Structured Cognitive Therapies
Cognitive-behavioral therapy and interpersonal therapy are systems of short-term individual and group psychotherapy that were developed specifically for the treatment of depression. Interpersonal therapy focuses on discrete manageable psychological and interpersonal issues and has shown promise in research pertaining to patients with human immunodeficiency virus (HIV) or breast cancer. Cognitive-behavioral therapy has been well established as a treatment for depression. It has also been used to help with symptom management in terminally ill patients. This type of intervention focuses on cognitive distortions that negatively affect mood. Improvement in such distortions often helps patients to better cope with or adapt to the vicissitudes of their illness.
Existential psychotherapy involves the evaluation of one’s relationship to life, with the goal of helping patients live more fully in the moment. It is an appropriate intervention for some terminally ill persons, who confront daily choices that affect quality of life and often have questions concerning the meaning, purpose, and value of life. The way in which seriously ill patients cope influences both their emotional state and their ability to adjust. It has been demonstrated that avoidance of feelings, denial of concerns, ongoing feelings of helplessness, a stance of passive compliance, and social isolation all result in decreased quality of life, and possibly an increased risk of disease or mortality. However, open and honest expression of both feelings and thoughts corresponds to a higher quality of life and, indeed, may bolster one’s physical health.
Group existential psychotherapy allows the patient to hear about the experience of others, thereby providing "lateral experience" from which the patient may consider alternative ways of understanding and action. Moreover, the perspective of other patients can challenge one’s own conclusions about life, facilitate an adjustment to one’s current circumstances, and assist in choosing actions that are truly meaningful. The group has the potential to help the patient realize that he or she is not alone, and that others have different perspectives that may bear consideration.[45,46]
The Therapeutic Life Narrative
Patient distress may not be directly related to the fear of death itself, but to concerns regarding missed opportunities, loss of autonomy and control, and regret for decisions not taken. All of these feelings may be examined through use of the psychodynamic life narrative (or life review). This form of therapy is particularly useful in patients whose previously successful adaptation has been disrupted by a crisis or a specific life event. It permits patients to understand their present experience in the context of their life history and to view their current reaction as the logical product of previous experience, rather than as an arbitrary response to illness. This may offer a reassuring sense of coherence, order, and logic in a situation that is largely beyond the patient’s individual control.
The patient is also provided with a protective therapist/physician who can offer reassurance, while attempting to capture the life narrative. The therapy gradually assumes the quality of a shared experience. For example, we recently counseled an elderly gentleman with an advanced oral malignancy. This patient gained considerable comfort in being able to review his life as a successful musician. He found that the therapeutic task of sharing this history provided a context within which to understand his current existential distress and helped give him a much needed sense of life’s continued meaning and purpose.
Depression is a treatable condition, even in the cancer care setting. Recognizing and treating depression in severely ill patients is as important in this population as in the physically healthy, if not more so. Quality-of-life issues are never more germane than they are for patients whose lives are in jeopardy, facing the physical, psychological, and spiritual challenges that a cancer illness inevitably brings.
Screening for depression can be done simply and effectively, and treatment initiated with any of various appropriate interventions, as previously described. Moderating the level of specific neurotransmitters is only a small part of treating depression in cancer patients. The physician-patient relationship is of critical importance and should be characterized by warmth, caring, honesty, and recognition, not simply of the physical domains of patient care, but of the psychological and spiritual dimensions as well. The judicious use of medication and supportive therapies should significantly alleviate depression and enable the patient to navigate the cancer course with dignity, purpose, and the best quality of life possible.