Treat the Whole Patient

Can identifying and treating depression improve the quality or lengthen the life of patients with metastatic cancer?

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By the age of 24, Janine Giese-Davis had lost her father, uncle and husband to cancer and, over the years, she’d known many other people with cancer. Now a self-described “researcher and patient advocate,” these tragic experiences led her to pursue psychological research as a means of helping cancer patients and survivors.

“I’d been on many sides of people living and dying with cancer, and I felt that if I turned my career in that direction, I wouldn’t just be a researcher – I’d be someone who intimately knew the family standpoint and what might matter to regular people,” she says. She became a researcher and clinician at Stanford University’s Psychiatry Department and worked with many women with breast cancer in group and individual therapy. Now an associate professor in the Department of Oncology, Division of Psychosocial Oncology, at the University of Calgary, Giese-Davis found growing evidence that depression might negatively impact survival with cancer. She wanted to find out more.

A cancer diagnosis can trigger a depressive episode. It’s the start of an emotional journey that closely parallels the stages of grief. It begins with shock and disbelief, and gradually moves towards reconciliation with mortality and a greater sense of oneself. But how each person responds to the diagnosis can vary.

“Many people go on to live happier lives than they did before,” says Giese-Davis. Others, however, find themselves mired in depression, especially without the support of a counsellor, group therapy or an understanding family. And depression isn’t just unhealthy for the mind – it’s bad for the body, too. In a past-literature review, Giese-Davis and a colleague found that chronic or severe depression predicted early death in cancer patients; other studies confirm this.

Knowing that depression and death from cancer are correlated isn’t particularly helpful to clinicians or patients. What Giese-Davis found much more interesting – and relevant to patients – was the question of whether treating depression could help a person with cancer live longer.

This was the impetus for a recently published study she co-authored with Dr. David Spiegel, a well-known Stanford University psychiatrist, and a number of other clinicians, including Edmonton’s Dr. Kate Collie. The study followed 125 women with metastatic breast cancer living in the San Francisco Bay area. These women participated in group therapy.

Their study, published in the February 2011 issue of The Journal of Clinical Oncology, tracked the women for 14 years and found that decreasing their depression symptoms during the first year was associated with longer survival rates. While the study had a limited scope (breast cancer patients) and focused only on one intervention (group therapy), it’s good news for all cancer patients. Depression is an illness with a wide range of treatments, says Giese-Davis. “People can do many things to recover from depression, from taking anti-depressants, receiving support from friends and family, seeking therapy, going to church, exercising,” she says. “A lot of treatments are effective in decreasing depression levels.” This study found that it didn’t matter what patients did to reduce their depression, only that they reduced it over the first year from diagnosis.

This study is positive news for patients and their families, but isn’t license for loved ones or doctors to nag them to look on the bright side, Giese-Davis warns. “The frustrating thing for many patients is that they feel really afraid, angry and sad at first, and everyone around them is trying to get them to think positively. Usually it drives them deeper into their depression,” she says. “We don’t think you need to think positively, but if you are depressed, you need to seek help to resolve the depression.”

It’s only recently that the importance of the mental health care of cancer patients has come to the fore. Often, depression was considered par for the course, but today it is common for Canadian doctors to screen patients for signs of distress, says Giese-Davis, and many oncologists refer their patients to psychological services. But some still prefer to stick to medical issues, she says, maybe because they feel it’s outside of their area of expertise. However, for patients who aren’t inclined to seek treatment on their own, this can mean they’re not treated at all. “I think there are many more people who could benefit from some sort of therapy or support than seek it out,” says Giese-Davis.

Study co-author Collie hopes that this study will motivate more doctors to be on the lookout for signs of mental illness. “I want oncologists to be more sensitive to this,” she says, “and aware that treating or not treating depression could be a life-and-death matter.”

She thinks that this study, and others that demonstrate health outcomes associated with treating depression, will encourage medical professionals to be on the lookout for signs of depression. Putting mental health into the medical context “makes it a broader picture” – and perhaps something doctors can better relate to. “So, people who generally think about the physiological dimensions of cancer can be thinking about this too,” says Collie.

Collie points out that mental health care for cancer patients will also become a greater priority as more people are surviving cancer and the “culture” of care evolves.

“Cancer is now seen more as a chronic disease. That changes everything: it changes the amount of money being put into cancer research and research topics” Collie says. Assessing and, where necessary, treating patients for signs of depression may become another tool to help manage the disease and improve its outcomes.

Find out more! Giese-Davis’ study can be found in the Feb. 1, 2011, issue of The Journal of Oncology (Volume 29, Number 4). jco.ascopubs.org

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