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Section 17
Depression and Cancer

Question 17 | Test | Table of Contents

Grief and depression present similarly in patients who are dying. Conventional symptoms (e.g., frequent crying, weight loss, thoughts of death) used to assess for depression in these patients may be imprecise because these symptoms are also present in preparatory grief and as a part of the normal dying process. Preparatory grief is experienced by virtually all patients who are dying and can be facilitated with psychosocial support and counseling. Ongoing pharmacotherapy is generally not beneficial and may even be harmful to patients who are grieving. Evidence of disturbed self-esteem, hopelessness, an active desire to die and ruminative thoughts about death and suicide are indicative of depression in patients who are dying. Physicians should have a low threshold for treating depression in patients nearing the end of life because depression is associated with tremendous suffering and poor quality of life

Distinguishing between grief and depression in patients who are dying can be difficult. Many of the signs and symptoms traditionally used to diagnose depression are also present in patients who are grieving (Figure 1). Weight loss, anorexia and sleep disturbance, for example, might reflect depression, grief, poor control of physical symptoms or the normal physiologic changes associated with dying. Survey instruments designed to detect depression have not been well studied in patients who are dying and lack specificity because questions addressing somatic, functional and affective criteria can generate false-positive results. The Geriatric Depression Scale, for example, rates frequent crying. Crying can reflect depression or normal grief in dying patients. Differentiating between preparatory grief and depression is essential because of therapeutic implications. While some researchers have suggested that grief and depression differ in significant ways, evidence supporting such distinctions is lacking.

Illustrative Case
An 82-year-old man with a history of metastatic prostate cancer was admitted to an inpatient hospice unit because of progressive debilitation. His pain was well controlled, but he had a poor appetite, was losing weight and had crying spells. When asked about possible depression, he replied that he was not sure if he was depressed. One of his daughters who lived near him and helped care for him felt that his crying indicated that he was finally coming to terms with his terminal diagnosis; another daughter felt that he was depressed. Statements the patient made like, "I can't believe I'm dying" suggested that he was grieving. The physician treating him was unsure whether he might also be depressed. The patient received psychologic counseling and started taking a selective serotonin reuptake inhibitor (SSRI) antidepressant. He demonstrated a good response--his affect and energy level improved. The patient died peacefully a few weeks later.

Depression
Virtually all patients who are faced with dying experience episodes of sadness. These sad feelings are usually very intense for a variable period of time and then often gradually diminish in intensity: In some patients, dysphoria is persistent and is associated with a sense of hopelessness and disturbed self-image. An estimated 22 to 75 percent of patients who are dying experience clinical depression.However, depression is not inevitable and should not be considered a normal part of the dying process.

Depression shares common features with grief. Misdiagnosis can result in overlooking depression when it is present or inappropriately treating grief. Depression and grief are different conditions that require different treatments although, clinically, they often overlap. Patients with depression may benefit from counseling and pharmacotherapy.

Preparatory Grief
Grief is a reaction to any loss. As Freud observed, grief is "the reaction to the loss of a loved person, or to the loss of some abstraction which has taken the place of one, such as one's liberty...". Grief manifests as a progression of emotional, social, spiritual, physical, cognitive and behavioral changes through which a person attempts to reorganize and resolve or adjust to the loss at his or her own pace.

Preparatory grief, as introduced by Kubler-Ross in "On Death and Dying,"is "that [grief that] the terminally ill patient has to undergo in order to prepare himself for his final separation from this world." Preparatory grief is the normal grief reaction to perceived losses experienced by persons who are dying. (The terms anticipatory grief and anticipatory mourning are commonly used to refer to grief experienced by family members or friends before the death of a loved one. The grief experienced by patients as they prepare for their impending death is different from anticipatory grief as defined by the extensive body of existing literature. Consequently, preparatory grief, as defined by Kubler-Ross in reference to grief experienced by the dying person, is used here.)

Persons who are dying prepare for their death by mourning the losses implicit in death. The anticipated separation from loved ones is an obvious one. Simple pleasures of living may be grieved. People may reflect on their past and relive great moments and disappointments, and mourn for missed opportunities. Looking to the future, they may grieve the loss of much-anticipated experiences such as a child's graduation or the birth of a grandchild. In the present, the person who is dying usually experiences a radical change in self-image. Previously independent, the person may now be weak and dependent on others for even the most basic needs. The old self-image has been lost and is grieved as the person who is dying and their family adjusts to a new, more fragile sense of self.

Grief, which is often experienced as a painful tearing sensation, is also a process by which the grieving person adjusts to a radical change in the relationship between the self and that which is being lost--an object of attachment or love called the "loss object." Loss objects can be people or they can be simple pleasures like drinking coffee in the morning. The loss object can be a person's self image. Grief can be understood as the physical, psychological and cognitive changes that occur in response to an abrupt change in the relationship between the grieving person and the loss object. The grieving person moves, sometimes slowly, sometimes quickly, toward a new equilibrium as the changed relationship is redefined with the loss object.

Preparatory grief, while normal, can be facilitated through proper support. Grief per se rarely requires pharmacologic intervention. Inappropriate use of antidepressants or anxiolytics for treating grief may result in iatrogenic complications that have little, if any, benefit.

Differentiating Between Preparatory Grief and Depression: A Diagnostic Dilemma
Because many of the traditional signs of depression are also present in patients who are grieving, it can be challenging to separate the relative contribution of depression and grief in patients' presentations. The following questions can be used to explore a patient's moods.

  • Do you feel depressed most of the time?
  • Do you feel that you are better off than many other people in similar situations?

Some patients and their families will be readily able to identify depression. Others, however, may not be able to differentiate possible depression from grief or the normal changes that occur in the dying process. The following points highlight differences between preparatory grief and depression.

Temporal Variation. Grief is often experienced in waves, which are usually triggered in response to a specific loss. New waves of grief may be "predictably" triggered in response to a new loss (e.g., when an ambulatory patient becomes bedridden), or "unpredictably" triggered by seemingly minor incidents (e.g., hearing a treasured song or noticing a stranger's resemblance to a loved one).

In contrast, persistent flat affect or dysphoria that pervades all aspects of patients' lives is characteristic of depression.

Progress with Time. In most cases, patients progress through grief and it slowly diminishes in intensity over time. Patients may periodically experience intense waves of grief (an acute grief reaction), but the overall intensity wanes.
Depression is a pathologic state. Patients can "get stuck" in this state without treatment.

Negative Self-Image. Patients who are grieving usually have a normal self-image. Some patients may have a loss of self-esteem because of the debilitation and dependency caused by progressing disease. When these feelings are disproportionate to a patient's situation, underlying depression should be considered. Patients who are depressed may have a sense of worthlessness and disturbed self-esteem.

Anhedonia. The ability to feel pleasure is not lost in persons who are grieving. Most will still look forward to special occasions and visits from family and friends. Anhedonia is a clue to clinical depression.

Hopelessness. A person who is grieving maintains a sense of hope. Hope may shift, for example, from the hope for a cure to the hope for prolonging life to the hope to live comfortably and well for the duration of life, but it is not lost in persons who are dying. Pervasive hopelessness, however, is a hallmark of depression.

Response to Support. Patients who are grieving often need social interaction to help them through the grieving process. Social support enables patients to tolerate the pain of loss while providing the necessary assistance for completion of grief work. Patients may withdraw socially during the grief process, but this withdrawal is usually a temporary pause for reflection. When patients have processed their acute grief, they usually slowly reenter society. Social withdrawal can be a manifestation of untreated physical symptoms such as pain. In advanced stages of dying, social withdrawal can also naturally occur when the person who is dying begins to let go of social attachments.

Patients who are depressed often do not derive pleasure or solace from social interaction and may appear isolated and withdrawn. While temporary social withdrawal might serve a purpose in the grieving process (e.g., facilitating the process of reviewing life), it contributes to a worsening spiral of isolation and depressed mood in patients who are depressed. While increased social interaction may be beneficial to some patients who are depressed, it is not adequate to resolve depression.

Agitation. Persons who are grieving may be agitated during the early stages but usually respond to support and counseling. Agitation and hyperarousal often diminish or resolve with time.

When agitation is present in patients with depression, it may persist without much response to supportive measures.
Active Desire for an Early, Death. Many persons who are dying consider the possibility of an early death. Suffering associated with uncontrolled pain, concern about being a burden and a desire to be in control of dying can all result in thoughts of an earlier death.

A persistent, active desire for an early death in a patient whose symptomatic and social needs have been reasonably met is suggestive of clinical depression.

Management of Grief
The acronym RELIEVER can serve as a reminder about supportive interventions that can facilitate preparatory grief.

Reflect. Mirror the patient's emotions. Example: If the patient says, "Why did I have to get this horrible disease?" respond with "I can see that you are angry."

Empathize. Try to make a personal connection with the patient. Example: "I can imagine that you are going through rough times. It must be hard not to be able to get out of bed. What can I do to help?"

Lead. Guided questions can help facilitate the grief process. Example: "What concerns do you have about how your loved ones will do after you are gone?" or "When you went through difficult situations in the past, how did you handle them?" Identifying coping strategies that the patient used in the past can be useful so that they can try the strategies that have already been effective for them.

Improvise. Respect the emotional boundaries of patients and offer support within those boundaries. The physician's approach must be tailored to individual patients. What might work with one patient might fail with another. For example, some patients may desire support through talking; others may just want a supportive presence. Some may want time alone; others may cope best by continuing established routines. Patients may suddenly change coping strategies, which requires flexibility on the part of the physician to be able to respond appropriately.

Educate. Explain that grief often comes in waves. Let patients and family members know that people grieve in different ways. It is important to explain that anger experienced by the patients and families toward the self, the situation and others is a common and normal response when facing a terminal illness. Identifying, validating and channeling constructive outlets for anger helps decrease conflicts between patients and their families.

Validate the Experience. Reflect to the patient the normalcy of the experience. Example: "It is okay to cry," or "It seems to me you are responding normally to a very difficult situation."

Recall. Many patients who are dying want to look back over their lives and do a review of their life. Physicians can help by asking about accomplishments, special stories or legacies that patients may wish to hand down to future generations.
- Periyakoil, Vyjeyanthi S., Hallenbeck, James; Identifying and Managing Preparatory Grief and Depression at the End of Life; American Family Physician; March 1, 2002; Vol. 65, Issue 5.

Personal Reflection Exercise #3
The preceding section contained information regarding the identification and management of grief. Write three case study examples regarding how you might use the content of this section in your practice.

Update
Anxiety, Depression, and Concentration
in Cancer Survivors: National Health
and Nutrition Examination Survey results

Fardell, J. E. (2023). Anxiety, depression, and concentration in cancer survivors: National Health and Nutrition Examination Survey results. Supportive Care in Cancer, 31(273).

Peer-Reviewed Journal Article References:
Arch, J. J., Mitchell, J. L., Genung, S. R., Judd, C. M., Andorsky, D. J., Bricker, J. B., & Stanton, A. L. (2021). Randomized trial of acceptance and commitment therapy for anxious cancer survivors in community clinics: Outcomes and moderators. Journal of Consulting and Clinical Psychology, 89(4), 327–340.

Kuba, K., Esser, P., Mehnert, A., Hinz, A., Johansen, C., Lordick, F., & Götze, H. (2019). Risk for depression and anxiety in long-term survivors of hematologic cancer. Health Psychology, 38(3), 187–195.

Saracino, R. M., Cham, H., Rosenfeld, B., & Nelson, C. J. (2020). Confirmatory factor analysis of the Center for Epidemiologic Studies Depression Scale in oncology with examination of invariance between younger and older patients. European Journal of Psychological Assessment, 36(2), 229–236.

QUESTION 17
According to Periyakoil and Hallenbeck , what are the clues that a patient is experiencing depression, not preparatory grief? To select and enter your answer go to Test.

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