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Case History

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Image not available. A 42-year-old woman with a recent diagnosis of breast cancer is referred for assessment. She has been crying persistently since diagnosis, unable to manage at home and is tearful during most of her recent consultations. Her husband thinks she is depressed and is concerned about her. Past history includes an episode of depression 20 years ago.

How do you make a distinction between 'appropriate' distress and a markedly depressed mood?

Are there any risk factors that may predispose to depression?

When should you treat depression?

How should you treat depression?

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Background

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How do you make a distinction between 'appropriate' distress and a markedly depressed mood?

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Image not available. Many patients with cancer develop distress. For most patients this is transient, often appropriate and adaptive to what is extremely distressing news. For some patients, however, this develops into a major depression. Prevalence rates in the literature vary widely between 20% and 35% for depression in patients with cancer, depending on the studies reviewed. Although there are notable problems with some of these studies, there is no doubt that a large subgroup of patients with cancer become depressed. Distinguishing depression from distress is particularly difficult in patients with cancer as many of the so-called 'biological' depressive symptoms and signs are unhelpful. Thus, many patients with cancer have anorexia, weight loss, insomnia and poor concentration for reasons related directly to their cancer. One must rely therefore on other aspects of depression to make the diagnosis. These include the following:

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  • With depression the low mood/distress is pervasive, persisting throughout all or most of the day with no appreciable alleviation. It permeates all aspects of the patient's life. Sometimes there is diurnal mood variation, with the mood being worse in the morning and improving as the day goes on.

  • Patients show reduced interest and motivation. This has to be assessed within the confines of physical disability. Patients, however, are usually clear that their lack of interest and motivation is not just due to physical constraints. But one can ask about activities that do not require much physical exertion, for example reading, watching TV, or following their favourite football team.

  • Reduced enjoyment is another key feature of low mood. Patients describe how nothing can lift their mood, not even, for example, visits from friends or close family.

  • Patients are often pessimistic and hopeless, feeling things will never get better.

  • Rarely a patient may feel life is not worth going on with, even possibly considering suicide.

  • Symptoms are present for a large part of the time, at least a 2-week period.

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Are there any risk factors that may predispose to depression?

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In general, patients with a previous episode of depression are at increased risk of a further episode. It is important, however, to clarify whether this patient did, indeed, have an episode of depression, and whether it required treatment, responded ...

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