Depression, hopelessness and thoughts about death are not uncommon in oncology patients. The estimated prevalence of major depression is 16 percent for people with cancer. Minor depressive disorders, including dysthymia and adjustment disorders, is reported to affect up to 22 percent of people with cancer (Mitchell, Chan, Bhatti, Halton, Grassi, Johansen, & Meader, 2011) although prevalence varies widely with cancer type, treatment phase and method of diagnosis (Krebber, Buffart, Kleijn, Ryepma, deBree, Leemans, Verdonck-de Leeuw, 2014). Depression has been associated with prolonged hospital stays, increased physical distress, poorer treatment compliance, lower quality of life and increased desire for hastened death (Fitzgerald, Lo, Li, Gagliese, Zimmerman, & Rodin, 2015).
 

The literature on treating depression in people with cancer presents challenges in which the clinician must distinguish between physical symptoms of cancer from the neuro-vegetative symptoms of depression. In addition, the clinician must distinguish existential distress and grief from the emotional and cognitive symptoms of depression, and rational thoughts of death from suicidal ideation. Other challenges include pain and/or inadequate social supports. Clinicians are also challenged to understand complex drug interactions in the cancer context, and to apply evidence about the treatment of depression in the non-cancer population to those who are depressed and also dealing with cancer.

The cancer experience may create many losses: loss of health, loss of relationships, loss of employment, loss of identity, loss of the sense of the future—to name a few. Grief is a normal and anticipated component of the cancer experience. An important distinction between grief and depression is that the inner world of the bereaved is one of loss and sadness, but is different from depression. In grief, the emotions are intermittent and malleable; sadness comes in waves, usually interspersed with positive thoughts. The bereaved person maintains a capacity to be consoled (Prigerson, Shear, Newsom, Frank, Reynolds, Maciejewski…Dupher, 1996). Depression is characterized by symptoms of guilt, hopelessness and possible suicidal ideation, all of which differentiate depression from grief. In patients who also have cancer, neuro-vegetative symptoms (weight loss, sleep disturbances, fatigue, thoughts of death) are not reliable indicators of depression. Anhedonia is the most helpful indicator. Are there still things the patient enjoys? In grief, there usually are things that bring enjoyment to the person with cancer; generally, this is not true with people who are significantly depressed.

Figure 1 may help to determine whether the patient is experiencing grief versus depression.

Figure 1

The American Society of Clinical Oncology recommends for patients who may be depressed that “all patients should be screened for depressive symptoms at initial visit and at appropriate intervals, as clinically indicated, especially with changes in disease or treatment status (i.e., post treatment, recurrence, progression) and transition to palliative and/or end of life care” (Li, Fitzgerald, & Rodin, 2012, pg. 1187). It further emphasizes that treatment approaches should be interdisciplinary. Other important factors suggest the use of screening, the assessment of pertinent history and/or risk factors, as well as the assessment of self-harm, using culturally sensitive assessments and interventions.

The symptoms of harm to self or others, severe depression or agitation, or the presence of psychosis or confusion (delirium) require immediate referral to a psychiatrist, psychologist or other mental health professional. The assessment should identify signs and symptoms of depression, the severity of cancer symptoms, possible risk factors and times of vulnerability.

In cancer care, other considerations for risk of depression are disease and/or treatment related. They include interferon, pancreatic cancer, steroids and unrelieved symptoms such as pain, fatigue and infections. All of these can contribute to the development of depression.

The treatment of major depression is optimized by a combination of psychotherapy and medication. Behavioral interventions include psychoeducation, cognitive behavioral therapy and exercise (delivered by appropriately trained professionals).

Many people with cancer, especially those experiencing terminal disease, face numerous existential challenges. It is not uncommon to think about death in this situation, though these thoughts are not necessarily indicative of suicidal ideation.

As part of this search, some terminally ill patients may make, as author Ruth Anne Van Loon (1999) describes, “desire to die” statements. According to Van Loon, these statements may serve a variety of functions for people with terminal illness. For example, they may be expressions of depression or suicidal ideation, they may be a way of coping, they may express a spiritually based acceptance of death or they may be an indication of a rational choice for suicide. Van Loon further stresses that it must be assumed that expressing a desire for death is common among the terminally ill, and therefore a “normal” response to and way of coping with terminal illness.

Oncology social workers are challenged to differentiate among depression, hopelessness and suicidal ideation, and to understand the differences in ‘desire to die’ statements and what they mean clinically.

For people with cancer, and most especially those facing the end of life, there are a number of interventions that can be helpful. For example, clarifying patient perceptions can be very helpful (i.e., enhance communication skills with providers, examine the adequacy of social support) as well as cognitive behavioral therapy and medication. The clinician must balance reasonable optimism with the reality of the patient’s situation. Patients who are suicidal require immediate attention with a psychiatric evaluation and treatment.

As noted, some patients who express a desire for death are depressed; most are not. Three patterns can be seen with these patients:

• Those who make a desire for death as a way of coping,
• Those who are expressing an acceptance of death based on spiritual, religious or philosophical beliefs, and
• Those who are considering or have made an active choice to end their life. As with depressed patients, careful assessment is essential.

For patients who have a desire to die as a way of coping, these statements may be used to promote feelings of control, invite a discussion of existential concerns or to elicit help. Feelings of personal control are jeopardized by terminal illness, particularly as it progresses. Patients may suggest that suicide is an option when “things get too bad.” Other statements suggest existential searching: Did my life have meaning? Haven’t I suffered enough? What is the point of all this?

The “desire to die” talk as acceptance may reflect “readiness.” For example, “I am ready for God to take me,” which may reflect an acceptance based on religious beliefs or existential thought. Dale, one of my patients, just 37 years old, wrote just days before his death:

“My body is in shut down phase.
Just as trees turn from green to gold, I too
Turn slowly to gold. There is no fear in going,
Especially when compassion is all around me.
A good life has been. I’ve no regrets.”

“Desire to Die” Talk and Rational Choice

Occasionally, oncology social workers encounter patients who make “desire to die” statements and are neither depressed nor using this statement as a way of coping. With an increasing number of states legalizing physician aid in dying, it behooves us to develop the clinical skills to tolerate, sit with and explore these conversations with our patients. These patients may express a well thought out and persistent belief that hastening death is their best option. Important elements of these conversations include ruling out depression and/or other psychological disturbances that may compromise capacity. Examining a patient’s process and time frame for decision making, asking how long they have felt this way and ruling out other symptoms (e.g., pain) that may be influencing the decision are all important elements of assessment. Other components are determining if the patient has a realistic appraisal of the situation and, when possible, significant others should be involved.

In closing, it is important to remember that “desire to die” statements have many meanings for people who are terminally ill. Careful assessment to differentiate among meanings and to assess for depression is essential. Screening of all patients who desire to die for depression can lead to beneficial interventions for those who are depressed as well as for those who are not.

Depression is not inevitable for terminally ill patients, and they can benefit from a variety of psychosocial and pharmacological interventions, making accurate identification imperative. On the other hand, patients who are not depressed can benefit from having their feelings validated and normalized, and it gives clinicians an opportunity to take a “deeper dive” into the meaning of their concerns and questions.

References

Fitzgerald, P., Lo, C., Li, M., Gagliese, L., Zimmerman, C., & Rodin, G. (2015).  The relationship between depression and physical symptom burden in advanced cancer. BMJ Supportive & Palliative Care, 5, 381-388.

Krebber, A., Buffart, L., & Kleijn, G., Ryeoma, I., deBree, R., Leemans, C., Becker, A., Brug, J., van Straten, A., Culpers, P., & Verdonck-de Leeuw, I., (2014). Prevalence of depression in cancer patients: a meta-analysis of diagnostic interviews and self-report instruments. Psychooncology, 23, 121-130.

Li, M., Fitzgerald, P., & Rodin, G. (2012). Evidence-based treatment of depression in patients with cancer. Journal of Clinical Oncology, 30, 1187-1196.

Mitchell, A., Chan, M., Bhatti, H., Halton, M., Grassi, L., Johansen, C., & Meader, N. (2011). Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative care settings: A meta-analysis of 94 interview-based studies. Lancet Oncology, 12, 160-174.

Prigerson, H., Shear, M., Newsom, J., Frank, E., Reynolds, C., Maciejewski, P., Hourck, P., Beirhals, A., & Dupfer, D. (1996). Anxiety among widowed elders: Is it distinct from depression and grief? Anxiety, 2, 1-12.

Van Loon, R. (1999). Desire to die in terminally ill people: A framework for assessment and intervention. Health & Social Work, 24, 260-268