A 54-year-old woman was diagnosed with breast cancer 6 months ago after seeing her physician for a lump in her breast. The patient underwent a mastectomy and has been receiving chemotherapy. She has had poor sleep and decreased appetite for the last 3 weeks. She has some nausea that is relieved by prescription medications. The patient feels down and says, "The chemo makes me feel weak and drained, so I don't want to do anything." She spends most of her time at home and does not feel like going out or talking to family and friends. Some days, she does not get out of bed and does not answer her phone. The patient has lost interest in reading and her favorite television programs. She feels at fault for having breast cancer because she missed 2 mammogram appointments. Which of the following is the most appropriate next step in management of this patient?

Question

A 54-year-old woman was diagnosed with breast cancer 6 months ago after seeing her physician for a lump in her breast.  The patient underwent a mastectomy and has been receiving chemotherapy.  She has had poor sleep and decreased appetite for the last 3 weeks.  She has some nausea that is relieved by prescription medications.  The patient feels down and says, "The chemo makes me feel weak and drained, so I don't want to do anything."  She spends most of her time at home and does not feel like going out or talking to family and friends.  Some days, she does not get out of bed and does not answer her phone.  The patient has lost interest in reading and her favorite television programs.  She feels at fault for having breast cancer because she missed 2 mammogram appointments.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

It is normal for patients with cancer to have feelings of sadness, and adverse effects of chemotherapy can include low energy and decreased appetite. However, recognition of major depression in medically ill patients is important, as it decreases quality of life and can negatively affect treatment adherence and medical outcome. This patient's 3-week history of sadness; sleep and appetite disturbance; low energy; decreased interest in friends, family, and activities; and excessive guilt is consistent with a major depressive episode (≥ 2 weeks of at least 5 of 9 symptoms: Depressed mood plus SIGECAPS [Sleep disturbance, loss of Interest, Guilt, low Energy, impaired Concentration, change in Appetite, Psychomotor retardation or agitation, and Suicidal thoughts]). Although several of this patient's symptoms can be explained by both depression and medication adverse effects, there should be a low threshold for initiating treatment for depression, given the potential to provide relief and improve quality of life. Patients with cancer can be safely and effectively treated with antidepressant medications with or without psychotherapy. (Choice A) Although some of this patient's symptoms (eg, decreased appetite, fatigue) may be attributed to chemotherapy, she has other symptoms that raise concern for major depression. The patient should be offered treatment to alleviate her depression. (Choice B) Although improving communication with family would be beneficial, depression can cause patients to withdraw from those who care for them the most. Treatment of depression may restore this patient's interest in family and friends, making communication easier. (Choice D) Reassurance might be appropriate if this patient had only normal grief or an adjustment disorder. The development of symptoms many months after the diagnosis and the severity of the symptoms make major depression more likely. Treatment is indicated. (Choice E) Cancer support groups are an important adjunctive intervention and should be recommended in addition to aggressive treatment of the depression. However, this patient struggles to talk with family and friends and hardly leaves the house. She will likely find it difficult to attend a meeting until her depression has improved. Recommending a breast cancer support group alone would not be sufficient at this time, given the severity of this patient's depression and her difficulty communicating with others. Educational objective: Patients with cancer may have somatic symptoms that overlap those of depression (eg, sleep disturbance, appetite change, poor energy). However, if there are additional symptoms such as persistent sadness, guilt, loss of interest, and suicidal thoughts, major depression should be considered, with a low threshold for beginning treatment. References: Pharmacological treatment of depression in women with breast cancer: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/24077731) 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 54-Year-Old Woman Was Diagnosed with Breast Cancer 6 Months