How to Treat Depression in Patients With Cancer: A Practical Framework

In this second installment of their conversation on depression in oncology, Daniel C. McFarland, DO, and Boris Kiselev, MD, moved from diagnosis, covered in Part 1, into treatment. The discussion opened with the differential diagnoses that need to be ruled out before starting therapy: delirium, bipolar disorder, medical conditions such as endocrinopathies and severe anemia, and neurocognitive issues stemming from central nervous system involvement or dementia. McFarland and Kiselev outlined the specific red flags that should prompt an oncologist to bring in a mental health specialist rather than manage treatment alone, including suicidality, psychosis, and complex psychiatric histories.

From there, the conversation turned to how depression is categorized by severity using the PHQ-9 scale, and how that severity, along with patient preference and access to care, should guide the choice between lifestyle modification, psychotherapy, and pharmacotherapy. Kiselev introduced a simplified 4-drug toolkit for oncologists: 1 selective serotonin reuptake inhibitor, 1 serotonin and norepinephrine reuptake inhibitor, mirtazapine (Remeron), and bupropion, explaining how to match each option to a patient’s specific symptoms and adverse effect (AE) concerns.

The back half of their discussion served as a practical walkthrough for starting a patient on medication. They covered how to frame the conversation to reduce stigma, what to say about timelines for benefit, and specific dosing and titration guidance for each of the 4 core drugs. McFarland and Kiselev closed by highlighting the most common AEs to flag upfront, a real-world case illustrating why dose titration matters, and general guidance on how long patients typically stay on treatment.

McFarland is the director of the Psycho-Oncology Program at Wilmot Cancer Center and a medical oncologist who specializes in head, neck, and lung cancer, in addition to being the psycho-oncology editorial advisory board member for the journal ONCOLOGY. Kiselev is a consult liaison psychiatrist at Atrium Health Carolinas Medical Center, an assistant professor in the Psycho-oncology Program in the Department of Supportive Oncology at Atrium Health Levine Cancer Institute, and an assistant professor in internal medicine.

00:02-02:24: Recap of the prior episode and framing for treatment

02:24-11:17: Ruling out other causes: delirium, bipolar disorder, medical conditions, and neurocognitive issues

11:49-15:17: Deciding when an oncologist can treat directly vs when to refer to a mental health specialist

15:45-23:01: Categorizing depression severity with the PHQ-9 and matching it to lifestyle, psychotherapy, or medication

23:46-26:05: Choosing between non-pharmacologic and pharmacologic treatment based on severity and access

26:05-35:49: Selecting a medication from a core 4-drug toolkit and preparing the patient to start it

37:30-48:30: Drug-specific dosing, titration strategy, and managing common adverse effects

50:37-51:59: How long patients typically stay on treatment and closing thoughts