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Diagnosed by psychiatric interview rather than questionnaire, depression affects about one in six people being treated for cancer: 16.3 per cent across 70 studies and 10,071 people. Years later the rate is no higher than in people who have not had cancer. The treatment with the largest trial behind it is nurse-delivered collaborative care, which tripled the response rate.
The number depends entirely on how the question is asked, and most quoted figures come from self-report questionnaires, which measure distress rather than diagnose illness. The meta-analysis that restricted itself to studies using psychiatric interviews is therefore the one to start from. In oncological and haematological settings it pooled 70 studies of 10,071 people in 14 countries: depression by diagnostic criteria in 16.3 per cent (95 per cent confidence interval 13.4 to 19.5), major depression in 14.9 per cent, minor depression in 19.2 per cent, adjustment disorder in 19.4 per cent, anxiety disorders in 10.3 per cent and dysthymia in 2.7 per cent. Because diagnoses overlap, all types of depression together came to 20.7 per cent, depression or adjustment disorder to 31.6 per cent and any mood disorder to 38.2 per cent. In palliative care settings, across 24 studies and 4,007 people, depression by diagnostic criteria was 16.5 per cent, major depression 14.3 per cent, adjustment disorder 15.4 per cent and anxiety disorders 9.8 per cent. The authors' conclusion is worth quoting because it cuts against the headline: "Interview-defined depression and anxiety is less common in patients with cancer than previously thought, although some combination of mood disorders occurs in 30-40% of patients in hospital settings without a significant difference between palliative-care and non-palliative-care settings. Clinicians should remain vigilant for mood complications, not just depression."
A second review applied quality filters as well as the interview requirement: random or consecutive sampling, a response rate of at least 70 per cent, a clear definition of caseness and at least 100 participants. Only 15 of 66 relevant studies met them. In those, estimated prevalence was 5 to 16 per cent in outpatients, 4 to 14 per cent in inpatients, 4 to 11 per cent in mixed samples and 7 to 49 per cent in palliative care, and studies using expert interviewers, psychiatrists or clinical psychologists, reported lower estimates than those using others.
Later on, the rate comes back down. A meta-analysis of people at least two years from diagnosis found depression in 11.6 per cent (7.7 to 16.2) of a pooled sample of 51,381 survivors against 10.2 per cent (8.0 to 12.6) of 217,630 healthy controls, a relative risk of 1.11 (0.96 to 1.27, p equals 0.17), which is to say no significant excess. The companion finding about anxiety is different and has its own record alongside this one.
Treatment. The largest randomised trial in this field tested a manualised programme called Depression Care for People with Cancer, delivered by cancer nurses and psychiatrists working with the patient's general practitioner, against usual care from the general practitioner. Five hundred outpatients with major depression at three Scottish cancer centres were randomised. At 24 weeks, 143 of 231 in the programme (62 per cent) had responded, meaning at least a halving of their depression score, against 40 of 231 (17 per cent) in usual care: an absolute difference of 45 per cent (95 per cent confidence interval 37 to 53) and an adjusted odds ratio of 8.5 (5.5 to 13.4). The programme group also had less anxiety, less pain, less fatigue and better functioning, health, quality of life and perceived quality of depression care at every time point.
The companion trial asked whether this works when the cancer is likely to shorten life. In lung cancer, 142 people with major depression were randomised to an adapted version of the same programme or usual care. Forty-three of the 142 (30 per cent) had died by 32 weeks. Among those who provided outcome data, average depression severity was 1.24 on the Symptom Checklist Depression Scale against 1.61 with usual care, a standardised mean difference of 0.62 in favour of the programme, with better anxiety, quality of life, role functioning and perceived quality of care. Depression in someone with a cancer that is likely to shorten their life is treatable, and the trial that asked the question answered it.
What the guidelines say. The ASCO 2023 update recommends a stepped-care model, "provide the most effective and least resource-intensive intervention based on symptom severity", with education for everyone, and for moderate depressive symptoms cognitive behaviour therapy, behavioural activation, mindfulness-based stress reduction, structured physical activity or an empirically supported psychosocial intervention; for severe symptoms, cognitive therapy, behavioural activation, cognitive behaviour therapy, mindfulness-based stress reduction or interpersonal therapy. On drugs it is cautious: the panel found the evidence for pharmacological management of depression and anxiety in cancer survivors "inconsistent", and places medication for people who cannot access first-line treatment, who prefer it, who have responded to it before, or who have not improved on psychological management. The guideline also records that survivors from minoritised groups were under-represented in the evidence it reviewed.
Collaborative care works by changing the system rather than the drug: a named non-medical case manager delivers a structured psychological intervention, monitors symptoms on a scale at every contact, and escalates to a psychiatrist on a protocol when there is no response, with the general practitioner kept in the loop and prescribing. The active ingredient is systematic follow-through, which is why it outperforms usual care by a margin no single antidepressant has shown in this population.
Query for this technology: (TITLE:"Depression during and after cancer: the interview-based prevalence, and the care model that works" OR ABSTRACT:"Depression during and after cancer: the interview-based prevalence, and the care model that works") AND (cancer OR tumor OR tumour OR oncology OR carcinoma OR lymphoma OR leukemia OR leukaemia OR myeloma OR sarcoma OR melanoma OR glioma). Results are unfiltered search hits about Depression during and after cancer: the interview-based prevalence, and the care model that works, not a curated reading list.
Shares Children of a parent treated for cancer, Anxiety after cancer, in survivors and in their partners, Psycho-oncology and distress screening, Quality of life and the tags rejuvenation, survivorship, psychosocial.
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