Is Mrs S depressed? Diagnosing depression in the cancer patient.

A 43-year-old woman, Mrs S, was seen for a follow-up visit 6 months after completing adjuvant chemotherapy and radiotherapy for a 2.5-cm estrogen receptor/progesterone receptor–negative, node-negative breast cancer. Her visit took place in the middle of the day in a busy ambulatory practice. Mrs S was premenopausal at diagnosis and her periods ceased after chemotherapy. When asked how she was doing overall, she replied “I’m doing OK, but I’m having some problems.” She went on to say that she was still quite fatigued and as a result had not yet returned to work. I asked her, “How is the fatigue affecting your daily life?” Before diagnosis, Mrs S played tennis on a regular basis and had an active social calendar. She said, “I get tired playing, so I don’t play often. We go out with friends, but it takes a lot out of me.” She was also having from four to six hot flashes per day and had vaginal dryness and dyspareunia. By now, her physical demeanor had changed and she appeared downcast. At this point, I said, “It must be very hard to have all these body changes happen to you in such a short time.” She broke into tears and said, “It’s so overwhelming. I should be happy that my cancer is in remission. I’m sorry for crying.” “That’s OK. It’s healthy to get your feelings out. Do you find yourself crying a lot?” She replied, “There are times when I feel sorry for myself, because I can’t do the same things I did before. It’s frustrating that I don’t have the energy for things. But I can snap myself out of it. My husband and friends are very supportive. ” Thinking that she might be depressed, I asked if she could still get pleasure from things, and she replied, “Definitely.” She denied any sleep or appetite problems, excessive guilt, memory or concentration difficulties, hopelessness, or suicidality. I wondered in passing if she was minimizing her symptoms, but I decided not to pursue it because of time constraints. I said, “With regards to fatigue, it’s very common for it to persist after finishing treatment. It’s especially tough when you’re such an active person and can’t do everything you want to do right now. The fatigue will definitely improve over time, but I understand your impatience. Going into menopause after treatment can also be very difficult. Many of my patients have hot flashes, and they can be very bothersome. A medication, venlafaxine, can, in my experience, can be helpful to reduce their frequency.” “Decreased sex drive and vaginal dryness are unfortunately also common with chemotherapyinduced menopause. The vaginal dryness can be a real problem. There are good personal lubricants available.” I noted to myself that I was feeling rushed due to the need to see waiting patients. Then, I proceeded with the physical examination, which was normal. I ended the visit by saying, “There seems to be so much that you’re dealing with. It would be good to bring your husband next time to talk more about how we can help you deal with all this.” Mrs S thanked me for listening, was given a prescription for venlafaxine for her hot flashes, and told to purchase a lubricant for the vaginal dryness. I asked my secretary to schedule her next visit as the last one of that day, so I would not feel rushed. On the follow-up visit, her husband stated, “Normally, she’s an upbeat and optimistic person. Unfortunately, she’s having a lot of these side effects, and she doesn’t see them getting any better. It’s getting her down.” Wondering if she was minimizing her symptoms of depression during the last visit, I asked her, “Your husband thinks you’ve been down. What’s your take on it?” She replied, “I don’t like to complain. I should be able to snap myself out of it. I know I’m in remission and should be grateful, but I’ve noticed lately that I can’t even enjoy being with my grandchildren. I’m worried about this, and I’m not able to sleep well.” At this juncture, I was more certain Mrs S was depressed, but I thought she would benefit from expert consultation. I referred her to a psychiatrist for further evaluation and treatment. Although reluctant, she agreed. In addition, I gave her literature and contact information regarding support groups. From the Division of HematologyOncology and the Palliative Care Service of the Department of Medicine, and the Division of Consultation Liaison Psychiatry, Department of Psychiatry, and of Long Island Jewish Hospital campus of the Albert Einstein College of Medicine, New Hyde Park, NY.