The Corpus Callosum

“Doctors think, ‘Well, of course
she’s depressed — she’s dying of breast
cancer,’” he said.

I do see that kind of response sometimes, not just with regard to
terminally ill patients.  The physician does not think the
depression should be treated, because it is felt to be an expected
response to the situation.

If I even show up in an emergency department with a gunshot wound in my
abdomen, I sure hope the doc doesn’t refuse to treat it, saying “of
course he’s bleeding to death, he’s been shot in the spleen.”

The fact is, some patients with terminal cancer do develop major
depression.  But it is not inevitable.  It happens in
only about 25% of such patients.  

Plus, the cause of the condition does not matter.  If the
condition is present, and causes a problem, and the patient wants
something done, then it should be treated.  An update to a
Cochrane Review on the subject shows that psychotherapy can be an
effective treatment for depression in terminally ill cancer patients.
 Moreover, psychotherapy is comparable in effectiveness to
antidepressant medication.

I saw a reference to this finding in a href="http://www.hbns.org/getDocument.cfm?documentID=1689">news
release from the Center for the Advancement of Health.
 When I went to the Cochrane site, there was a message saying
“The Cochrane Library is being updated today with the latest issue.
Please note that you may experience difficulties viewing articles or
performing searches…”  I was not able to find the actual
report; only the abstract for the study protocol was available.

Still, the bottom-line conclusion is what is important.  

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.

Dr. Spiegel may lack objectivity on the matter.  But the
Cochrane review process is designed carefully to eliminate as much bias
as possible.  The conclusions of such reviews generally are
held to be valid.  If something does not work, or if the
evidence is insufficient to warrant a conclusion, they will say so.

Comments

  1. #1 stumpy
    April 16, 2008

    I remember once, long ago, seeing a patient in a nursing home because she tripped the OBRA requirements for a psychiatric evaluation. She was 99 years old, had a history of recurrent major depression, and met criteria for that diagnosis at the time that I saw her. Unfortunately, one of her symptoms was decreased appetite and, altho she had no other life-threatening medical conditions (apart from advanced age), she had lost so much weight as a consequence of the depression that she ended up dying from that. In fact, the cause of death was listed as starvation. Altho the patient said that she wanted help, and wanted to get better, the family doc caring for her was so incensed at my “meddling” — and having the temerity to suggest the patient take the antidepressant (nortriptyline) that had worked for her in the past — that she (the fMD) lodged a complaint against me with the coordinator of the OBRA program. The family doc neglected to treat a correctable condition, with the consequence that the patient suffered unnecessarily and ended up dying. An extreme example of the phenomenon you mention at the start of this excellent posting.

  2. #2 D
    April 17, 2008

    Plus, the cause of the condition does not matter. If the condition is present, and causes a problem, and the patient wants something done, then it should be treated.

    Have we really come to the point where being upset because you’re fricking dying automatically medicalizes to “depression” that needs “treatment”?

  3. #3 Joseph j7uy5
    April 17, 2008

    D:

    No. You are completely missing the point. Read the post again, this time look at the numbers. If you still have a serious objection, post a comment with your real name, and I will tactfully point out the error in your reasoning.

  4. #4 D
    April 17, 2008

    I prefer to maintain a certain decoupling between online and real life, if you don’t mind. If you do, please feel free to ignore the following.

    The only number I see in your post is 25%. Is that what you mean, the fact that only one in four are very depressed? To be perfectly honest, I don’t see the relevance of that, or of the fact that said depression is treatable, to my point.

    After all, you’d probably find similar numbers in people who’ve recently lost a loved one. Should one in four people who’ve lost a parent or a spouse also receive treatment (probably quite effective) to “cure” them of depression?

  5. #5 outeast
    April 17, 2008

    D, it’s not my place to say this really, but the post reads:

    If the condition is present, and causes a problem, and the patient wants something done, then it should be treated. (my emphasis)

    That’s not really what I would call ‘automatic medicalization’. But the bottom line is: depression is hell, regardless of its causes. If something helps, and if the patient wants that help, should it not be used?

  6. #6 stumpy
    April 17, 2008

    An important point, that D might be missing, is that there is a difference between the illness of major depression, and the transient emotional experience of depressed mood. Altho depressed or sad mood is one necessary criterion for the diagnosis of major depression, it is not sufficient for the diagnosis. Depressed mood alone should not be “medicalized”, but major depression should generally be treated — either with medications or (as in the paper referred to in this posting) with psychotherapy.

  7. #7 D
    April 17, 2008

    outeast –

    1. perhaps the dispositional difference between us is revealed in the bit I quoted that you didn’t: Plus, the cause of the condition does not matter. I emphatically think it *does* matter why a person is depressed (using here the term colloquially, as I suspect you were. See below)

    2. regardless of its causes. If something helps, and if the patient wants that help, should it not be used?

    I don’t think so. I’ve never been dying, but I have lost people close to me, and shouldn’t be surprised if I was above the 75th percentile of grief-sadness at least some of the time. It seems peculiarly dehumanizing to say that an emotion similar to such grief is a medical condition in one out of four – even if the grieving person wants to say as much. The idea seems of a piece with the positively scary notion that any emotion dissonant with bliss is ipso facto Bad.

    In any case, I fail to see why the question you asked has a *medical* answer. Surely doctors are no more qualified to answer it than anyone else!

    stumpy -

    Certainly I grasp this distinction – if nothing else, we all know at least second hand someone who’s clinically depressed. Obviously I don’t disagree that there is fear of imminent death on the one hand and clinical depression on the other, and I have no doubt whatsoever that for some the issue is the latter, but I’m inclined to doubt a diagnosis that says – apparently without incredulity – that the latter happens something like 25% of the time in people who know they are about to cease to be. Are we really saying 25% of all people who’re dying have a psychiatric condition that consists (crudely) in their not being happy about that fact?

    I can’t help feeling this grotesquely bloated number comes from refusing to acknowledge that “being able to function” is a bit of a different proposition for a dying guy than for others…

  8. #8 Hyperion
    April 17, 2008

    One other thing I’d be interested to see is a study looking at depression rates compared to the rate of adequate pain relief in terminal cancer patients. Use of painkillers is and likely always be a difficult topic in medicine, and it would be interesting to see if there is any interrelation between depression and pain relief. Excessive chronic pain can lead to depressive symptoms, but on the other hand, depression could easily lower pain tolerance. Finally, might painkillers in and of themselves have some antidepressant activity, or conversely, might antidepressants increase the effectiveness of some painkillers?

    On the other hand, there could be little or no correlation whatsoever. It’s also possible that in 10 or 20 years, the use of antidepressants in terminal patients will be considered part of palliative care just as pain management is.

  9. #9 stumpy
    April 17, 2008

    D makes a number of worthwhile points — too many for me to address right now. Let me just address one: It may be that the 25% figure is bloated, as he puts it. It is sometimes difficult to distinguish between a major medical condition (including terminal illness) and major depression, since many signs and symptoms can overlap between the two. However, in my experience, it’s a moot point. The reason is, as the author of the post mentions, that the cause of the condition (depression) does not matter. The author might have continued to say that the reason the cause of the condition does not matter is that, as long as the condition (major depression) exists — as defined by DSM or other externally verifiable criteria — the chances that the symptoms of the illness of depression will improve, with a given treatment, are independent of the cause of the depression. I don’t think that this is such a difficult concept to understand, except that, for many of us, it flies in the face of our long-held prejudices about depression, ie, that depression is not a physical illness.

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