Efficacy and acceptability of antidepressants on the continuum of depressive experiences in patients with cancer: Systematic review and meta-analysis

Feasibility and acceptability of a remote physical activity intervention coupled with short text messages in women with breast cancer and severe depressive or anxiety symptoms

PURPOSE

To test the feasibility and acceptability of a remote physical activity (PA) intervention coupled with motivational text messages among women experiencing severe depressive and/or anxiety symptoms during or after breast cancer (BC) treatment.

METHODS AND MATERIALS

A three-phase-single-case experimental study design (16-week) was conducted among 18 women diagnosed with BC reporting high levels of depressive and anxiety symptoms. Our intervention included behaviour change techniques (BCTs) and 2-3 supervised PA sessions per week, for at least 30 min, coupled with 4-7 weekly personalised text messages. Feasibility (satisfaction and drop-out rates), acceptability (participation rates, therapeutic alliance, and qualitative data), fidelity (quality of BCTs delivered), and the efficacy on PA level and physical fitness were assessed.

RESULTS

Participants expressed high satisfaction and reported an excellent working alliance with their kinesiologist. Notably, there was a very high participation rate (90%) along with a low dropout rate (11%). However, only 3 patients significantly increased their PA post-intervention.

CONCLUSION

This study highlighted the importance to personalise remote PA interventions for women with BC and severe depressive or anxiety symptoms. The combination of a remote PA intervention with daily text messages appears to be very suitable to increase their adherence.

Exercise Interventions for Depression, Anxiety, and Quality of Life in Older Adults With Cancer: A Systematic Review and Meta-Analysis

Importance

Cancer and its treatment negatively impact the mental health of older adults. The potential of exercise interventions as a complementary treatment to alleviate the psychological impacts of cancer is promising, but there are gaps in the current literature.

Objective

To determine if exercise interventions are associated with improvements in psychological outcomes among older adults with cancer.

Data Sources

PubMed, Embase, PsycINFO, and Cochrane databases were searched from database inception to November 5, 2024. Search terms used were geriatrics, cancer, depression, anxiety, quality of life, and exercise interventions.

Study Selection

English-language randomized clinical trials (RCTs) that analyzed the association of various exercise interventions with at least 1 of 3 psychological outcomes (depression, anxiety, or health-related quality-of-life [HRQOL]) were included. The control groups were given usual care. Studies were included if the mean age of participants was older than 60 years and had participants with a diagnosis of any cancer regardless of comorbidities.

Data Extraction and Synthesis

Studies were screened, and data were extracted by 2 independent authors. Random-effects meta-analyses and meta-regressions were used for analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was followed.

Main Outcomes and Measures

The primary outcomes were depression, anxiety, and HRQOL. Standardized mean difference (SMD) was used to quantify the association of exercise interventions with outcomes.

Results

A total of 27 RCTs with 1929 participants were included. Meta-analyses observed an association of exercise with a significant reduction in levels of depression (SMD = -0.53; 95% CI, -0.79 to -0.28) and anxiety (SMD = -0.39; 95% CI, -0.66 to -0.12) and improvements in overall HRQOL (SMD = 0.63; 95% CI, 0.10 to 1.17). Subgroup analyses revealed that mind-body exercise interventions were significantly associated with improved depression (SMD = -0.89; 95% CI, -1.51 to -0.27) and anxiety levels (SMD = -0.77; 95% CI, -1.54 to -0.01) compared with conventional exercise interventions.

Conclusion

In this systematic review and meta-analysis of 27 RCTs, exercise interventions were found to be associated with significantly reduced levels of depression and anxiety and significantly improved HRQOL in older adults with cancer. These findings suggest that health care professionals and policymakers should focus more on implementing exercise interventions to improve mental health outcomes in this vulnerable population.

Efficacy and Safety of Antidepressants in Patients With Comorbid Depression and Medical Diseases: An Umbrella Systematic Review and Meta-Analysis

Importance

Every third to sixth patient with medical diseases receives antidepressants, but regulatory trials typically exclude comorbid medical diseases. Meta-analyses of antidepressants have shown small to medium effect sizes, but generalizability to clinical settings is unclear, where medical comorbidity is highly prevalent.

Objective

To perform an umbrella systematic review of the meta-analytic evidence and meta-analysis of the efficacy and safety of antidepressant use in populations with medical diseases and comorbid depression.

Data Sources

PubMed and EMBASE were searched from inception until March 31, 2023, for systematic reviews with or without meta-analyses of randomized clinical trials (RCTs) examining the efficacy and safety of antidepressants for treatment or prevention of comorbid depression in any medical disease.

Study Selection

Meta-analyses of placebo- or active-controlled RCTs studying antidepressants for depression in individuals with medical diseases.

Data Extraction and Synthesis

Data extraction and quality assessment using A Measurement Tool for the Assessment of Multiple Systematic Reviews (AMSTAR-2 and AMSTAR-Content) were performed by pairs of independent reviewers following PRISMA guidelines. When several meta-analyses studied the same medical disease, the largest meta-analysis was included. Random-effects meta-analyses pooled data on the primary outcome (efficacy), key secondary outcomes (acceptability and tolerability), and additional secondary outcomes (response and remission).

Main Outcomes and Measures

Antidepressant efficacy presented as standardized mean differences (SMDs) and tolerability (discontinuation for adverse effects) and acceptability (all-cause discontinuation) presented as risk ratios (RRs).

Results

Of 6587 references, 176 systematic reviews were identified in 43 medical diseases. Altogether, 52 meta-analyses in 27 medical diseases were included in the evidence synthesis (mean [SD] AMSTAR-2 quality score, 9.3 [3.1], with a maximum possible of 16; mean [SD] AMSTAR-Content score, 2.4 [1.9], with a maximum possible of 9). Across medical diseases (23 meta-analyses), antidepressants improved depression vs placebo (SMD, 0.42 [95% CI, 0.30-0.54]; I2 = 76.5%), with the largest SMDs for myocardial infarction (SMD, 1.38 [95% CI, 0.82-1.93]), functional chest pain (SMD, 0.87 [95% CI, 0.08-1.67]), and coronary artery disease (SMD, 0.83 [95% CI, 0.32-1.33]) and the smallest for low back pain (SMD, 0.06 [95% CI, 0.17-0.39]) and traumatic brain injury (SMD, 0.08 [95% CI, -0.28 to 0.45]). Antidepressants showed worse acceptability (24 meta-analyses; RR, 1.17 [95% CI, 1.02-1.32]) and tolerability (18 meta-analyses; RR, 1.39 [95% CI, 1.13-1.64]) compared with placebo. Antidepressants led to higher rates of response (8 meta-analyses; RR, 1.54 [95% CI, 1.14-1.94]) and remission (6 meta-analyses; RR, 1.43 [95% CI, 1.25-1.61]) than placebo. Antidepressants more likely prevented depression than placebo (7 meta-analyses; RR, 0.43 [95% CI, 0.33-0.53]).

Conclusions and Relevance

The results of this umbrella systematic review of meta-analyses found that antidepressants are effective and safe in treating and preventing depression in patients with comorbid medical disease. However, few large, high-quality RCTs exist in most medical diseases.

Comorbidity between major depressive disorder and physical diseases: a comprehensive review of epidemiology, mechanisms and management

Populations with common physical diseases - such as cardiovascular diseases, cancer and neurodegenerative disorders - experience substantially higher rates of major depressive disorder (MDD) than the general population. On the other hand, people living with MDD have a greater risk for many physical diseases. This high level of comorbidity is associated with worse outcomes, reduced adherence to treatment, increased mortality, and greater health care utilization and costs. Comorbidity can also result in a range of clinical challenges, such as a more complicated therapeutic alliance, issues pertaining to adaptive health behaviors, drug-drug interactions and adverse events induced by medications used for physical and mental disorders. Potential explanations for the high prevalence of the above comorbidity involve shared genetic and biological pathways. These latter include inflammation, the gut microbiome, mitochondrial function and energy metabolism, hypothalamic-pituitary-adrenal axis dysregulation, and brain structure and function. Furthermore, MDD and physical diseases have in common several antecedents related to social factors (e.g., socioeconomic status), lifestyle variables (e.g., physical activity, diet, sleep), and stressful live events (e.g., childhood trauma). Pharmacotherapies and psychotherapies are effective treatments for comorbid MDD, and the introduction of lifestyle interventions as well as collaborative care models and digital technologies provide promising strategies for improving management. This paper aims to provide a detailed overview of the epidemiology of the comorbidity of MDD and specific physical diseases, including prevalence and bidirectional risk; of shared biological pathways potentially implicated in the pathogenesis of MDD and common physical diseases; of socio-environmental factors that serve as both shared risk and protective factors; and of management of MDD and physical diseases, including prevention and treatment. We conclude with future directions and emerging research related to optimal care of people with comorbid MDD and physical diseases.

Marasmius androsaceus mitigates depression-exacerbated intestinal radiation injuries through reprogramming hippocampal miRNA expression

INTRODUCTION

Cancer patients commonly experience high levels of psychological stress, which poses significant risks to their well-being. Radiotherapy is a primary treatment modality for cancer; however, it often leads to intestinal injuries in these patients. Nevertheless, the impact of mental stress on radiotherapy-intertwined complications remains unclear.

METHODS

To induce intestinal injury, we employed total abdominal irradiation in our experimental model. We conducted high-throughput sequencing to analyze the expression profile of miRNAs in the hippocampus.

RESULTS

We observed that mice with depression exhibited more severe intestinal injuries following total abdominal irradiation. Remarkably, oral administration of Marasmius androsaceus not only alleviated the depressive phenotype but also mitigated radiation-induced intestinal toxicity. Notably, this radioprotective effect was not observed in mice without depression. Depression disrupted the hippocampal miRNA expression profile in mice subjected to local irradiation of the abdomen, leading to the accumulation of miR-139-5p and miR-184-3p in the hippocampus, serum, and small intestine tissues. However, treatment with Marasmius androsaceus reprogrammed the miRNA expression signature in mice with depression. Furthermore, intravenous injection of antagomirs targeting miR-139-5p and miR-184-3p ameliorated depression, up-regulated Spn expression, reduced radiation enteritis, and improved the integrity of the small intestine in irradiated mice.

CONCLUSION

Our findings demonstrate the efficacy of Marasmius androsaceus, a small mushroom, in alleviating depression-aggravated intestinal toxicity following radiotherapy by reprogramming hippocampal miRNA expression.

Anxiety and depression in adult cancer patients: ESMO Clinical Practice Guideline

•Anxiety and depressive disorders are common in patients with cancer. •A higher prevalence seen in patients with cancer than the general population is often underrecognised. •Psychotherapy, cognitive behavioural therapy and mindfulness-based therapies are effective treatments. •Psychopharmacological treatments have been shown to be effective treatments of anxiety and depressive disorders.

Antidepressants for the treatment of depression in people with cancer

BACKGROUND

Major depression and other depressive conditions are common in people with cancer. These conditions are not easily detectable in clinical practice, due to the overlap between medical and psychiatric symptoms, as described by diagnostic manuals such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD). Moreover, it is particularly challenging to distinguish between pathological and normal reactions to such a severe illness. Depressive symptoms, even in subthreshold manifestations, have a negative impact in terms of quality of life, compliance with anticancer treatment, suicide risk and possibly the mortality rate for the cancer itself. Randomised controlled trials (RCTs) on the efficacy, tolerability and acceptability of antidepressants in this population are few and often report conflicting results.

OBJECTIVES

To evaluate the efficacy, tolerability and acceptability of antidepressants for treating depressive symptoms in adults (aged 18 years or older) with cancer (any site and stage).

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was November 2022.

SELECTION CRITERIA

We included RCTs comparing antidepressants versus placebo, or antidepressants versus other antidepressants, in adults (aged 18 years or above) with any primary diagnosis of cancer and depression (including major depressive disorder, adjustment disorder, dysthymic disorder or depressive symptoms in the absence of a formal diagnosis).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was 1. efficacy as a continuous outcome. Our secondary outcomes were 2. efficacy as a dichotomous outcome, 3. Social adjustment, 4. health-related quality of life and 5. dropouts. We used GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

We identified 14 studies (1364 participants), 10 of which contributed to the meta-analysis for the primary outcome. Six of these compared antidepressants and placebo, three compared two antidepressants, and one three-armed study compared two antidepressants and placebo. In this update, we included four additional studies, three of which contributed data for the primary outcome. For acute-phase treatment response (six to 12 weeks), antidepressants may reduce depressive symptoms when compared with placebo, even though the evidence is very uncertain. This was true when depressive symptoms were measured as a continuous outcome (standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.92 to -0.12; 7 studies, 511 participants; very low-certainty evidence) and when measured as a proportion of people who had depression at the end of the study (risk ratio (RR) 0.74, 95% CI 0.57 to 0.96; 5 studies, 662 participants; very low-certainty evidence). No studies reported data on follow-up response (more than 12 weeks). In head-to-head comparisons, we retrieved data for selective serotonin reuptake inhibitors (SSRIs) versus tricyclic antidepressants (TCAs) and for mirtazapine versus TCAs. There was no difference between the various classes of antidepressants (continuous outcome: SSRI versus TCA: SMD -0.08, 95% CI -0.34 to 0.18; 3 studies, 237 participants; very low-certainty evidence; mirtazapine versus TCA: SMD -4.80, 95% CI -9.70 to 0.10; 1 study, 25 participants). There was a potential beneficial effect of antidepressants versus placebo for the secondary efficacy outcomes (continuous outcome, response at one to four weeks; very low-certainty evidence). There were no differences for these outcomes when comparing two different classes of antidepressants, even though the evidence was very uncertain. In terms of dropouts due to any cause, we found no difference between antidepressants compared with placebo (RR 0.85, 95% CI 0.52 to 1.38; 9 studies, 889 participants; very low-certainty evidence), and between SSRIs and TCAs (RR 0.83, 95% CI 0.53 to 1.22; 3 studies, 237 participants). We downgraded the certainty of the evidence because of the heterogeneous quality of the studies, imprecision arising from small sample sizes and wide CIs, and inconsistency due to statistical or clinical heterogeneity.

AUTHORS' CONCLUSIONS

Despite the impact of depression on people with cancer, the available studies were few and of low quality. This review found a potential beneficial effect of antidepressants against placebo in depressed participants with cancer. However, the certainty of evidence is very low and, on the basis of these results, it is difficult to draw clear implications for practice. The use of antidepressants in people with cancer should be considered on an individual basis and, considering the lack of head-to-head data, the choice of which drug to prescribe may be based on the data on antidepressant efficacy in the general population of people with major depression, also taking into account that data on people with other serious medical conditions suggest a positive safety profile for the SSRIs. Furthermore, this update shows that the usage of the newly US Food and Drug Administration-approved antidepressant esketamine in its intravenous formulation might represent a potential treatment for this specific population of people, since it can be used both as an anaesthetic and an antidepressant. However, data are too inconclusive and further studies are needed. We conclude that to better inform clinical practice, there is an urgent need for large, simple, randomised, pragmatic trials comparing commonly used antidepressants versus placebo in people with cancer who have depressive symptoms, with or without a formal diagnosis of a depressive disorder.

Relevance of Diagnosed Depression and Antidepressants to PROMIS Depression Scores Among Hand Surgical Patients

PURPOSE

We aimed to test the utility of screening for depressive symptoms in the hand surgical office focusing on chances of heightened depressive symptoms in patients with no history of diagnosed depression and by quantifying ongoing depressive symptoms among patients diagnosed with depression accounting for antidepressant use. The clinical importance of this study was predicated on the documented negative association between depressive symptoms and hand surgical outcomes.

METHODS

This cross-sectional study analyzed 351 patients presenting to a tertiary hand center between April 21, 2016, and November 22, 2017. Adult patients completed self-administered Patient-Reported Outcomes Measurement Information System (PROMIS) Depression computer adaptive tests at registration. Health records were examined for a past medical history of diagnosed depression and whether patients reported current use of prescription antidepressants. Mean PROMIS Depression scores were compared by analysis of variance (groups: no diagnosed depression, depression without medication, depression with medication). Four points represented a clinically relevant difference in PROMIS Depression scores between groups and Depression scores greater than 59.9 were categorized as having heightened depressive symptoms.

RESULTS

Sixty-two patients (18%) had been diagnosed with depression. Thirty-four of these patients (55%) reported taking antidepressant medications. The PROMIS Depression scores indicated greater current depressive symptoms among patients with a history of diagnosed depression when not taking antidepressants (11 points worse than unaffected) and also among patients taking antidepressants (7 points worse than unaffected). Heightened depressive symptoms were detected in all groups but were more prevalent among those diagnosed with depression (36% with no medication, 29% with antidepressant medication) compared with unaffected patients (7%).

CONCLUSIONS

Depression screening for heightened depressive symptoms identifies 1 in 14 patients without diagnosed depression and 1 in 3 patients diagnosed with depression as having currently heightened depressive symptoms. Hand surgeons can use PROMIS Depression screening in all patients and using this to guide referrals for depression treatment to ameliorate one confounder of hand surgical outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Symptom prevalence study II.

Beyond pain: can antidepressants improve depressive symptoms and quality of life in patients with neuropathic pain? A systematic review and meta-analysis

Neuropathic pain can be a predictor of severe emotional distress, up to full-blown depressive states. In these patients, it is important to move beyond the sole treatment of pain, to recognize depressive symptoms, and to ultimately improve the quality of life. We systematically searched for published and unpublished clinical trials assessing the efficacy and tolerability of antidepressants vs placebo on depression, anxiety and quality of life in patients with neuropathic pain, and pooled data in a meta-analysis. A total of 37 studies fulfilled eligibility criteria and 32 provided data for meta-analysis. Antidepressants were more effective than placebo in improving depressive symptoms (standardized mean difference -0.11; 95% confidence interval -0.20 to -0.02), although the magnitude of effect was small, with a number needed to treat of 24. No significant difference emerged between antidepressants and placebo in reducing anxiety. Quality of life seemed improved in patients on antidepressants, as did pain. Acceptability and tolerability were higher in patients on placebo. To the best of our knowledge, this is the first meta-analysis specifically focusing on the effect of antidepressants on psychiatric symptoms and quality of life in patients with neuropathic pain. Our findings suggest that despite their potential benefit in patients with neuropathic pain, antidepressants should be prescribed with particular care because they might be less tolerable in such a fragile population. However, our findings warrant further research to explore how a correct use of antidepressants can help patients to cope with the consequences of neuropathic pain on their psychosocial health and quality of life.

Comorbid depression in medical diseases

Depression is one of the most common comorbidities of many chronic medical diseases including cancer and cardiovascular, metabolic, inflammatory and neurological disorders. Indeed, the prevalence of depression in these patient groups is often substantially higher than in the general population, and depression accounts for a substantial part of the psychosocial burden of these disorders. Many factors can contribute to the occurrence of comorbid depression, such as shared genetic factors, converging biological pathways, social factors, health behaviours and psychological factors. Diagnosis of depression in patients with a medical disorder can be particularly challenging owing to symptomatic overlap. Although pharmacological and psychological treatments can be effective, adjustments may need to be made for patients with a comorbid medical disorder. In addition, symptoms or treatments of medical disorders may interfere with the treatment of depression. Conversely, symptoms of depression may decrease adherence to treatment of both disorders. Thus, comprehensive treatment plans are necessary to optimize care.

A potential role for psilocybin in the treatment of obsessive-compulsive disorder

The recent revivification of interest in the therapeutic use of psychedelics has had a particular focus on mood disorders and addiction, although there is reason to think these drugs may be effective more widely. After outlining pertinent aspects of psilocybin and obsessive-compulsive disorder (OCD), the current review summarizes the evidence indicating that there may be a role for psilocybin in the treatment of OCD, as well as highlighting a range of potential therapeutic mechanisms that reflect the action of psilocybin on brain function. Although the current evidence is limited, that multiple signals point in directions consistent with treatment potential, alongside the psychological and physiological safety of clinically administered psilocybin, support the expansion of research, both in animal models and in further randomized controlled trials, to properly investigate this potential.

Psychiatric comorbidities in cancer patients: acute interventions by the psychiatric consultation liaison service

AIM

The aim of this study was to explore the psychiatric comorbidities in cancer patients examined by the psychiatric consultation liaison services (CLP) in a general hospital. Furthermore, we intended to examine associations between certain cancers types and psychiatric disorders as well as to give an overview of the psychiatric treatments options that were recommended by the CLP.

METHODS

This retrospective analysis investigated 119 psychiatric consultations for cancer patients in a one year period. The assessment covered demographics and cancer diagnosis, psychiatric diagnosis and proceedings.

RESULTS

One third of all patients were treated for hematological cancer, followed by lung cancer. Depression was the most common psychiatric disorder. One third of all patients with hematological cancer were diagnosed with depression, followed by delirium. Inpatient psychiatric treatment and psychotherapy were most commonly recommended by the consultant psychiatrist. Furthermore, 80.2% of all patients received recommendations for medication with antidepressants.

CONCLUSION

Our data showed that the CLP provides an important service of detecting and initiating early and appropriate treatment for cancer patients with comorbid psychiatric disorders by directing patients to the relevant treatment procedure or facility.

Long-term follow-up of psilocybin-assisted psychotherapy for psychiatric and existential distress in patients with life-threatening cancer

BACKGROUND

A recently published randomized controlled trial compared single-dose psilocybin with single-dose niacin in conjunction with psychotherapy in participants with cancer-related psychiatric distress. Results suggested that psilocybin-assisted psychotherapy facilitated improvements in psychiatric and existential distress, quality of life, and spiritual well-being up to seven weeks prior to the crossover. At the 6.5-month follow-up, after the crossover, 60-80% of participants continued to meet criteria for clinically significant antidepressant or anxiolytic responses.

METHODS

The present study is a long-term within-subjects follow-up analysis of self-reported symptomatology involving a subset of participants that completed the parent trial. All 16 participants who were still alive were contacted, and 15 participants agreed to participate at an average of 3.2 and 4.5 years following psilocybin administration.

RESULTS

Reductions in anxiety, depression, hopelessness, demoralization, and death anxiety were sustained at the first and second follow-ups. Within-group effect sizes were large. At the second (4.5 year) follow-up approximately 60-80% of participants met criteria for clinically significant antidepressant or anxiolytic responses. Participants overwhelmingly (71-100%) attributed positive life changes to the psilocybin-assisted therapy experience and rated it among the most personally meaningful and spiritually significant experiences of their lives.

CONCLUSION

These findings suggest that psilocybin-assisted psychotherapy holds promise in promoting long-term relief from cancer-related psychiatric distress. Limited conclusions, however, can be drawn regarding the efficacy of this therapy due to the crossover design of the parent study. Nonetheless, the present study adds to the emerging literature base suggesting that psilocybin-facilitated therapy may enhance the psychological, emotional, and spiritual well-being of patients with life-threatening cancer.

Depression and anxiety among people living with and beyond cancer: a growing clinical and research priority

Background

A cancer diagnosis can have a substantial impact on mental health and wellbeing. Depression and anxiety may hinder cancer treatment and recovery, as well as quality of life and survival. We argue that more research is needed to prevent and treat co-morbid depression and anxiety among people with cancer and that it requires greater clinical priority. For background and to support our argument, we synthesise existing systematic reviews relating to cancer and common mental disorders, focusing on depression and anxiety.

We searched several electronic databases for relevant reviews on cancer, depression and anxiety from 2012 to 2019. Several areas are covered: factors that may contribute to the development of common mental disorders among people with cancer; the prevalence of depression and anxiety; and potential care and treatment options. We also make several recommendations for future research. Numerous individual, psychological, social and contextual factors potentially contribute to the development of depression and anxiety among people with cancer, as well as characteristics related to the cancer and treatment received. Compared to the general population, the prevalence of depression and anxiety is often found to be higher among people with cancer, but estimates vary due to several factors, such as the treatment setting, type of cancer and time since diagnosis. Overall, there are a lack of high-quality studies into the mental health of people with cancer following treatment and among long-term survivors, particularly for the less prevalent cancer types and younger people. Studies that focus on prevention are minimal and research covering low- and middle-income populations is limited.

Conclusion

Research is urgently needed into the possible impacts of long-term and late effects of cancer treatment on mental health and how these may be prevented, as increasing numbers of people live with and beyond cancer.

Distress Management, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology

Distress is defined in the NCCN Guidelines for Distress Management as a multifactorial, unpleasant experience of a psychologic (ie, cognitive, behavioral, emotional), social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment. Early evaluation and screening for distress leads to early and timely management of psychologic distress, which in turn improves medical management. The panel for the Distress Management Guidelines recently added a new principles section including guidance on implementation of standards of psychosocial care for patients with cancer.

The use of antidepressants in oncology: a review and practical tips for oncologists

Background

The use of psychotropic drugs, namely those with an antidepressant profile (ADs), is a mandatory part of an integrated treatment of psychiatric disorders among cancer patients. We aimed to synthetize the most relevant data emerging from published studies to provide tips about the use of ADs in oncology.

Design

A search was made of the major databases over the last 30 years (Embase/Medline, PsycLIT, PsycINFO, the Cochrane Library), including narrative reviews, systematic reviews and meta-analyses summarizing the results from observational studies and randomized clinical trials assessing effectiveness, safety profile, interactions, contraindications and use of ADs in oncology with regard to both psychiatric (depressive spectrum, stress-related, anxiety disorders) and cancer-related symptoms (e.g. pain, hot flashes and fatigue).

Results

The weight of evidence supports the efficacy of ADs for more severe major depression in individuals with cancer and as an adjuvant treatment in cancer-related symptoms, although the methodological limitations of reported randomized controlled trials do not permit definite conclusions. Data also indicate that there should be caution in the use of ADs in cancer patients in terms of their safety profile and potential clinically significant interactions with other prescribed medications. Practical recommendations that have been made for the use of ADs in cancer patients, in the context of a multimodal approach to depression treatment, have been summarized here.

Conclusions

ADs are a relatively safe and effective treatment for more severe major depression in cancer patients. However, more research is urgently needed regarding the efficacy of ADs in different cancer types and cancer settings, their interactions with anticancer agents and their additive benefit when integrated with psychosocial interventions.

Efficacy and acceptability of antidepressants in patients with ischemic heart disease: systematic review and meta-analysis

To assess the efficacy and acceptability of antidepressants in adults with ischemic heart disease (IHD). We gathered all available randomized-controlled trials comparing antidepressants versus placebo or other antidepressants in adults with IHD. The primary outcome was depressive symptoms at the study endpoint, as measured by validated rating scales. We pooled data in a meta-analysis using a random-effects model. The confidence in the estimates (or certainty of the evidence) was assessed using the GRADE approach. Antidepressants appeared to be more effective than placebo in reducing depressive symptoms (11 comparisons; 1685 participants; standardized mean difference -0.71, 95% confidence interval: -1.11 to -0.30; GRADE quality: moderate). This result was confirmed in the subgroup of serotonin selective reuptake inhibitors, and for the single drugs sertraline and citalopram, with a greater magnitude of effect and a higher quality of evidence for the former. No differences between antidepressants and placebo emerged in terms of acceptability and tolerability, quality of life, mortality, and cardiovascular events. Only two small head-to-head studies were identified. Sertraline is a reasonable first-line choice in patients with IHD and depression, whereas the role of citalopram as the first-line agent should be reconsidered.

Maximizing New Technologies to Treat Depression

In an era of rapid technological evolution, mental healthcare providers are tapping into technology that offers feasible and effective alternatives to reach patients who suffer from depression. This paper provides a brief history and description of current technologies, frequently used taxonomies, and specific applications for the assessment and treatment of depression. These include online healthcare communities and social media, automated screening, wearable technology, and virtual reality therapy. A review of a secondary analysis that incorporated technology used with patients experiencing depressive symptoms is provided and future trends in mHealth or cellular-based technologies to treat depression are explored.

Purchases of antidepressants after cancer at a young age in Finland

According to previous studies, childhood cancer survivors have an elevated risk for late mental health effects. However, only few studies exist on young adulthood (YA) cancer survivors' mental health outcomes. In our study, we examined first time antidepressant (AD) medication purchases of childhood and YA cancer patients compared to siblings. The first time AD medication purchases of 7,093 cancer patients aged 0-34 years at diagnosis and a sibling cohort (N = 26,882) were retrieved from the Social Insurance Institution of Finland (Kela) since 1.1.1993. Cancer patients diagnosed between 1.1.1994 and 31.12.2004 were identified from the Finnish Cancer Registry and sibling controls via the Population Registry Centre. Statistical analyses were performed via the Cox regression model, and the hazard ratios (HR) were adjusted for age and gender. Increased hazard ratios for AD purchases were found in the younger (0-19 years at cancer diagnosis) [HR 5.2, 95%CI (3.7-7.2)] and older (age 20-34 years at cancer diagnosis) [HR 4.5, 95%CI (3.9-5.2)] cancer patient groups compared to siblings. The gender effect was similar in patients and controls, showing that females have higher risk for AD purchases than males. Males in the younger patient group had highest HR (5.6) for AD purchases compared to siblings. Patients with sarcoma or CNS tumor in the younger age group and leukemia or CNS malignancy in the older age group had the highest risk for AD medication purchases. The frequency and risk for AD purchases has been increasing during recent decades in both cancer patient age groups compared to siblings. Thus, cancer patients' psychological support should be properly assessed already after primary treatment. Certain diagnostic groups as well as female patients may require more psychological support than others.

Psychiatric, behavioral, and cognitive disorders in patients with extracranial cancers

Patients with cancer may report neuropsychiatric abnormalities including cognitive impairment, behavioral disturbances, and psychiatric disorders that potentially worsen their quality of life, reduce their treatment response, and aggravate their overall prognosis. Neuropsychiatric disturbances have a different pathophysiology, including immuno-inflammatory and neuroendocrine mechanisms, as a consequence of oncologic treatments (chemo- and radio-therapy). Among clinicians involved in the management of such patients, psychiatrists need to pay particular attention in recognizing behavioral disturbances that arise in oncologic patients, and determining those that may be effectively treated with psychotropic medications, psychotherapeutic interventions, and an integration of them. Through the contribution of different clinicians actively involved in the management of oncological patients, the present review is ultimately aimed at updating psychiatrists in relation to the pathophysiological mechanisms responsible for the onset of cognitive, affective, and behavioral syndromes in these patients, along with epidemiologic and clinical considerations and therapeutic perspectives.

Citalopram and group psychotherapy in breast cancer patients: A randomized clinical trial

Background: Depression is a common psychiatric disorder in breast cancer patients. This study was designed to evaluate the clinical efficacy of group psychotherapy on breast cancer patients with depressive disorder who took citalopram.

Methods: This clinical trial was conducted on 40 breast cancer patients with depressive disorder. The control group received citalopram 20-40 mg/ day for 12 weeks and the intervention group participated in 8 sessions of group psychotherapy in addition to the same dose of citalopram. At the baseline and 3, 6, and 12 weeks after treatment, patients were followed- up. Treatment outcomes and quality of life were compared between the 2 groups.

Results: Overall, the depression score of Hospital Anxiety and Depression Scale (HADS) at baseline with the mean of 11.6±1.6 was signed in the range of clinical depression and after intervention it declined to 8.8±3.6 (in the 3rd week), 7.1±3.9 (6th week), and 5.9±4.5 (12th week). Furthermore, HADS anxiety score at baseline with the mean of 12.6±2.6 was signed in the range of clinical anxiety and after intervention it declined to 9.1±3.0, 7.3±4.1, and 6.0±4.0, respectively. This improvement was significantly more in the combined therapy intervention group (p<0.001). The mean score of quality of life based on WHO QOL-BREF questionnaire increased by 1.85 fold in the case group, improved from 44.09 to 81.70, while the slight change was observed in the control group (p<0.001). During the treatment, no significant adverse drug event was observed in the 2 groups (p>0.05).

Conclusion: Group psychotherapy has a significant effect on improving depression, anxiety, and quality of life in breast cancer patients.

Antidepressants for the treatment of depression in people with cancer

BACKGROUND

Major depression and other depressive conditions are common in people with cancer. These conditions are not easily detectable in clinical practice, due to the overlap between medical and psychiatric symptoms, as described by diagnostic manuals such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD). Moreover, it is particularly challenging to distinguish between pathological and normal reactions to such a severe illness. Depressive symptoms, even in subthreshold manifestations, have been shown to have a negative impact in terms of quality of life, compliance with anti-cancer treatment, suicide risk and likely even the mortality rate for the cancer itself. Randomised controlled trials (RCTs) on the efficacy, tolerability and acceptability of antidepressants in this population are few and often report conflicting results.

OBJECTIVES

To assess the efficacy, tolerability and acceptability of antidepressants for treating depressive symptoms in adults (aged 18 years or older) with cancer (any site and stage).

SEARCH METHODS

We searched the following electronic bibliographic databases: the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 6), MEDLINE Ovid (1946 to June week 4 2017), Embase Ovid (1980 to 2017 week 27) and PsycINFO Ovid (1987 to July week 4 2017). We additionally handsearched the trial databases of the most relevant national, international and pharmaceutical company trial registers and drug-approving agencies for published, unpublished and ongoing controlled trials.

SELECTION CRITERIA

We included RCTs comparing antidepressants versus placebo, or antidepressants versus other antidepressants, in adults (aged 18 years or above) with any primary diagnosis of cancer and depression (including major depressive disorder, adjustment disorder, dysthymic disorder or depressive symptoms in the absence of a formal diagnosis).

DATA COLLECTION AND ANALYSIS

Two review authors independently checked eligibility and extracted data using a form specifically designed for the aims of this review. The two authors compared the data extracted and then entered data into Review Manager 5 using a double-entry procedure. Information extracted included study and participant characteristics, intervention details, outcome measures for each time point of interest, cost analysis and sponsorship by a drug company. We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We retrieved a total of 10 studies (885 participants), seven of which contributed to the meta-analysis for the primary outcome. Four of these compared antidepressants and placebo, two compared two antidepressants, and one three-armed study compared two antidepressants and placebo. In this update we included one additional unpublished study. These new data contributed to the secondary analysis, while the results of the primary analysis remained unchanged.For acute-phase treatment response (6 to 12 weeks), we found no difference between antidepressants as a class and placebo on symptoms of depression measured both as a continuous outcome (standardised mean difference (SMD) -0.45, 95% confidence interval (CI) -1.01 to 0.11, five RCTs, 266 participants; very low certainty evidence) and as a proportion of people who had depression at the end of the study (risk ratio (RR) 0.82, 95% CI 0.62 to 1.08, five RCTs, 417 participants; very low certainty evidence). No trials reported data on follow-up response (more than 12 weeks). In head-to-head comparisons we only retrieved data for selective serotonin reuptake inhibitors (SSRIs) versus tricyclic antidepressants, showing no difference between these two classes (SMD -0.08, 95% CI -0.34 to 0.18, three RCTs, 237 participants; very low certainty evidence). No clear evidence of a beneficial effect of antidepressants versus either placebo or other antidepressants emerged from our analyses of the secondary efficacy outcomes (dichotomous outcome, response at 6 to 12 weeks, very low certainty evidence). In terms of dropouts due to any cause, we found no difference between antidepressants as a class compared with placebo (RR 0.85, 95% CI 0.52 to 1.38, seven RCTs, 479 participants; very low certainty evidence), and between SSRIs and tricyclic antidepressants (RR 0.83, 95% CI 0.53 to 1.30, three RCTs, 237 participants). We downgraded the certainty (quality) of the evidence because the included studies were at an unclear or high risk of bias due to poor reporting, imprecision arising from small sample sizes and wide confidence intervals, and inconsistency due to statistical or clinical heterogeneity.

AUTHORS' CONCLUSIONS

Despite the impact of depression on people with cancer, the available studies were very few and of low quality. This review found very low certainty evidence for the effects of these drugs compared with placebo. On the basis of these results, clear implications for practice cannot be deduced. The use of antidepressants in people with cancer should be considered on an individual basis and, considering the lack of head-to-head data, the choice of which agent to prescribe may be based on the data on antidepressant efficacy in the general population of individuals with major depression, also taking into account that data on medically ill patients suggest a positive safety profile for the SSRIs. To better inform clinical practice, there is an urgent need for large, simple, randomised, pragmatic trials comparing commonly used antidepressants versus placebo in people with cancer who have depressive symptoms, with or without a formal diagnosis of a depressive disorder.

Potential prognostic value of clinical characteristics, hormone status and major depressive disorder in breast cancer

AIM

To identify independent factors predicting overall survival (OS) of breast cancer (BC) patients.

PATIENTS & METHODS

Two hundred and eighty one women with BC were recruited and clinical characteristics including lymphovascular invasion, clinical stage of Tumor Node Metastasis and positive axillary lymph nodes were documented; immunohistochemistry/fluorescence in situ hybridization was used to examine the expression of estrogen receptor, progesterone receptor, HER2 and Ki-67; major depressive disorder was assessed with Diagnostic and Statistical Manual of Mental Disorders V.

RESULTS

Multivariable analyses indicated that in BC patients, lymphovascular invasion, Tumor Node Metastasis, pN, Ki-67 and major depressive disorder were significantly negatively correlated with OS; estrogen receptor was significantly positively associated with OS.

CONCLUSION

Early diagnostic approaches and effective psychologic intervention are indispensable for BC patients.

Depressive Spectrum Disorders in Cancer: Diagnostic Issues and Intervention. A Critical Review

Depressive spectrum disorders, including major depression, persistent depression, minor and sub-syndromal depression, and other forms of depressive conditions, such as demoralization, are among the most common psychiatric consequences of cancer patients, affecting up to 60% of patients. In spite of the negative effects and the burden for cancer patients and their families, these disorders often remain under-recognized and undertreated. The present review aims at summarizing the relevant data concerning the diagnostic challenges within the depressive spectrum disorders among cancer patients. Also, the most relevant data relative to integrated intervention, including psychopharmacological and psychosocial treatment, for depression in cancer patients are critically evaluated. It is mandatory that health care professionals working in oncology (e.g., oncologists, surgeons, radiation oncologists, primary care physicians, nurses, social workers, psychologists) receive training in the diagnosis and integrated management of the different types of disorder within the spectrum of clinical depression.

Psychosocial interventions for post-traumatic stress disorder in refugees and asylum seekers resettled in high-income countries: Systematic review and meta-analysis

Treatment of post-traumatic stress disorder (PTSD) in refugees and asylum seekers resettled in high-income countries presents specific challenges. This systematic review examined the effectiveness of psychosocial interventions for this group. We searched the Cochrane Central Register of randomised trials, CINAHL, EMBASE, PILOTS, PsycINFO, PubMed and Web of Science up to July 2016. Studies included randomised and controlled clinical trials comparing psychosocial interventions with waiting list or treatment as usual in adult refugees and asylum seekers with PTSD resettled in high-income countries. PTSD symptoms post-intervention was the primary outcome. We computed standardized mean differences (SMD) with 95% confidence intervals (CI). This study is registered with PROSPERO: CRD42015027843. Twelve studies were included in the meta-analysis. Psychosocial interventions were effective in decreasing PTSD symptoms relative to control groups (SMD -1·03, 95% CI -1·55 to -0·51; number needed to treat 4·4; I2 86%; 95% CI 77 to 91). Narrative exposure therapy, a manualized short-term variant of cognitive behavioural therapy with a trauma focus, was the best-supported intervention (5 RCTs, 187 participants, SMD -0·78, 95% CI -1·18 to -0·38, I2 37%; 95% CI 0 to 77). Methodological quality of the included studies was limited. Overall, psychosocial interventions for asylum seekers and refugees with PTSD resettled in high-income countries were found to provide significant benefits in reducing PTSD symptoms. Yet, the number of studies is small and their methodological quality limited, so that more rigorous trials should be conducted in the future.

Management of Depression in Patients With Cancer: A Clinical Practice Guideline

PURPOSE

This report updates the Cancer Care Ontario Program in Evidence-Based Care guideline for the management of depression in adult patients with cancer. This guideline covers pharmacologic, psychological, and collaborative care interventions, with a focus on integrating practical management tools to assist clinicians in delivering appropriate treatments for depression in patients with cancer.

METHODS

Recommendations were developed by synthesizing information from extant guidelines and reviews and searching for randomized controlled trials from the date of database inception (1964 for MEDLINE and 1974 for EMBASE) to January 2015. Quality assessment of guidelines and systematic reviews were conducted by using the Appraisal of Guidelines for Research and Evaluation II (AGREE II), Assessment of Multiple Systematic Reviews (AMSTAR), and Cochrane Risk of Bias tools. Final recommendations were developed through a standardized Program in Evidence-Based Care multidisciplinary expert and knowledge user review process.

RESULTS

Two high-quality relevant clinical practice guidelines, eight pharmacologic trials, nine psychological trials, and eight collaborative care intervention trials composed the evidence base upon which the recommendations were developed. Eight specific recommendations were made to establish a standard of care for the management of depression in patients with cancer. The recommendations and practical management tools were reviewed as being well organized and helpful, although systemic barriers to implementation were identified.

CONCLUSION

This updated guideline supports the previous general recommendation that patients with cancer who have depression may benefit from psychological and/or pharmacologic interventions, without evidence for the superiority of any specific treatment over another. New recommendations for a collaborative care model that incorporates a stepped care approach suggest that multidisciplinary mental health care restructuring may be required for optimal management of depression.