Depression and panic disorder in cancer patients

James Slaughter, M.D.

Cancer patients often experience psychiatric comorbidity during the course of their illness. The disorders most commonly complicating cancer are depression and anxiety. Such psychiatric distress greatly impairs the patient's quality of life, comfort level and treatment compliance, which ultimately can affect the patient's survival.^1,2,3

Oncologists are challenged with the difficult task of determining what is a normal or pathological emotional reaction to cancer. While clinicians naturally anticipate some level of both anxiety and depression with cancer, they may underestimate the severity of the emotional distress. Some clinicians may assume that a profoundly anxious or sad reaction is to be expected with cancer. Not assessing for treatable depression and anxiety may result in unnecessary suffering.^1,4

Depression and anticipatory grief
Depression is the most common emotional disorder in cancer patients. Prevalence rate estimates vary from 4.5 percent to 58 percent.^1,2,5,6 This occurrence rate is alarming and highlights the need for a clearer understanding of the different reactions to the presence of cancer.

Many clinicians struggle to differentiate a normal grief reaction from a pathological grief reaction (depression). In one study, we attempted to elucidate the difference between a normal grief reaction to the presence of terminal illness and one that would be considered pathological or diagnosable as depression.⁷ Normal grief in simplest terms is sadness with a desire for the return of the loss, which in the cancer patient is a long, healthy life.

Normal grief involves physical, behavioral, emotional and cognitive reactions that enable the individual to adapt successfully to the loss. With normal grief, energy decreases. Sadness and preoccupation with the loss occur. Physical symptoms include poor sleep and appetite.

The behavioral characteristics include tearfulness, withdrawal from others and decreased activity. The cognitive aspects include a focus on the loss, regret or mild guilt and mild concentration problems.

With normal grief, self-esteem remains intact with no evidence of suicidal ideation. Furthermore, normal grief changes with time, allowing the individual to adapt appropriately to the circumstances of the new loss.

Conversely, pathological grief involves physical, behavioral, emotional and cognitive processes that do not enable the individual to adapt to the loss. With pathological grief, the physical symptoms of poor sleep and appetite and decreased energy might result in marked insomnia, weight loss and weakness. The behavioral alterations may result in marked isolation and tearfulness.

Emotionally, pathological grief is so intensified that the patient feels overwhelmed with anxiety, debilitating sadness or anger. The individual may be completely preoccupied with thoughts of an idealized past or, alternatively, may be in such a state of shock and dismay that the loss may be denied. The patient also may experience intense guilt, encounter marked concentration problems, have suicidal thoughts or attempt suicide, experience possible psychosis in the form of hallucinations or delusions or lose self-esteem.

Pathologic grieving does not progress toward resolution.⁸ Ambivalence toward the loss is an important feature in initiating pathological grief.⁹ Of those experiencing pathological grief, a majority will meet the criteria for major depression and generalized anxiety disorder. A significant minority will meet the criteria for panic disorder.^{10, 11} Major depression is more likely to complicate grief if the patient has a personal or family history of depression.^12,13

Anxiety and panic
In addition to depression, anxiety and panic can complicate cancer treatment and affect patients' quality of life. Although physicians may expect anxiety in cancer patients, they may underestimate its severity.⁴ Anxiety in oncology patients may be considered a reaction to the stress of cancer or a manifestation of a medical or physiologic problem related to the cancer rather than recognized as a psychiatric disorder requiring treatment.¹⁴

While anxiety is not as common as depression in cancer patients, its presence can cause equal or more profound discomfort. A recent meta-ananalysis regarding emotional disorders in cancer patients reported a range of anxiety from .9 percent to 49 percent.¹⁵ Our study found 25 percent of cancer patients had at least one diagnosis of anxiety [panic disorder (PD), generalized anxiety disorder or panic attack (PA)]. Specifically, about 20 percent experienced PD or PA.¹

In our study of panic in cancer patients, we found four patients whose panic symptoms were so severe that they preferred to discontinue their chemotherapy rather than continue to live with their discomfort.¹

Treatment
In most cases, psychiatric comorbidity is treatable when recognized. From a physiological perspective, both depression and anxiety respond well to psychotherapy and medication. A selective serotonin re-uptake inhibitor (SSRI) such as sertraline, 50 to 100 mg, is effective in alleviating both depression and panic symptoms. And benzodiazepines such as clonazepam or lorazepam .5 mg in the morning and at noon and 1 mg in the evening are useful in diminishing panic within 24 hours.¹ The benzodiazepine, if not indicated for nausea, may then be tapered off in three to four weeks. The SSRI may be continued for one year.

Counseling is beneficial to cancer patients. Social workers, nurses, psychologists, psychiatrists and pastoral counselors may be highly instrumental in alleviating the emotional sequelae of cancer. Cancer survivors' quality of life is greatly enhanced when emotional issues are identified and treated.

References

Slaughter JR, Jain A, Holmes SE, Reid JC, Bobo W. Panic and Cancer Therapy Discontinuation. Submitted. (1999).
Carrol BT, Kanthol RG, Noyes R, Wald T and Clamon G. Screening for depression and anxiety in cancer patients using the hospital anxiety and depression scale. General Hospital Psychiatry. 1993;15,69-74.
Massie MJ, Holland JC: Overview of normal reaction and prevalence of psychiatric disorders. In: Holland JC, Rowland JH, eds. Handbook on Psycho-oncology Psychological Care of Patient with Cancer. New York: Oxford University Press; 1990:273-282.
Shakin Kunkel EJ. The assessment and management of anxiety in the patient with cancer. New Directions for Mental Health Services. 1993;57.
Hinton J. Psychiatric consultation in fatal illness. Proc R Soc Med. 1972;65:29-32.
Lansky SB, List MA, Herman CA, et al. Absence of major depressive disorder in female cancer patients. J Clin Oncol. 1985;3:1552-1560.
Slaughter JR, Beck DA, Johnston S, Holmes SE and McDonald A. Anticipatory Grief and Depression in Terminal Illness. In Press.
Corr C, Doka K. Current models of death, dying and bereavement. Critical Care Nursing Clinics of North America. 1994;6(3):545-552.
Freud S. Mourning and melancholia (1917). In: Jones E, ed. Collected Works of Sigmund Freud. London: Hogarth Press Ltd.; 1950.
Corr CA. Lessons that we should and should not learn from the work of Elizabeth Kubler-Ross. Coping with Dying. 1993;7:69-83.
Kim K, Jacobs S. Pathological grief and its relationship to other psychiatric disorders. Journal of Affective Disorders. 1991;21:257-263.
Doka KL. Living with Life-Threatening Illness. Lexington, Mass.: Lexington Books, 1993.
Jacobs S, Hansen F, Berkman L, Kasl S, Ostfeld A. Depression of bereavement. Comprehensive Psychiatry. 1989;30:218-224.
Breitbart W. Psycho-oncology: Depression, anxiety, delirium. Seminars in Oncology. 1994;21(6):754-769.
Van't Spijker A, Trijsburg RW, Duivenvoorden HJ. Psychological sequelae of cancer diagnosis: a meta-analytical review of 58 studies after 1980. Psychosomatic Medicine. 1997;59: 280-293.