Patients with pancreatic cancer, known for its frequent diagnosis
at an advanced stage, rapid progression, extremely low survival
rate, and associated pain, are intuitively expected to present
with depression and anxiety, based on the logic that feelings
of hopelessness, helplessness, sadness, and grief would be common
and even "normal" in these patients. Corroborating this
notion, several studies have reported that depression and anxiety
occur in as many as 50% of patients with carcinoma of the pancreas
Although sadness is a normal situational reaction to pain and
potential loss for many people with pancreatic cancer, for others
depression is a concomitant illness. Many reports have noted an
excessive comorbidity between depression and pancreatic cancer,
as compared with other types of cancer [1,4-6]. Even more striking,
psychiatric symptoms appear in approximately 50% of these patients
before the diagnosis of cancer is made and somatic symptoms
are noted [2,3,7]. In fact, psychiatric symptoms have been reported
to occur up to 2 years prior to the onset of abdominal symptoms
in some pancreatic cancer patients , and it has been suggested
that the presence of depression, anxiety, insomnia, restlessness,
or agitation may sometimes aid in the earlier diagnosis of this
usually late-detected cancer [3,7].
This sequence of events suggests that pain, knowledge of a cancer
diagnosis, or worry over unexplained physical symptoms cannot
be the sole etiologic basis for psychiatric symptoms in many patients.
Rather, it implies the existence of neuropsychiatric causes, such
as tumor-based biologic pathogeneses ; such factors potentially
involve adrenocorticotropic hormone, parathyroid hormone, thyrotropin-releasing
hormone, glucagon, serotonin, insulin, or bicarbonate [3,8]. The
role of the psycho-oncologist is to distinguish between normal
emotional reactions to having advanced cancer and symptoms of
comorbid psychiatric illness, perhaps with a biologic basis, which
warrant more extensive treatment .
Depression is often overlooked in people with advanced pancreatic
cancer because anorexia, weight loss, loss of energy, insomnia,
loss of libido, and fatigue are more likely to be symptoms of
the cancer than of a depressive syndrome . Therefore, a diagnosis
of major depression in cancer patients relies more on psychological
symptoms, such as dysphoric mood for 2 or more weeks, hopelessness,
helplessness, and a sense of worthlessness or despair, than on
somatic complaints. In particular, anhedonia (total loss of interest
or pleasure; not to be confused with a mere reduction in the number
of pleasure-providing activities) and suicidal ideation are dependable
diagnostic markers for depression in patients with pancreatic
cancer. When these cognitive or ideational symptoms are present,
a family history of depression or a history of alcoholism, drug
abuse, or two or more previous depressive episodes (particularly
if the first episode was before age 25 or after age 50) increase
the risk and further substantiate the diagnosis .
For cancer patients whose sadness and grief are normal emotional
reactions to the grim medical situation that they are facing,
depressive symptoms resolve gradually within 7 to 10 days with
support from family, friends, clergy, and others. The medical
team can assist by providing clear medical information and a treatment
plan that offers hope--if not for a cure, perhaps for control
of pain and suffering. For pancreatic cancer patients, this treatment
plan may include surgical resection, neoadjuvant or post-resection
therapies, multimodality chemoradiation with or without surgery,
enrollment in clinical trial protocols, or the assurance that
physical and psychological symptoms will be addressed (ie, the
patient will not die alone or in pain).
Intervention beyond that provided by empathic physicians, nurses,
social workers, and clergy is usually not required unless symptoms
of emotional distress are sustained, intolerable, or interfere
with functioning . However, prescribing a hypnotic or low-dose
antidepressant to permit normal sleep and/or a benzodiazepine
to reduce daytime anxiety can assist the patient through crisis
periods and facilitate adaptation.
For patients who meet the Diagnostic and Statistical Manual-IV
(DSM-IV) criteria for mood disorders or adjustment disorders,
a combination of supportive psychotherapy (in the form of either
individual or group counseling), cognitive-behavioral techniques
(such as relaxation and distraction with pleasant imagery), and
antidepressants has been shown to decrease psychological distress
and depressive symptoms [9-11].
Psychopharmacologic interventions are the centerpiece of treatment
of severe depression  and especially merit a trial in patients
whose depressive mood disorder has a hormonal or neuropsychiatric
complication, such as disruption of serotonin synthesis. Tricyclic
antidepressants are the most commonly used antidepressants in
cancer patients because of their analgesic properties and side
effects that can alleviate cancer symptoms. For example, tricyclics
with sedating properties, such as amitriptyline or doxepin, can
be helpful in patients with agitation or insomnia [9,10]. If a
patient does not respond to a tricyclic or cannot tolerate its
anticholinergic side effects, a second-generation tricyclic (eg,
trazodone), heterocyclic (eg, amoxapine or maprotiline), or serotonin-selective
antidepressant (eg, fluoxetine [Prozac], sertraline [Zoloft],
or paroxetine [Paxil]) can be used. Trazodone is strongly sedating
and can be used at bedtime for insomnia. Serotonin-selective reuptake-inhibiting
antidepressants have fewer sedating and autonomic effects than
the tricyclics, but because they can be associated with nausea,
weight loss, and anorexia, their usefulness may be limited in
patients with pancreatic cancer .
In addition, psychostimulants, such as dextroamphetamine, methylphenidate,
and pemoline (Cylert), can also be used for managing depression
or advanced cancer-related fatigue and can have a dramatic impact
on patients' functioning . Psychostimulants have been shown
to improve attention and concentration, and low doses may stimulate
appetite, promote well-being, improve feelings of weakness and
fatigue, and reverse the sedating effects of opioids used for
pain management .
For the person without an extensive psychiatric history who is
undergoing the crises inherent in coping with pancreatic cancer,
reducing symptoms of distress is the key to facilitating better
adjustment. The goal of the psycho-oncologist performing crisis
intervention therapy is to restore the patient's baseline (precancer)
psychological functioning by using hypnosis, relaxation therapy,
and other psychotherapeutic techniques and modalities that reduce
pain and distress. Crisis intervention focuses on solving concrete,
daily-life problems, including teaching specific coping skills
(eg, how to take analgesics correctly), emphasizing past strengths,
and mobilizing inner resources . Referrals to such "low-tech"
interventions as support groups and cancer survivor networks are
often successful because for some patients less stigma is attached
to participating in such groups than to seeing a psychologist
or psychiatrist. Suggestions of coping techniques are sometimes
better received from other patients than from mental health professionals.
Psycho-oncologists who care for pancreatic cancer patients can
attest that depression and anxiety are neither inevitable nor
untreatable in this population. Regardless of whether the depression
and anxiety accompanying a patient's pancreatic cancer are the
normal results of anticipatory grief, pain, and distress or are
comorbid psychiatric conditions, these mood disorder symptoms
are controllable using supportive psychotherapy, cognitive-behavioral
techniques, crisis intervention, and/or psychopharmaceuticals.
1. Fras I, Litin EM, Pearson JS: Comparison of psychiatric symptoms
in carcinoma of the pancreas with those in some other intraabdominal
neoplasms. Am J Psychiatry 123:1553-1562, 1967.
2. Jacobsson L, Ottosson JO: Initial mental disorders in carcinoma
of pancreas and stomach. Acta Psychiatr Scand 221:120-127, 1971.
3. Green Al, Austin CP: Psychopathology of pancreatic cancer:
A psychobiologic probe. Psychosomatics 34:208-221, 1993.
4. Joffe RT, Adsett CA: Depression and carcinoma of the pancreas.
Can J Psychiatry 30:117, 1985.
5. Joffe RT, Rubinow DR, Denicoff KD, et al: Depression and carcinoma
of the pancreas. Gen Hosp Psychiatry 8:241-245, 1986.
6. Holland JC, Korzun AH, Tross S, et al: Comparative psychological
disturbance in pa-tients with pancreatic and gastric cancer. Am
J Psychiatry 143:982-986, 1986.
7. Fras I, Litin EM, Bartholomew LG: Mental symptoms as an aid
in the early diagnosis of carcinoma of the pancreas. Gastroenterology
8. Brown JH, Paraskevas F: Cancer and depression: Cancer presenting
with depressive illness: An autoimmune disease? Br J Psychiatry
9. Massie MJ: Depression, in Holland JC, Rowland JH (eds): Handbook
of Psychooncology: Psychological Care of the Patient With Cancer,
pp 283-290. New York, Oxford University Press, 1989.
10. Breitbart W: Psycho-oncology: Depression, anxiety, delirium.
Semin Oncol 21:754-769, 1994.
11. Loscalzo M: Psychological approaches to the management of
pain in patients with advanced cancer. Hematol Oncol Clin North
Am 10:139-155, 1996.