A 68-year-old man is seen for follow-up of non-small cell lung cancer with bone metastases. He is accompanied by his wife, who is worried about his condition. The patient has undergone surgical resection and several courses of combination chemotherapy. His prognosis is 3-6 months. At today's visit, the patient reports that his cancer pain is generally controlled, but he feels extremely weak and fatigued. He has difficulty falling asleep and also awakens at 2:00 and 4:00 AM. His wife says, "I make his favorite foods but he barely takes a bite. When the children visited last weekend, he seemed uninterested in spending time with his son and grandson and retired to his room while they were still there." The patient says, "I am just so exhausted all the time. I know I'm not getting better and feel guilty about being a burden to my family."
The patient has lost 8.2 kg (18 lb) since his last visit. Physical examination is otherwise unchanged. His mood is sad but he is able to smile when appropriate. He thinks about death and dying but has no suicidal ideation, intent, or plan.
Which of the following symptoms is most suggestive of major depression in this patient?

Question

A 68-year-old man is seen for follow-up of non-small cell lung cancer with bone metastases.  He is accompanied by his wife, who is worried about his condition.  The patient has undergone surgical resection and several courses of combination chemotherapy.  His prognosis is 3-6 months.  At today's visit, the patient reports that his cancer pain is generally controlled, but he feels extremely weak and fatigued.  He has difficulty falling asleep and also awakens at 2:00 and 4:00 AM.  His wife says, "I make his favorite foods but he barely takes a bite.  When the children visited last weekend, he seemed uninterested in spending time with his son and grandson and retired to his room while they were still there."  The patient says, "I am just so exhausted all the time.  I know I'm not getting better and feel guilty about being a burden to my family."
The patient has lost 8.2 kg (18 lb) since his last visit.  Physical examination is otherwise unchanged.  His mood is sad but he is able to smile when appropriate.  He thinks about death and dying but has no suicidal ideation, intent, or plan.
Which of the following symptoms is most suggestive of major depression in this patient?

Quizplus · Accepted Answer

Depression in cancer patients is under-recognized and undertreated. Diagnosis is challenging as somatic symptoms of depression (eg, low energy, anorexia, weight loss, sleep disturbance) overlap with the physiological effects of cancer itself and its treatment. Therefore, assessment should emphasize nonsomatic symptoms such as loss of interest and pleasure in activities, feelings of worthlessness, excessive guilt, and suicidal ideation. This patient's low energy, loss of appetite, and insomnia are less reliable indicators of depression as they may be caused by his metastatic lung cancer or chemotherapy side effects (Choices A and C). His loss of interest in spending time with his family and inability to engage with them in shared interests are the most concerning signs for depression. Nondepressed cancer patients may be periodically sad and discouraged, but they retain the ability to experience pleasure and engage with their loved ones. The American Society of Clinical Oncology recommends screening every patient with cancer for depression when the initial cancer diagnosis is made and periodically thereafter. There should be a low threshold for initiating treatment as untreated depression has a significant impact on quality of life for the patient and family. (Choice B) Guilt over burdening one's family is an understandable reaction to a cancer diagnosis with poor prognosis and can also occur in nondepressed cancer patients. In contrast, excessive guilt (eg, feeling sinful and deserving of punishment) associated with despair would be more indicative of depression. (Choice D) Thinking about death is normal for patients who have advanced cancer and only months to live. Patients should be assessed for thoughts of suicide, which would be concerning for depression. Educational objective: The diagnosis of depression in patients with advanced cancer should rely primarily on nonsomatic symptoms such as loss of interest and pleasure, worthlessness, excessive guilt, and suicidality. Patients with cancer should be evaluated periodically for symptoms of depression as treatment can improve quality of life for both patients and families. __________ References: Depressive spectrum disorders in cancer: diagnostic issues and intervention. A critical review. (http://www.ncbi.nlm.nih.gov/pubmed/28488207) Depressive spectrum disorders in cancer: prevalence, risk factors and screening for depression: a critical review. (http://www.ncbi.nlm.nih.gov/pubmed/28140731)

A 68-Year-Old Man Is Seen for Follow-Up of Non-Small Cell