Breast cancer is a disease that not only has a high prevalence
and mortality but also profound psychological and psychosocial
ramifications. Women with breast cancer fear death and face complicated
medical decisions and concerns about their body image, sexuality,
and relationships.1

Thus, it is important to monitor patients' emotional adaptation
throughout the course of their disease, to support adaptive coping,
and to recognize psychological symptoms that are beyond the range
of "normal" adjustment and require psychiatric intervention.
In the following case report, we describe the treatment of depression
in a woman at two different points during the course of her treatment
for breast cancer.

Depression After Initial Therapy

A 53-year-old divorced woman with no personal or family history
of depression was diagnosed with stage I breast cancer in 1988
and was treated with a modified radical mastectomy and chemotherapy
(cyclophosphamide, metho-trexate, fluorouracil-CMF). Because the
tumor was estrogen-receptor positive, she was started on the antiestrogen
tamoxifen (Nolvadex), 20 mg daily.

Four weeks after the start of tamoxi-fen, she told her primary
care physician that she was crying daily, and although she was
working at a job that she had previously enjoyed, she now was
uninterested in her work and had difficulty concentrating. She
stated that she felt hopeless about her future, and she believed
she had somehow caused her breast cancer. Both her appetite and
energy level were good.

A psychiatric consultation produced a diagnosis of major depression,
and the patient was started on fluoxetine (Prozac), 20 mg in the
morning. In addition, she began weekly psychothearapy that utilized
both cognitive behavioral and supportive techniques designed to
alleviate psychological distress and provide emotional support.

After 2 weeks of both psychotherapy and fluoxetine, and while
continuing on tamoxifen, she felt better and was less tearful.
Initially, she experienced mild nausea from fluoxetine; however,
4 weeks later she stated that her depressive symptoms had resolved
and she was no longer nauseated. Fluoxetine was continued for
6 months and then slowly tapered and discontinued. The patient
remained on tamoxifen with no further depression.

Four Years Later

The patient was followed by her primary care physician, with no
evidence of disease for 4 years, but in 1992 she was found to
have metastases to both lungs and brain. She was treated with
whole-brain irradiation, followed by adjuvant chemotherapy.

Two months after completion of whole-brain irradiation, the patient
began to complain of depressed mood with feelings of hopelessness
and loss of interest in activities that previously had been pleasurable
to her. She voiced feelings of guilt and again wondered what she
had done to cause her breast cancer. The patient reported hypersomnia,
persistent fatigue, and vague suicidal ideation, stating "maybe
it would be better if I didn't wake up tomorrow."

The patient called her psychiatrist and was started on paroxetine
(Paxil), 10 mg in the morning, which was increased to the standard
therapeutic dosage of 20 mg daily after 4 weeks. She did not experience
nausea related to paroxetine; however, fatigue remained a persistent
problem, and 18.75 mg of pemoline (Cylert), a psychostimulant,
was added at 8:00 AM to increase energy and improve appetite.

The patient once again entered psychotherapy, focusing on the
impact of her disease progression on her family. As she began
to discuss the possibility of her own death, end-of-life issues
were explored, and she was able to resolve her conflicts about
termination of medical treatment.

An Often Difficult Diagnosis

Optimal management of depression in breast cancer patients requires
consideration of the differential diagnosis, the possible role
of medical factors (including drugs), and appropriate treatment.

Our recent review of depression in patients with cancer suggests
that there is great variability in the reports of the prevalence
of depression in women with breast cancer (ranging from 1.5% to
50%), depending on the criteria used to establish the diagnosis.2
However, it is likely that 10% to 25% of women with breast cancer
will at some point in the course of their illness have depressive
symptoms that require evaluation and treatment.

The diagnosis of depression is dependent upon the presence of
at least one of three symptoms: depressed mood (pre-sent for at
least 2 weeks), loss of interest or pleasure, or feelings of hopelessness
and helplessness.

Feelings of worthlessness or guilt and difficulty concentrating
also are symptoms associated with depression. Disturbances in
sleep (either hypersomnia or insomnia), weight gain or loss, fatigue
and/or loss of energy, and psychomotor agitation or retardation
represent physical symptoms associated with depression.

Suicidal ideation (not just fear of dying) is a symptom requiring
special assessment that should take into account whether the patient
has a plan for following through with the suicide attempt, whether
she would or could act upon the plan, and the presence of barriers
to acting upon the plan (eg, stating that one would shoot oneself
but not having access to a gun).

To establish the diagnosis of depression, at least five of the
above symptoms, including either depressed mood or diminished
sense of pleasure, should be present. If the patient has depressed
mood but does not possess five of the above symptoms, she likely
qualifies for the diagnosis of an adjustment disorder with depressed
mood, and may benefit from antidepressants, hypnotics, and psychological
support.

Both psychological and physical symptoms are usually present in
the symptom profile of depressed patients who are physically well.
In the case of cancer patients who are undergoing hormonal therapy
or chemotherapy or who have advanced disease, however, the above-mentioned
physical symptoms are less reliable indicators of depression.

Women with advanced breast cancer, or those at any stage who are
undergoing chemotherapy or radiation therapy, frequently feel
fatigued, may have sleep difficulties and appetite disturbances,
and may appear slowed down or, conversely, agitated in their psychomotor
function.3

Management Issues

When this woman was first diagnosed and treated for breast cancer,
the doctor realized that tamoxifen may be a contributing factor
in some patients' depression,4 but decided to continue the medication
while treating the depression.

Many of the drugs utilized in oncologic settings (hormones, steroids,
analgesics, and antiviral drugs, among others) are associated
with changes in mood or mental status. Consequently, a careful
assessment of the contribution of medications to depression is
required, although often it is not possible to discontinue these
medications.

When this patient's disease progressed, many of her physical symptoms
were, in all likelihood, due to both the advanced nature of her
disease and the treatment she was receiving. By focusing on the
psychological symptoms of depression (depressed mood, hopelessness,
guilt, lack of pleasure, and suicidal ideation), rather than the
physical symptoms, a more accurate diagnosis of depression in
this debilitated patient was possible.

In her case, the physical symptoms of depression that were more
likely associated with her advancing disease (eg, fatigue, appetite
disturbance, and sleep difficulties) were treated with an antidepressant
and psychostimulant.