Depression

ONS PEP Weight-of-Evidence Category: Recommended for Practice

Clinical Practice Guidelines for the Psychosocial Care of Adults With Cancer (National Health and Medical Research Council [Australia], 2003)¹³

Comprehensive, evidence-based guidelines developed to assist healthcare professionals in providing optimal psychosocial care. The guidelines are multidisciplinary in focus, with recommendations applicable to diverse treatment settings. Evidence was presented using levels I, II, III-1, III-2, III-3, and IV rating system with level I representing the gold standard.

Content includes general interactional skills, discussing prognosis and treatment options, preparing patients for potentially threatening procedures and treatments, providing emotional and social support, ensuring continuity of care, and providing support toward the end of life. Clinically relevant recommendations supported by level I and II evidence about depression include the following.

• Referring high-risk patients to specialized psychological services to minimize the likelihood of developing significant distress (level I)

• Using a range of psychoeducational interventions to decrease distress (level I)

• Managing depression by incorporating a combination of supportive psychotherapy, cognitive and behavioral techniques, and pharmacotherapy (levels I, II)

• There is no evidence that any particular antidepressant is superior to another in the management of depression in people with cancer (level I).

• Other therapies that may improve depression are art, music, painting, reading, poetry, wellness programs, meditation, hypnosis, acupuncture, relaxation, exercise, prayer, laughter, etc. (levels I, II, III-3, IV).

The treatment of depression should incorporate psychotherapeutic interventions and the use of medication.

There is clear evidence of the efficacy of antidepressant medication in treating depression in patients with cancer.

There is no evidence that any particular antidepressant is superior to another.

• The sedating properties of tricyclics may be beneficial to some patients, as may their potentiation and enhancement of opioid analgesia in those with pain.

• Their anticholinergic side effects may aggravate stomatitis, exacerbate constipation, and affect cardiac rhythm.

• Patients with cancer may respond to a lower dose of tricyclic antidepressants.

• Selective serotonin reuptake inhibitors have been demonstrated to be effective in treating depression in patients with cancer.

• The long half-life of fluoxetine makes it less desirable in patients with hepatic or renal dysfunction where sertraline or paroxetine is preferable.

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Depression (PDQ) (National Cancer Institute, 2006)²⁸

Physician Data Query (PDQ) is composed of treatment summaries that are peer reviewed and updated monthly. Although not strictly considered guidelines, the expert recommendations do provide current treatment information. This PDQ discusses antidepressant medications and psychotherapy as interventions for patients with cancer and depression. Drug tables with starting doses for patients with cancer and side effects are included.

Refer for consultation to psychiatry when

• Oncology provider does not feel competent (i.e., prominent suicidal tendency present)

• Depressive symptoms are resistant after two to four weeks of intervention

• Depressive symptoms worsen rather than improve

• Adverse effects of medication interfere with antidepressant treatment

• Depressive symptoms interfere with the patient’s ability to cooperate with medical treatment.

Factors important in antidepressant selection for adult patients with cancer include cardiac history, hepatics dysfunction, renal dysfunction, glaucoma, and neuropathic pain.

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Clinical Practice Guidelines, Depression

Clinical Practice Guidelines: Depression (Ministry of Health, Singapore, 2004)¹⁵

These psychiatric guidelines are for assessment and treatment of depression; they do not address depression in patients with cancer.

The briefly describe psychotherapy treatments such as cognitive-behavior and group therapy.

The guidelines describe the evidence for effective pharmacotherapy.

• Choice of antidepressant

• Treatment response

• Phases of treatment

Depression can coexist with medical conditions such as cancer and often is not detected because the patient does not present with depressive symptoms.

The guidelines do not take into consideration the physical impairments of the patient with cancer, so they must be applied with caution.

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Practice Guideline for the Treatment of Patients With Major Depressive Disorder (American Psychiatric Association, 2000)¹⁶

Guidelines are directed to assist physicians in implementing antidepressant treatment in patients 18 years and older. They use three categories of confidence.

I Recommended with substantial clinical confidence

II Recommended with moderate clinical confidence

III May be recommended on the basis of individual circumstances

The guidelines do not address depression in patients with cancer.

Although not specific to depression in patients with cancer, the guidelines provide detailed information about antidepressant treatment and may be consulted for assistance in

• Selecting an antidepressant

• Adjusting a dose

• Assessing response

• Switching medications

• Continuation phase

• Maintenance phase

• Discontinuation of treatment.

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Guidelines for Distress Management in Patients With Cancer

Clinical Practice Guidelines in Oncology: Distress Management (National Comprehensive Cancer Network, 2006)¹⁴

Practice guidelines were developed by an expert committee and are reviewed and updated annually.

Search strategy was not described.

Distress should be assessed; distress thermometer (a 0–10 visual analog scale) is recommended as a brief screening measure.

Level of distress was measured from 0–10, and problems associated with distress were also ascertained via a problem list. They included practical, family, emotional, spiritual/religious, and physical problems.

Algorithms describe care of identified conditions, including mood and adjustment disorders.

The oncology RN role is primarily one of assessment and referral to oncology social workers, pastors, or mental health professionals.

Pharmacology, cognitive-behavioral, or psychotherapy and assurance of safety are recommended interventions.

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