Research has consistently demonstrated an increased prevalence of depression among oncology patients.¹ Despite this well-established fact, depression continues to be underdiagnosed within this population.^2,3 Some attribute this to the overlap between the symptomatology of depression and that of cancer (e.g., sleep disturbance, fatigue, and decreased appetite). Others attribute it to the healthcare team’s tendency to prioritize somatic symptoms over psychiatric ones, especially in more medically complex cases.

As medical students and healthcare providers who frequently interact with oncology patients in clinical settings, we believe that part of the reason for the underdiagnosis of depression among oncology patients is that healthcare teams often neglect to elicit patients’ perspectives of mood-related symptoms. With this in mind, we made an intentional effort to discuss mood-related symptoms by asking all oncology patients a simple question: “Do you feel depressed?” When we made this small but deliberate effort, we quickly realized that patients’ experiences of mood changes are complex and heterogeneous. In other words, oncology patients perceive and experience depressive symptoms in different ways, which may explain why some patients’ mood disorders go undetected. Here, we share three different perspectives of mood changes that we more commonly encountered among our patients.

I’m depressed but I don’t have depression

These patients acknowledge changes to their mood since their cancer diagnosis but accept these changes as a natural and inevitable part of their medical illness rather than a separate psychiatric process. They frequently endorse that they are not as active or happy as they were prior to their diagnosis. However, when queried whether they believe that these are depressive symptoms, they deny it and attribute their symptoms wholly to external causes, specifically the cancer, associated physical symptoms, and treatments. These patients view their mood-related symptoms as unavoidable and believe that nothing can be done to alleviate them. Such a belief of helplessness is concerning as it may discourage patients from disclosing their symptoms to their providers and accepting mental health treatment.

What mood changes?

These patients lack insight into their mood and are unaware of their mood-related symptoms until prompted to discuss them. While these patients may be acutely attentive to physical symptoms related to their cancer, such as stabbing low back pain, dull pain in the soles of their feet, insatiable thirst, and challenges in eating, they are less in touch with their mood-related symptoms. When asked about their mood, they become hesitant and provide shorter answers. This highlights the importance of prompting patients to explore their emotional states.

I’m not depressed

Lastly, these patients deny changes to their mood. They may appear to be in a good or even cheerful mood. They often fully reject having any emotional stress from the diagnosis or treatment of cancer. Many verbalize a high level of confidence that their mood and mental health are normal. Furthermore, there are no easily identifiable signs of depressive symptomatology during verbal interactions. However, if given a formal questionnaire to evaluate depressive symptomatology, these patients score above the cutoff for clinical significance. For such patients, the heightened denial of depressive symptoms is likely to interfere with the clinician’s ability to recognize and appropriately manage the patients’ symptoms. Therefore, a more formal means of evaluation, such as use of a validated screening tool, may help identify depressive symptoms and lead to further communication about the patient’s perspective.

These examples illustrate the importance of recognizing the many faces of depression among oncology patients. Not all patients perceive or interpret their depressive symptoms in the same way, which may create a potential barrier to care. In our experience, a simple, direct and isolated question was helpful in opening discussions about depression. However, asking more specific and relevant questions can help the team obtain a more nuanced understanding of the patient’s mood and elicit important clinical information. Standardized screening tools, such as the depression module of the Patient Health Questionnaire (PHQ-9), can help characterize the severity of depression.⁴ In addition to interviewing patients, addressing potential barriers to effective communication, such as clinician attitudes, inadequate training or interview skills, and restrictions imposed by the healthcare system (e.g., time limitations), can improve the evaluation of depression.

Furthermore, patients’ unique perspectives can help guide interventions. For those resigned to thinking that mood changes are an inescapable component of the cancer experience, education on depression as a treatable complication of cancer may be helpful. For those who are unaware of mood changes, encouraging deeper discussions about mood-related symptoms with the healthcare team may lead to a greater likelihood of initiating treatment and making timely referrals to a mental health provider. Finally, for those who deny mood changes, regular formal assessments may be warranted.

Disclosure Statement

The authors state that there is no conflict of interest.

References

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