Patients With Terminal Cancer Can Beat Depression
Though it might seem like depression is a logical response to terminal cancer - and therefore, its sufferers are unlikely to respond to psychotherapy - a new research review has found that talk therapy can effectively treat symptoms of depression, even among the dying.
"Psychotherapy can be a promising treatment for ameliorating depressive states in advanced cancer patients if they prefer to receive it," said lead author Tatsuo Akechi. He is an associate professor of psychiatry and cognitive-behavioral medicine at the Nagoya City University Graduate School of Medical Sciences in Japan.
The review appears in the latest issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
In the review, treatment effects for this group of patients were only slightly less than those found in clinical trials of antidepressant medications in people treated outside of cancer centers. "The effects are almost comparable to those obtained in antidepressant pharmacotherapy studies in general psychiatry settings," Akechi said.
"It's a clinically meaningful difference," said David Spiegel, associate chair of psychiatry and behavioral sciences at Stanford University School of Medicine. "The key finding is that psychotherapy for depression for gravely ill cancer patients works."
Spiegel, an expert on therapy in cancer patients, was not involved in the Cochrane review, although he was the lead investigator on one included study of this therapy.
The review comprised results from six randomized controlled trials, including 517 patients - all with incurable cancer and symptoms of depression. The treatments were primarily supportive expressive group therapies, in which patients were encouraged to discuss their deepest fears and feelings and help one another cope with them.
One study looked at cognitive behavioral group therapy, a treatment that explores how thoughts affect emotions and behavior, and focuses on depressive thinking patterns. Participants in control groups received alternate interventions such as receiving with educational materials.
The review excluded four other trials because of what Spiegel believes to be overly strict inclusion criteria. Reviewers rate various measures of quality and disqualify studies that fail to meet a certain number.
One standard is that both the patient and the health care provider must be "blinded" as to which treatment is being given, which is impossible in trials of psychotherapy. "If the therapist were blind to the treatment," Spiegel said, "he wouldn't administer it very well. If anything, they were a bit too stringent in which studies they accepted."
Although the reviewed studies did not involve diagnosing patients with depression, they looked at patients' experiences of the characteristic symptoms of the disorder, including problems with eating and sleeping, inability to take pleasure in positive experiences and thoughts of despair.
"You can explain away a lot of the symptoms," Spiegel said, giving the example of loss of appetite, often attributed to chemotherapy side effects. As a result, many physicians do not look for depression in advanced cancer patients - or consider it a normal and untreatable response to their conditions. "Doctors think, 'Well, of course she's depressed - she's dying of breast cancer,'" he said.
In fact, only about 25 percent of cancer patients with incurable disease have a depressive response to the disorder, which is distinct from the experience of grief, sadness and anger that naturally comes from facing death.
"Depression and existential dread or sadness is not the same thing," Spiegel said. "Patients with depression feel hopeless, helpless and worthless. They feel like a burden to others."
Although the review also looked for effects of psychotherapy on anxiety, the therapy did not produce significant improvement. Both Akechi and Spiegel say that this is probably not because the therapy did not help with anxiety, but because the small number of subjects did not give the research enough statistical power to demonstrate an effect.
The review did not explore whether therapy could improve survival or response to cancer treatment. Other research on this question has produced mixed results.