Barriers to the treatment of depression in cancer patients.

Major depressive disorder is a relapsing syndrome with grave morbidity and mortality. Much like asthma, it has a genetic predisposition and environmental triggers. Specific antidepressant medications alone, tested in randomized, placebo-controlled studies, show that this is a treatable condition with 65%-70% clinical response. Treatment guidelines written for psychiatric patients and patients in primary care clarify the role of medications and psychotherapy. Physicians are compelled to treat syndromes that are serious and treatable, but barriers to diagnosis and treatment of major depressive disorder in cancer patients include two major barriers to quality medical care generally: uncertainty and cost. Given uncertainty about diagnosis and treatment, cancer physicians with limited time avoid questions about emotions. Cases of depression are often missed. Mental health specialists often work in systems that are separated from oncologists by location, organization, and insurance. Most successful interventions to improve treatment of depressive disorders require multiple strategies: clinical education, enhanced role of nurses, and integrated oncology and specialist care. Recent strategies in oncology settings are reviewed. Research concepts to improve outcomes in treatment of depression include staging of depressive disorder in cancer to reveal prognosis, evaluation of depression outcomes in the context of one tumor type, new organizational models in the acute cancer setting, use of the cancer protocol, and assessment of access to care of depression in cancer survivors. Major depressive disorder in cancer is staged by positive past history, comorbid anxiety disorder or substance abuse, use of specific cancer medications that destabilize mood, and active cancer or no evidence of disease.