1. Explain why some patients are distressed when told they have a “good” cancer.

2. Teach the patient to consider cancer and its treatment as a rite of passage that requires as much attention as any other life transition.

3. Discuss why the diagnosis of depression is difficult in an elderly patient with comorbid medical illness.

4. Describe possible biologic underpinnings in late-life depression.

5. Select appropriate antidepressant medications for geriatric patients with depression and comorbid medical illness.

“Good” Cancer: Understanding and Addressing Distress in Cancer Patients with a Good Prognosis
Jennifer J. Griggs, MD, MPH, Associate Professor, Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor

Introduction: cancer and its treatment represent “rite of passage,” just as with any other life crisis or life transition; rites of passage originally defined as ceremonies that accompany individual life crises; life transitions, whether welcome or unwelcome, characterized by rites of passage in almost all cultures; rites of passage consist of 3 phases (separation, liminality, and reincorporation)

Liminality: state of “betwixt and between”; characteristics—individual is both in danger (eg, develops neutropenia from chemotherapy) and dangerous (eg, must protect others from his or her bodily secretions, which can contain chemotherapy medications); subjection to authority (eg, of physicians); undergoing physical changes (eg, loss of hair); undergoing intentional scarification (eg, from surgery); physical appearance erasing individuality (eg, losing hair makes one individual look more like others who have lost hair); ambiguous state of neither “before” nor “after” (ie, individual is not who he or she was before cancer and not who he or she will be after treatment); after treatment, individual with breast cancer classified as “no evidence of disease” (NED), ie, since breast cancer can recur many years later, patient not “cured” until he or she dies of something else

Hypothesis: breast cancer follow-up visits analogous to rituals of reincorporation; patient in prolonged liminal state after breast cancer because of possibility of late recurrence (this situation not seen with most cancers [ie, with most cancers, patient considered cured if cancer does not recur within 5 yr; that time limit does not apply to breast cancer]); return visits way of “marking time” as patient makes meaning and sense of illness and its treatment

Ductal carcinoma in situ (DCIS): also called intraductal carcinoma, noninvasive carcinoma, and stage 0 breast cancer; in United States, diagnosed in ≈58 000 women per year; although DCIS classified as stage 0, mastectomy may be indicated (eg, if DCIS or calcifications present in >1 quadrant of breast); chemotherapy not indicated; all cells contained within basement membrane (as opposed to invasive cancer), meaning chance of recurrence or metastases at later date almost zero; survival rate for DCIS 100%

Patients’ understanding of DCIS: patients with DCIS told they have a “good” cancer, an “excellent” cancer, “favorable” cancer, or “if there’s a kind of cancer to have, this is it”; what patients understand, however, very different and often inaccurate; in true-false survey to determine patients’ knowledge of prognosis of DCIS, 78% incorrectly responded to “over time, DCIS will spread to other parts in the body”; “a fair number” thought it moderately likely or likely that they would develop metastases from DCIS

Speaker’s online survey: conducted through www.breastcancer.org, nonprofit, physician-run breast cancer Web site; information collected on disease and treatment, demographic characteristics, affective states, concerns about recurrence, prognostic information received, relationships with physicians, and perceived family support; ≈58% of patients with DCIS had been told they had good cancer; in subjects with invasive cancer, concern about recurrence lower in older women, in women who had had mastectomy, in women who got message of good cancer, and in women who had more aggressive treatment; however, concern higher in 30% of women with DCIS who were told they had good cancer

What explains paradoxical effects of reassurance? knowledge deficit; cognitive dissonance (patient remarked, “I was never told by my surgeon I had cancer; he gave me the long name and I looked it up; I feel it is downplayed by my surgeon; he makes it seem so rosy; I have a copy of my pathology report and understand it; it is not as he [represents] it to be”); fears of abandonment by family and medical professionals; feelings of being marginalized or delegitimized (“while my diagnosis was supposedly the best possible type of cancer, it is still cancer, and not to be belittled; the nurses associated with my surgeon tried to tell me I could wait a couple of months or more to deal with my surgery, and everyone was astounded when I demanded it occur as soon as possible”); survivor guilt (“I feel as though I am a cheat because I am not suffering the way some of my breast cancer sisters are; whilst I am grateful, I still feel guilty”); liminal state (“I resented people telling me it was not cancer, just DCIS; if it is not cancer, then why have to have surgery, have radiation therapy, and be refused life insurance? I felt as if I was in between a deadly disease and a full healthy life”); discrepancy between illness and disease model (eg, patient told “you’re not a survivor; DCIS is not an illness”)

Right message, wrong words: patient observed, “it’s the right message; it’s the wrong words; it’s a good prognosis; it’s not a good cancer”; speaker urges caregivers to think carefully and take time to explain to patient, “you have an excellent prognosis this is not, however, a good cancer; your life has been affected by this; and people will often tell you how lucky you are”

Further research needed: understanding cancer patients’ distress—relationship of knowledge level to distress; patient’s relationship to providers; hypochondriasis (people who have more intense relationships with physicians because of hypochondriasis are more distressed by message of “good cancer”); addressing distress—providing high- quality information; preparing patients for commonly heard messages; physician-directed intervention with other physicians

Depression and its Interaction with Medical Illness in Geriatric Patients
Helen C. Kales, MD, Assistant Professor, Department of Psychiatry, University of Michigan Medical School; and Director, Geriatric Psychiatry Clinic, Research Scientist, Geriatric Research, Education and Clinical Center, and Investigator, Serious Mental Illness Treatment Research and Evaluation Center, Veterans Affairs Ann Arbor Healthcare System

Heterogeneity of depression in geriatric patients: some elderly patients had depression earlier in life and it has continued into later life; their course may be somewhat different from those who develop depression in later life (in whom there tends to be less family history of depression); those who develop depression in later life tend to ascribe cause to life stressors rather than biologic causes, and often think they do not need medications for stress-induced depression; controversial whether late-life depression due to global medical burden or to specific medical conditions

Difficulty of diagnosing depression in elderly: older patients often describe vague physical symptoms that overlap with symptoms of depression; people raised during Great Depression of 1930s talk less about depression as psychologic condition; developing depression may be reaction to increased burden of medical illness; elderly people often resigned to idea that physical debility accompanies aging and leads to depression, or they think that depression is natural outgrowth of aging (study showed that patients who consider depression natural outgrowth of aging are 4 times less likely to discuss depression with their physicians)

Overlapping symptoms: include fatigue, anorexia, and sleep changes; patient should be worked up for medical illness when appropriate; study found that measures of somatization, such as respiratory rate and shortness of breath, are more significantly associated with psychologic symptoms of depression than with medical comorbidity; another study found that somatic complaints attributed to medication side effects declined by half when patients treated for depression; consider depression when symptoms out of proportion to medical illness or when “that particular problem has been worked up to the nth degree and no medical cause has been found”

2-question depression screen: approximately half of speaker’s patients do not acknowledge sadness when they are depressed (perhaps due to cohort effect); however, many acknowledge anhedonia

Somatic symptoms and cognitive problems: can be difficult to sort out; study showed that of patients whose cognitive symptoms (pseudodementia) improved with treatment of depression, ≈40% went on to develop frank dementia

Suicide: Canadian study of >1300 suicides did not find increased suicides with any particular medical condition, except severe pain, but “there was a very strong association between the number of illnesses and the risk of suicide”; suicides also increased with ≥2 psychiatric comorbidities

Comorbidity: Geriatric Psychiatry Association observes that “the hallmark of depression in late life is comorbidity”; comorbidity defined as co-occurrence of ≥2 disorders; clinical comorbidity affects clinical course or outcome of illness; familial comorbidity seems to run in families, due to genetics or to shared environment

Medical burden: several studies of late-life research find that comorbidity of depression not specific to particular illness, but to overall medical burden

Predictors of Response to Cardiac Resynchronization Theory (PROSPECT) study: found only pulmonary disease associated with poorer depression outcomes; atrial fibrillation associated with better outcomes, perhaps because patients get more intensive management and, therefore, attention

Possible biologic underpinnings to late-life depression

Poststroke depression: occurs in ≈15% after stroke (incidence possibly higher, depending on when measured after stroke); peak risk period for depression 3 to 6 mo after stroke, but risk elevated for ≤1 yr; thought to be biologic, with disruption in neural circuits, but some studies have also shown influence of psychosocial factors such as family and personal history of depression; site of lesion also plays role, with depression occurring more often with left-hemispheric stroke

Vascular disease: controversial whether vascular depression different from other types of depression; strong association exists between depression and cardiovascular disease, including that caused by diabetes; Japanese introduced concept of “silent stroke,” in which patients do not have changes in limb function or in speaking, but may demonstrate subtle personality changes, and areas of white matter hyperintensity show up on magnetic resonance imaging (MRI) of brain; these areas of hyperintensity found in all older people, but more extensive in patients thought to have vascular depression; 1 researcher has renamed vascular depression “subcortical ischemic depression,” which involves slowed speech and movements, family history of mood disorders, problems with executive functioning, and poor outcomes, and may require different treatment

Depression and dementia: depression affects 15% to 20% of those with Alzheimer’s disease, with higher rates in those with vascular dementia and some cortical dementias; study showed that those with dementia and depression 4 times more likely to be placed in nursing home at 1 yr

Parkinson’s disease: second most common neurodegenerative disease after Alzheimer’s disease; associated with high rates of depression and depressive symptoms that affect daily functioning, and may be accompanied by more anxiety; people with Parkinson’s disease have masked facies, so affect less discernible; some research suggests biologic underpinning, with disruption of frontal striatal circuits

Work-up: obtain thorough history from patient and/or caregiver; ask patient to bring in all medications, including herbal preparations and over-the-counter medications; obtain thorough physical examination; perform cognitive screening; laboratory tests include complete blood cell count (CBC), thyrotropin (TSH), and chemistry panels

Treatment

Generalizations: “start low and go slow”; changes of aging can result in medications reaching higher concentrations, having longer half-lives, and interacting more with other medications; selective serotonin reuptake inhibitors (SSRIs) have impact on platelets and can exacerbate effects of anticoagulants; SSRIs and venlafaxine may contribute to syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in patients who take diuretics

Efficacy of antidepressants: studies show that medically ill patients treated with antidepressants more likely to improve than those on placebo or no treatment; sertraline shown to be safe and effective in patients with hypertension, cardiovascular disease, diabetes, and arthritis; study found medical burden unrelated to treatment response

Poststroke depression: trials show nortriptyline and fluoxetine superior to placebo; in 2 studies focusing on prevention of poststroke depression, 10% of patients treated with nortriptyline or sertraline developed poststroke depression (vs 30% with placebo)

Alzheimer’s dementia with depression: sertraline had positive effect on depression but no effect on cognition

Bottom line: speaker recommends using citalopram, sertraline, or venlafaxine as first-line antidepressant in elderly; bupropion and mirtazapine second choice, with tricyclic antidepressants and nortriptyline third

Other: cognitive behavioral therapy and problem-solving therapy most effective psychotherapy in older people ; adherence problematic (≈40% of speaker’s patients discontinue antidepressant medications); polypharmacy, cost, and complexity of regimen contribute to nonadherence; adherence requires intact executive functioning; new device available that sounds alarm to remind patient to take medications and tells them whether they should take it with water or food