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(Drug information on fluorouracil)-CMF). Because the tumor was estrogen-receptor positive, she was started on the antiestrogen tamoxifen(Drug information on 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(Drug information 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(Drug information 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(Drug information on 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
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.