the
value of the patients life.
When depression is detected in a patient with advanced cancer, the
clinician should determine the appropriate therapy. With some
patients, depression may be related to a lack of knowledge about
their illness or treatment, and supplying them with further
information may be all that is necessary.
Patients who have unfinished personal business or need spiritual
counseling may benefit from meeting with a social worker, chaplain,
or mental health professional. Patients with cognitive distortions,
typically all or nothing thinking, may need cognitive
The mainstay of depression treatment, however, is pharmacologic
management. Antidepressants and stimulant medications like
dextroamphetamine and methylphenidate can be used safely in patients
with advanced disease. However, the physician should keep in mind
drug interactions, particularly with other medications that are
metabolized by the cytochrome p450 system.
Physicians should also start low and go slow so as not to
overwhelm patients with side effects. However, terminal patients may
have little time left to wait for medication to be slowly titrated to
a therapeutic dose. For these patients, drugs that work quickly, like
methylphenidate, may offer an important advantage.
The tricyclic antidepressants (TCAs) offer good anxiolytic and
sedative properties and can be used as an adjunct for pain. Blood
level monitoring is available for TCAs. Disadvantages are that they
require careful titration, have overlapping side effects, and carry
the risk of cardiotoxicity. Requesting an ECG may be prudent,
depending on the patients history, she said.
Familiarity with the dosage, side effects and pharmacologic
properties of one or two TCAs is useful for physicians treating
palliative care patients, she said.
Unlike the TCAs, serotonin reuptake inhibitors can be started with a
therapeutic dose. Some patients find them energizing, and
these drugs have a lower side effects profile than the TCAs. The
disadvantages include the risk of drug-drug interactions and the lack
of parenteral preparations. Further, their activating properties can
cause agitation, and patients who suddenly stop taking them will have
a flu-like withdrawal syndrome.
Several new antidepressants, including venlafaxine (Effexor),
mirtazapine (Remeron), and bupropion (Wellbutrin), are also
available. However, we dont have much experience with
them yet in palliative care patients, Dr. Stagno said.
Physicians should be aware of the side effects of these newer agents.
Venlafaxine can cause sustained hypertension at higher doses, as well
as agitation, nausea, insomnia, and headache. Mirtazapine can be very
sedating, and bupropion is contraindicated in patients with seizures.
Anxiety is a pervasive symptom in patients with advanced illness.
These patients have concerns about death, disfigurement, and
disability. However, physicians should maintain a vigilant watch for
medical factors and drug side effects that can also cause anxiety.
The use and withdrawal of steroids, for example, can cause
every psychiatric symptom known to man: anxiety, mania, depression,
and psychosis, she said.
Poorly controlled pain will cause symptoms of anxiety. A patient with
pulmonary embolus will feel short of breath and
disorientedclassic signs of anxiety. Other medical factors that
can cause anxiety include cardiac dysrhythmias, coronary artery
occlusion, congestive heart failure, and bleeding. Metabolic
conditions, including sepsis and thyroid disorders, may prompt signs
of anxiety, as will hormone-secreting tumors.
Neuroleptics (such as metoclopra-mide given to control nausea and
vomiting) can cause movement disorders, akathesia, and muscle spasms.
Bronchodilators, beta-adrenergic stimulants, and serotonin reuptake
inhibitors include anxiety among their side effects.
Finally, a patient who drinks a great deal of caffeine or a patient
withdrawing from narcotics, benzodiazepines, or alcohol may also be anxious.
Depending on the type of anxiety, the disorder may be treated with
non-pharmacologic interventions. Providing information about the
diagnosis and treatment options may help reassure an anxious patient.
Rehearsing events that cause anxiety can help. For patients with
chronic anxiety, behaviorial interventions, like relaxation training,
are the mainstay of treatment.
Medications, including benzodiazepines, antihistamines, neuroleptics,
and antidepressants, are available for the treatment of all forms of
anxiety. The clinician should become familiar with one or two
medications in each drug category.