A 72-year-old woman with breast cancer comes to the office for follow-up accompanied by her daughter. The patient has undergone surgery and completed chemotherapy over the last 7 months; she was informed at her appointment last month that her cancer was in remission. The daughter says that "despite the news of remission, Mother isn't any happier. She eats very little, does not sleep more than 2 or 3 hours at a time, and cries frequently. She also doesn't seem to enjoy visits from the family, reading, or watching her favorite television programs." The patient says, "Wouldn't anyone who has been through this be depressed?" She reports that her energy is still low following chemotherapy but that she is not in any pain. She has stopped reading as she has difficulty concentrating and remembering. The patient has lost 4.5 kg (10 lb) since her appointment a month ago. She has no suicidal thoughts. There are no changes on physical examination, and her laboratory results remain stable. In addition to providing support, which of the following is the most appropriate next step in management of this patient?

Question

A 72-year-old woman with breast cancer comes to the office for follow-up accompanied by her daughter.  The patient has undergone surgery and completed chemotherapy over the last 7 months; she was informed at her appointment last month that her cancer was in remission.  The daughter says that "despite the news of remission, Mother isn't any happier.  She eats very little, does not sleep more than 2 or 3 hours at a time, and cries frequently.  She also doesn't seem to enjoy visits from the family, reading, or watching her favorite television programs."  The patient says, "Wouldn't anyone who has been through this be depressed?"  She reports that her energy is still low following chemotherapy but that she is not in any pain.  She has stopped reading as she has difficulty concentrating and remembering.  The patient has lost 4.5 kg (10 lb) since her appointment a month ago.  She has no suicidal thoughts.  There are no changes on physical examination, and her laboratory results remain stable.  In addition to providing support, which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient's history of depressed mood, anhedonia (inability to enjoy normally pleasurable activities), sleep difficulty, appetite disturbance, low energy, and impaired concentration meet the criteria for major depressive disorder (MDD). The SIGECAPS mnemonic can assist in recall of the core signs and symptoms of MDD. Diagnosis requires ≥5 of 9 symptoms for at least 2 weeks; one of these symptoms must be anhedonia or depressed mood. core signs and symptoms of MDD Although some depressive symptoms in cancer patients are common, the development of major depressive disorder should not be normalized and considered an "expected" reaction (Choice C). Untreated depression in medically ill patients causes reduced quality of life and additional anguish for families, and can negatively impact treatment adherence and medical management. Treatment options include pharmacotherapy and/or psychotherapy. Antidepressants are indicated for cancer patients with major depression and are safe and effective in this setting. (Choices A, B, and G) Encouraging the patient to express her feelings to her family, increase interaction with her family, and/or engage with a cancer support group may be beneficial adjunctive strategies to address her depression but alone are not adequate. Support groups can be particularly important for cancer patients and family members who are distressed but are not a substitute for treating major depression. (Choices E and F) It is inappropriate to monitor the patient without intervention or reassure her that the symptoms will gradually improve now that she has completed chemotherapy. Although chemotherapy side effects can overlap with neurovegetative features of depression (eg, fatigue, insomnia, weight loss), this patient's nonsomatic symptoms of depression (eg, pervasive and persistent sadness, anhedonia, tearfulness) are concerning for major depression. Educational objective: Medically ill patients who develop comorbid depression can benefit from treatment with antidepressant medications and psychotherapy to improve their quality of life. References: Efficacy and acceptability of antidepressants on the continuum of depressive experiences in patients with cancer: systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26118318)

A 72-Year-Old Woman with Breast Cancer Comes to the Office