A 63-year-old woman with a history of metastatic breast cancer comes to the office due to depressed mood. Over the past month, the patient has become increasingly sad and frequently cries when thinking about her poor prognosis and dying. She has lost 4.5 kg (10 lb) over the past month. Her energy level is low, and she has difficulty falling asleep and frequent nighttime awakenings. The patient has become very withdrawn, doesn't answer the phone, and no longer looks forward to family visits. She feels bad about not wanting to be around her grandchildren. On mental status examination, the patient is alert and oriented with depressed mood and affect. She has no suicidal ideation. Which of the following symptoms is most indicative of major depressive disorder in this patient?

Question

A 63-year-old woman with a history of metastatic breast cancer comes to the office due to depressed mood.  Over the past month, the patient has become increasingly sad and frequently cries when thinking about her poor prognosis and dying.  She has lost 4.5 kg (10 lb) over the past month.  Her energy level is low, and she has difficulty falling asleep and frequent nighttime awakenings.  The patient has become very withdrawn, doesn't answer the phone, and no longer looks forward to family visits.  She feels bad about not wanting to be around her grandchildren.  On mental status examination, the patient is alert and oriented with depressed mood and affect.  She has no suicidal ideation.  Which of the following symptoms is most indicative of major depressive disorder in this patient?

Quizplus · Accepted Answer

11ec160b_3619_e222_9249_27817a9459cc_MD0001_00 Diagnosis of major depressive disorder in patients with cancer is challenging as somatic symptoms of depression overlap with those of cancer and/or the adverse effects of cancer treatments. This patient's weight loss, low energy, and sleep disturbance may also be due to metastatic cancer and/or chemotherapy. Therefore, these somatic symptoms are less reliable indicators of major depression (Choices B, C, and E). Nonsomatic depressive symptoms (eg, feelings of worthlessness, excessive guilt, and suicidal ideation) are more reliable for diagnosing depression in patients with advanced medical illness. This patient's withdrawal and inability to enjoy family visits (ie, loss of interest and anhedonia) are therefore the most concerning symptoms for major depression. (Choice D) Thinking about death and dying is normal in patients with advanced cancer and a poor prognosis. If the patient's thoughts of death included suicidal ideation, intent, or plan, this would be indicative of major depression. Educational objective: Somatic symptoms of depression (weight loss, low energy, sleep disturbance) are less reliable indicators of major depressive disorder in patients with advanced medical illness. Focusing on nonsomatic symptoms, such as loss of interest, anhedonia, worthlessness, excessive guilt, and suicidality, can assist in diagnosing comorbid depression in these patients. __________ References: Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: an American Society of Clinical Oncology guideline adaptation. (http://www.ncbi.nlm.nih.gov/pubmed/24733793) Distinguishing depressive symptoms from similar cancer-related somatic symptoms: implications for assessment and management of major depression after breast cancer. (http://www.ncbi.nlm.nih.gov/pubmed/28973709)

A 63-Year-Old Woman with a History of Metastatic Breast Cancer