As many as one in two cancer patients may suffer clinically significant psychological distress. Vigilance is required to elicit symptoms of anxiety and depression explain Dr P Tyllis and Dr C Karapetis. Psychological therapy and adjunctive pharmacotherapy have demonstrated efficacy in this patient population. Management strategies may need to involve patient carers. Psychiatric referral should be considered for severe states of psychological disturbance or suicidal ideation.

More people are surviving long after a diagnosis of cancer than ever before. As a result, a greater focus has fallen upon the aspects which impact on the quality of life of patients 'living with cancer'. The mental-health status of cancer patients had received relatively little attention by clinicians and researchers in the past. Among the many reasons for this was the belief shared by clinicians, patients, and carers that a certain level of depression and distress was 'normal'. The need to 'put on a brave face' was perhaps encouraged as an important and effective method of coping. Over the recent years, however, interest in the field of psycho-oncology has flourished, perhaps in keeping with the consumer-driven push for the medical profession as a whole to move toward a more holistic approach to patient care. Although a myriad of psychiatric syndromes may occur in the cancer patient, the focus here will be on depressive and anxiety states.

The few available estimates of the prevalence of long-term psychological distress in cancer patients range from 15-66 per cent¹. Derogatis et al² reported that of the 47per cent of cancer patients who met criteria for a psychiatric diagnosis, 13 per cent had a major affective disorder and 68 per cent had adjustment disorder. Of the latter, 78 per cent had depressive symptoms as part of the clinical picture.

In a two-year follow up of newly diagnosed cancer patients, Ell et al³ reported that psychological adaptation did not improve from baseline. Breitbart1 reiterated that the incidence of depression in cancer patients increased with higher levels of disability, advanced illness, and pain. Other authors have reported no significant association between psychological adaptation and stage of disease³. Although in the elderly there is a lower prevalence of major depression, dysthymia, subsyndromal depression, and anxiety disorders, the rates of these disorders among people with concurrent illness are much higher. Depressed elderly individuals are more likely to present with somatic complaints and their underlying psychiatric morbidity may go unrecognized. Importantly, suicide risk tends to be higher in the elderly, with major medical illness being a commonly reported risk factor⁴.

Comprehensive care begins with a thorough appraisal of the patient's overall health status including a review of psychological symptoms. In the elderly, depression tends to be under-diagnosed and under-treated. This is more so in the cancer patient primarily because clinicians expect that the patient 'should' be depressed given the nature of the diagnosis.

The need to make specific inquiry into emotional disturbances is highlighted by the suggestion that older patients tend to under-report symptoms of emotional distress⁵. The presence of feelings of sadness, panic, depressive cognitions such as hopelessness and helplessness, tearfulness, depressed or anxious mood, and suicidal ideation should be regularly assessed. The diagnosis of depression in the cancer patient may hinge less on neurovegatative disturbances such as weight loss, lethargy, and loss of appetite, as these may be a result of the cancer or its treatment.

Patients with a pre-existing affective disorder, lack of effective support, feelings of loss of control, and intractable pain are at increased risk of developing an adverse psychological reaction6. If present, these factors should alert the clinician of the need for closer monitoring. Greater vigilance is warranted during the months following initial diagnosis of cancer and after any subsequent relapse.

An appraisal of personal history may give clues about the patient's ability to cope at times of stress. For example, an isolative person who has had little contact with the health system may be overwhelmed by the proposed cancer treatment.

In dealing with emotional responses to cancer one may encounter a degree of therapeutic nihilism, where the poor prognosis of the cancer may be extrapolated by the clinician to an expectation of a poor outcome in attempted intervention to alleviate psychological morbidity. Contrary to this commonly held belief, Greimel et al7 reported that the stage of disease, and hence prognosis, did not impinge negatively on self-reported psychological well-being. Targeted interventions can relieve cancer patients of undue suffering and ease caregiver burden.

Among the issues faced by cancer patients that are amenable to psychotherapeutic intervention are changes in role functioning and body image, pain management challenges, financial concerns, and social stigmatization resulting from the cancer diagnosis. A meta-analysis of 45 randomized trials concluded that cancer patients receiving psychological therapy had a significant improvement of: