Predicting major depression in brain tumor patients

Meningiomatosis revealed by a major depressive syndrome

Depressive symptoms may be the only expression of brain tumours. Thus, it is challenging to suspect a brain tumour when patients with depression have a normal neurological examination. We illustrate this by a case report regarding a meningiomatosis revealed by a treatment-resistant depressive syndrome that improved after surgery. This case highlights the importance of identifying signs of brain tumour in patients with depression. Although there is no consensus about whether brain imaging is indicated for depressive syndromes, it should be performed, particularly in late onset of depressive syndrome (after 50 years of age), treatment-resistant depression or in apathy with a reduced emotional response or without dysphoric manifestations.

Depression--a common disorder across a broad spectrum of neurological conditions: a cross-sectional nationally representative survey

OBJECTIVE

To estimate the prevalence of depression across a range of neurological conditions in a nationally representative sample.

METHODS

The data source was the Survey of Living with Neurological Conditions in Canada (SLNCC), which accrued its sample by selecting participants from the Canadian Community Health Survey. The point prevalence of depression was estimated by assessment of depressive symptoms with the Patient Health Questionnaire, Brief (Patient Health Questionnaire, 9-item).

RESULTS

A total of n=4408 participated in the SLNCC. The highest point prevalence of depression (>30%) was seen in those with traumatic brain injury and brain/spinal cord tumors. Depression was also highly prevalent (18-28%) in those with (listed from highest to lowest) Alzheimer's disease/dementia, dystonia, multiple sclerosis, Parkinson's disease, stroke, migraine, epilepsy and spina bifida. The odds ratios for depression, with the referent group being the general population, were significant (from highest to lowest) for migraine, traumatic brain injury, stroke, dystonia and epilepsy.

CONCLUSIONS

All neurological conditions included in this study are associated with an elevated prevalence of depression in community populations. The conditions with the highest prevalence are traumatic brain injury and brain/spinal cord tumors.

Late new morbidity in survivors of adolescent and young-adulthood brain tumors in Finland: a registry-based study

BACKGROUND

Brain tumors (BTs) in adolescence and young adulthood (AYA) differ from those in childhood or late adulthood. However, research concerning late effects in this particular survivor group is limited. This study evaluates late morbidity of survivors diagnosed in AYAs.

METHODS

We identified from the Finnish Cancer Registry all survivors diagnosed with BT at the ages 16-24 years between 1970 and 2004 (N = 315) and used data from the Hospital Discharge Registry to evaluate their late (≥5 y after diagnosis) morbidity requiring treatment in a specialized health care setting. A sibling cohort of BT patients diagnosed before the age of 25 years was used as a comparison cohort (N = 3615).

RESULTS

The AYA BT survivors had an increased risk for late-appearing endocrine diseases (HR, 2.9; 95% CI, 1.1-8.0), psychiatric disorders (HR, 2.0; 95% CI, 1.2-3.2), diseases of the nervous system (HR, 9; 95% CI, 6.6-14.0), disorders of vision/hearing loss (HR, 3.6; 95% CI, 1.5-8.5), diseases of the circulatory system (HR, 4.9; 95% CI, 2.9-8.1), and diseases of the kidney (HR, 5.9; 95% CI, 2.5-14.1). Survivors with irradiation had an increased risk for diseases of the nervous system compared with non-irradiated survivors (HR, 3.3; 95% CI, 1.8-6.2). The cumulative prevalence for most of the diagnoses remained significantly increased for survivors even 20 years after cancer diagnosis.

CONCLUSIONS

The AYA BT survivors have an increased risk of morbidity for multiple new outcomes for ≥5 years after their primary diagnosis. This emphasizes the need for structured late-effect follow-up for this patient group.

Psychiatric symptoms in glioma patients: from diagnosis to management

Patients with primary intrinsic brain tumors can experience neurological, cognitive, and psychiatric symptoms that greatly affect daily life. In this review, we focus on changes in personality and behavior, mood issues, hallucinations, and psychosis, because these are either difficult to recognize, to treat, or are understudied in scientific literature. Neurobehavioral symptoms are common, often multiple, and causation can be multifactorial. Although different symptoms sometimes require a different treatment approach, we advise a comprehensive treatment approach, including pharmacological treatment and/or psychotherapy where appropriate. Further research is needed to obtain a better estimate of the prevalence of psychiatric symptoms in glioma patients, and the extent to which these affect everyday functioning and family life.

Affective Symptoms and White Matter Changes in Brain Tumor Patients

BACKGROUND

Affective symptoms are frequent in patients with brain tumors. The origin of such symptoms is unknown; either focal brain injury or reactive emotional distress may be responsible. This cross-sectional pilot study linked depressive symptoms and anxiety to white matter integrity. The objective was to test the hypothesis of a relationship between tissue damage and brain function in patients with brain tumors and to provide a basis for further studies in this field.

METHODS

Diffusion tensor imaging was performed in 39 patients with newly diagnosed supratentorial primary brain tumor. Patients completed the Beck Depression Inventory, and examiners rated them on the Hamilton Depression Rating Scale (HDRS). State and trait anxiety were measured using the State-Trait Anxiety Inventory. Correlations between fractional anisotropy (FA) and psychological measures were assessed on the basis of regions of interest; the defined regions of interest corresponded to clearly specified white matter tracts.

RESULTS

Statistical analysis revealed correlations between FA in the left internal capsule and scores on the HDRS, Beck Depression Inventory, and State-Trait Anxiety Inventory (P < 0.05). HDRS scores were also correlated with FA in the right medial uncinate fasciculus, and state anxiety scores were significantly correlated with FA in the left lateral and medial uncinate fasciculus (P < 0.05).

CONCLUSIONS

Our results suggest that neurobiologic mechanisms related to the integrity of tissue in specific white matter tracts may influence affective symptoms in patients with brain tumors, and these mechanisms can be investigated with diffusion tensor imaging. However, prospective observational studies are needed to investigate further the links between brain structures and the severity of affective symptoms in this patient population.

Symptom management and quality of life in glioma patients

Symptoms of fatigue, cognitive deficits, depression and changes in personality and behavior are frequently reported in patients with glioma. These symptoms have a large impact on the everyday life of patients and their partners and can contribute to a decrease in quality of life. While guidelines are available for managing most of these symptoms, these guidelines are often not suitable for the brain tumor patient population, as this population has very specific problems and needs. Obtaining more evidence on the effectiveness of existing and new interventions targeting fatigue, cognitive deficits, depression, and changes in personality and behavior in this population is advised. Screening combined with adequate referral to supportive care professionals has the potential to decrease the disease burden of glioma patients and their partners.

Depression screening in patients with brain tumors: a review

Brain tumor (BT) is often a devastating disease associated with poor prognosis. Depression is a common complication in BT patients that often remains under-recognized and untreated. Implementation of reliable depression screening algorithms in routine neuro-oncology setting could potentially improve recognition of depression. The Hospital Anxiety and Depression scale-Depression subscale and Patient Health Questionnaire-9 demonstrated adequate psychometric properties for depressive disorder screening in glioma patients. Patients screened positive for depression should be referred for detailed psychiatric assessment prior to initiating anti-depressive treatment. Further methodologically rigorous studies investigating psychometric properties of single-item and multiple-item depression scales are urgently warranted. Studies evaluating anti-depressive treatments' efficacy and clinical value of depression biomarkers are important avenues for future research endeavors in BT patients.

Palliative care and quality of life in neuro-oncology

Health-related quality of life has become an important end point in modern day clinical practice in patients with primary or secondary brain tumors. Patients have unique symptoms and problems from diagnosis till death, which require interventions that are multidisciplinary in nature. Here, we review and summarize the various key issues in palliative care, quality of life and end of life in patients with brain tumors, with the focus on primary gliomas.

Internet-based guided self-help for glioma patients with depressive symptoms: design of a randomized controlled trial

Background

Among glioma patients, depression is estimated to be more prevalent than in both the general population and the cancer patient population. This can have negative consequences for both patients and their primary informal caregivers (e.g., a spouse, family member or close friend). At present, there is no evidence from randomized controlled trials for the effectiveness of psychological treatment for depression in glioma patients. Furthermore, the possibility of delivering mental health care through the internet has not yet been explored in this population. Therefore, a randomized controlled trial is warranted to evaluate the effects of an internet-based, guided self-help intervention for depressive symptoms in glioma patients.

Methods/design

The intervention is based on problem-solving therapy. An existing 5-week course is adapted for use by adult glioma patients with mild to moderate depressive symptoms (Center for Epidemiology Studies Depression Scale score ≥12). Sample size calculations yield 126 glioma patients to be included, who are randomly assigned to either the intervention group or a waiting list control group. In addition, we aim to include 63 patients with haematological cancer in a non-central nervous system malignancy control group. Assessments take place at baseline, after 6 and 12 weeks, and after 6 and 12 months. Primary outcome measure is the change in depressive symptoms. Secondary outcome measures include health-related quality of life, fatigue, costs and patient satisfaction. In addition, all patients are asked to assign a primary informal caregiver, who does not participate in the intervention but who is asked to complete similar assessments. Their mood, health-related quality of life and fatigue is evaluated as well.

Discussion

This is the first study to evaluate the effects of problem-solving therapy delivered through the internet as treatment for depressive symptoms in glioma patients. If proven effective, this treatment will contribute to the mental health care of glioma patients in clinical practice.

Trial registration

Netherlands Trial Register NTR3223

Depression in glioma: a primer for clinicians and researchers

Depression is one of the leading causes of global disability, and a considerable hidden morbidity among patients with glioma. In this narrative review, we summarise what is currently known about depression in glioma, the main unanswered questions and the types of studies that should be prioritised in order to find out. We conclude by calling for a prospective Phase II study of antidepressants in depressed glioma patients, to test methodologies for a multicentre randomised controlled trial.

Together and apart: providing psychosocial support for patients and families living with brain tumors

PURPOSE

Brain tumors are associated with neurological sequelae and poor survival, contributing to distress in patients and their families. Our institution has conducted separate support groups for brain tumor patients and caregivers since 1999. This retrospective cohort study aimed to identify characteristics of brain tumor group participants in relation to attendance frequency, and compare themes of discussion in patient and caregiver groups.

METHODS

Demographic and medical characteristics were obtained from patient and caregiver group registration sheets and medical chart review. We quantified discussion topics recorded by group facilitators between 1999 and 2006, extracted themes, and examined similarities and differences in the way these themes were expressed.

RESULTS

A total of 137 patients and 238 caregivers attended the groups; about half attended more than one session. The chart review of a randomly selected subset of patient participants revealed that 57.5 % were married, 58.8 % had high-grade gliomas, and 55 % attended their first group within 3 months of diagnosis or at tumor progression. Both groups discussed physical and cognitive consequences, emotional reactions, relationships, coping, end of life, and practical issues. Caregivers discussed difficulties achieving self-care and caregiver burden.

CONCLUSIONS

Brain tumor support group facilitators can expect to encounter a range of medical and psychosocial issues in accommodating patients' and caregivers' diverse concerns. Separate brain tumor patient and caregiver groups may allow participants to explore those concerns without worrying about effects on their friends or family. It remains to be seen whether the groups meet the needs of attendees, and whether those who do not attend the groups have unmet needs.

Pharmacological treatment of depression in patients with a primary brain tumour

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 3, 2010.Patients with a primary brain tumour often experience depression, for which drug treatment may be prescribed. However, these patients are also at high risk of epileptic seizures, cognitive impairment and fatigue, all of which are potential side effects of antidepressants. The benefit, or harm, of pharmacological treatment of depression in brain tumour patients is unclear.

OBJECTIVES

To assess the benefits and harms of pharmacological treatment of depression in patients with a primary brain tumour.

SEARCH METHODS

We updated the search to include the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10), MEDLINE to October 2012, EMBASE to October 2012 and PsycINFO to October 2012. We searched the British Nursing Index, LILACS, PSYNDEX, the NHS National Research Register, the NHS Centre for Reviews and Dissemination's Database of Abstracts of Reviews of Effectiveness (DARE) and Web of Knowledge (covering Science Scisearch, Social Sciences Citation Index and Biological Abstracts) for the original review (to July 2009). In the original review we also handsearched Neuro-oncology, the Journal of Neuro-oncology, the Journal of Neurology, Neurosurgery and Psychiatry and the Journal of Clinical Oncology (July 1999 to June 2009) and wrote to all the pharmaceutical companies manufacturing antidepressants for use in the UK.

SELECTION CRITERIA

We searched for all randomised controlled trials (RCTs), controlled clinical trials, cohort studies and case-control studies of any pharmacological treatment of depression in patients with a histologically diagnosed primary brain tumour.

DATA COLLECTION AND ANALYSIS

No studies met the inclusion criteria.

MAIN RESULTS

We found no eligible studies evaluating the benefits of any pharmacological treatment of depression in brain tumour patients.

AUTHORS' CONCLUSIONS

No high-quality studies have examined the value of pharmacological treatment of depression in patients with a primary brain tumour. RCTs and detailed prospective studies are required to inform the effective pharmacological treatment of this common and important complication of brain tumours. Since the last version of this review none of the new relevant studies have provided additional information to change these conclusions.

Development of anxiety and depression in patients with benign intracranial meningiomas: a prospective long-term study

PURPOSE

The aim of this study was to provide the first prospective longitudinal assessment of anxiety and depression in patients with a benign intracranial meningioma (WHO° I).

METHODS

The Hospital Anxiety and Depression Scale was applied prior to (t1) and directly after (t2) neurosurgery as well as 6 months after surgery (t3). The research was conducted in a single treatment centre in Germany. Numerous sociodemographic, medical, psychological and cognitive accompanying measures were assessed. The study population consisted of 52 meningioma patients. Additionally, a control group of 24 patients with malignant brain tumours (astrocytoma WHO° III) was assessed.

RESULTS

In meningioma patients, anxiety was high prior to surgery but declined significantly after successful neurosurgical treatment. Low levels of depression were observed at all times. In contrast, astrocytoma patients showed constantly high levels of anxiety whilst depression increased over the course of the disease. Numerous medical, psychosocial and psychological factors were associated with psychiatric morbidity in meningioma patients.

CONCLUSIONS

In conclusion, psychiatric morbidity of patients with benign intracranial meningiomas was comparable to that of the general population after successful neurosurgical treatment. Numerous associated factors suggest complex relationships within a biopsychosocial model. However, due to the small sample size and recruitment in a single institution, our results are of limited generalisability and need cross-validation in future studies.

Depression, anxiety and positive affect in people diagnosed with low-grade tumours: the role of illness perceptions

OBJECTIVE

People with low-grade brain tumour experience a range of emotional, behavioural and psychosocial consequences. Using Leventhal's self-regulation model to explore biopsychosocial factors associated with distress, we examine the relationships between illness perceptions, coping and depression, anxiety and positive affect.

METHODS

A cross-sectional, self-report study in which 74 people (54% women) diagnosed with a low-grade brain tumour completed the Illness Perceptions Questionnaire-Revised was conducted. Mean time since diagnosis was 27.69 months (SD = 19.79). Mean age was 38.30 years (SD = 10.67). The Illness Perceptions Questionnaire-Revised, in addition to clinical, demographic and coping variables previously associated with psychological distress, was used to predict three psychological outcomes: depression, anxiety and positive affect.

RESULTS

Hierarchical multiple regression analyses demonstrated that a biopsychosocial causal attribution was a significant predictor of anxiety and depression. Illness identity also emerged as a significant predictor of depression scores. Coping through self-blame was the only coping variable to emerge as a significant predictor of anxiety scores. A combination of coping through venting, acceptance, positive reframing, denial, behavioural disengagement and self-blame contributed to the variance in all three psychological outcome scores. No illness perception variables significantly predicted positive affect.

CONCLUSIONS

Illness perceptions play a significant role in emotional distress experienced by people with low-grade brain tumours. Illness perceptions did not play a significant role in positive affect. Coping variables were shown to significantly contribute to the scores on all three psychological outcomes. Results suggest interventions targeted at modifying illness perceptions and enhancing problem-focused coping strategies may reduce psychological distress.

Adjustment and support needs of glioma patients and their relatives: serial interviews

OBJECTIVE

To understand factors influencing the process of adjustment to a diagnosis of glioma.

METHODS

Twenty-six patients and 23 relatives took part in 80 in-depth qualitative interviews conducted at five key stages: before formal diagnosis, at start of treatment, on completion of treatment, 6 months post treatment, and post bereavement.

RESULTS

High levels of distress were reported, particularly preceding and following diagnosis. Many participants described lack of specific information in the early part of their illness and a lack of clarity about what was wrong and what was going to happen next. They often desired more procedural information, as well as information about their condition and treatments available, although there was variation in the timing of when people were ready to hear this. Receiving reassurance and support was essential to patients and their relatives to help them come to terms with their illness. This need was particularly acute during the early phase of the illness when distress and uncertainty were at a peak and lessened over time as people adjusted to their illness.

CONCLUSIONS

Offering suitable information about what to expect early and frequently in a supportive way is much appreciated by patients. There is an important balance between ensuring that patients and their families are fully informed and fostering adaptive coping that allows for hope.

Cotard's syndrome with glioblastoma multiforme

Objective:

Brain tumors are classically associated with neurological and/or psychiatric symptomatology. Behavioral or cognitive disorders can underlie delirium, personality changes, psychotic reactions, and mood disorders.

Method:

To illustrate this, we report the case of a 60-year-old male patient confronted with an inoperable glioblastoma multiforme on the splenium of the corpus callosum, of poor prognosis, treated by concomitant radiochemotherapy with temozolomide, who developed psychotic depression with Cotard's syndrome. Clinical manifestations of this syndrome with untoward consequences in terms of prognosis are classically characterized by intense moral suffering, indignity and pessimistic fixations, suicidal ideations, and a nihilistic delusion relating to one's own body.

Results:

Nevertheless, this association between Cotard's syndrome and glioblastoma has been seldom described. To our knowledge, this is the first time that this has been described as a complication of this particular tumor location. Some neuropsychopathological hypotheses are proposed, which involve medical, iatrogenic, and psychogenesis issues.

Significance of results:

This case report points to the necessary collaboration between psychiatrists, neuro-oncologists and radiation oncologists in improving the patient's management and quality of life.

Applying a Biopsychosocial Perspective to Investigate Factors Related to Emotional Adjustment and Quality of Life for Individuals With Brain Tumour

Objective:This exploratory study applied a biopsychosocial perspective to investigate cognitive and psychosocial factors related to emotional adjustment and QoL after brain tumour.Methods:Participants included 30 adults with a brain tumour (60% benign and 40% malignant) who were aged 28 to 71 years (M= 51.5,SD= 12.3) and on average 5.4 years post-diagnosis (SD= 5.6 years). Participants completed a brief battery of cognitive tests and self-report measures of emotional status (Depression, Anxiety Stress Scale), subjective impairment (Patient Competency Rating Scale), coping (COPE), social support (Brief Social Support Questionnaire), and QoL (Functional Assessment of Cancer Therapy — Brain Tumour [FACT-Br]).Results:QoL was significantly associated with global cognitive ability (r= .49,p< .01), subjective impairment (r= .66,p< .01), and satisfaction with support (r= .50,p< .05). Level of depressive symptoms was significantly correlated with premorbid IQ (r= -.49,p< .01), use of planning to cope (r= -.48,p< .01), and satisfaction with support (r= -.47,p< .01).Conclusions:Overall, these exploratory findings indicate that emotional adjustment and QoL after brain tumour is related to a slightly different pattern of neuropsychological, psychological (self-perceptions and coping) and social factors. The clinical implications for interventions with individuals with brain tumour are discussed.

Frequency, Clinical Associations, and Longitudinal Course of Major Depressive Disorder in Adults With Cerebral Glioma

Purpose

There is a need for high-quality evidence regarding the frequency, independent clinical associations, and longitudinal course of depression in patients with cerebral glioma.

Patients and Methods

This was a twin-center, prospective, observational cohort study with 6-month follow-up. Consenting adults with a new diagnosis of cerebral glioma received the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition to diagnose major depressive disorder (MDD). Interviews occurred shortly after the start of radiotherapy (T1), with follow-up interviews 3 months later (T2) and 6 months later (T3). Independent associations between MDD and clinical variables were analyzed using logistic regression.

Results

One hundred fifty-five patients participated. The frequency of MDD was 13.5% ± 5.4% at T1 (n = 155); 14.8% ± 6.7% at T2 (n = 108); and 6.8% ± 5.3% at T3 (n = 88). Overall, 32 individuals were diagnosed with MDD during the study period (20.6% ± 6.4%). Inter-rater diagnostic agreement for MDD was good (κ = 0.81; 95% CI, 0.60 to 1.00). Independent predictors of MDD were functional impairment (odds ratio, 3.9; 95% CI, 1.5 to 10.8) and a previous history of depression (odds ratio, 2.7; 95% CI, 0.99 to 7.3). MDD persisted for at least 3 months in half of the patients with adequate follow-up, but many depressed patients also dropped out of the study as a result of clinical deterioration.

Conclusion

In this longitudinal study, one in five patients with glioma developed clinical depression in the 6 months after starting radiotherapy. Patients with functional impairment or previous depression were at higher risk. MDD often persisted for at least 3 months. Clinicians should seek and treat depression in adults with glioma.

Depression in relation to anxiety, obsessionality and phobia among neurosurgical patients with a primary brain tumor: a 1-year follow-up study

Depression is found to be present in up to 44% of brain tumor patients during their illness process. Anxiety as a comorbid psychiatric disorder with depression has formerly been studied, but phobia or obsessive-compulsive symptoms among brain tumor patients have not yet been noticed. By using a clinical prospective database of primary brain tumor patients (n=77) we studied the level of depression, anxiety, obsessionality (traits and symptoms) and phobic anxiety symptoms. Psychiatric symptoms were assessed before tumor operation as well as at three months and at one year after operation. The presence of comorbid anxiety, obsessionality and phobic anxiety symptoms was assessed before operation and at follow-ups in depressed and non-depressed patients, separately. Before tumor operation 16% of the patients had depression according to Beck Depression Inventory (BDI), while 10% had depression at three months and 15% at one year after operation. The depressed patients had statistically significantly higher anxiety scores and phobic scores at all three measurement points compared to corresponding scores among non-depressed brain tumor patients. The mean obsessionality scores among depressed brain tumor patients were significantly higher when measured before operation and at one year after the operation compared to non-depressed patients. To our knowledge, this is the first study so far in which comorbidity of psychiatric symptoms has been shown among depressive brain tumor patients. Concurrent comorbid conditions have been shown to be associated with increased severity, morbidity and chronicity of depression. It is recommended that treatment of depressive patients complicated with comorbid psychiatric disorders be planned by psychiatric units.

The prevalence and pharmacotherapy of depression in cancer patients

BACKGROUND

Depression is a frequent and serious comorbid condition in cancer patients that may require special attention. We investigate the prevalence of depression in cancer and review the current state of evidence regarding the effectiveness of drug treatment of depression in this group.

METHODS

We conducted a literature search for reports of prevalence rate of Major Depressive Disorder (MDD) in cancer patients based on Structured Clinical Interview based on DSM (SCID). We estimated the prevalence rate by combining the data of all reports. In addition we identified controlled trials studying the effect of psychotropic drugs in depressed cancer patients.

RESULTS

Based on the 31 reports, the estimated prevalence rate of depression in cancer patients is 10.8% (996/9248). There were 8 trials comparing antidepressant with other active treatment in cancer patients. Only mianserin and alprazolam demonstrated to improve the depressive symptoms.

LIMITATIONS

This literature review cannot resolve the challenge of diagnosing depression in severely ill and is subject to publication bias.

CONCLUSION

Despite the high prevalence of depression in cancer patients, studies on effective pharmacotherapy are relatively scarce. The evidence for the efficacy of conventional medication used for the treatment of depression such as tricyclics antidepressants and selective serotonin reuptake inhibitors is very limited. It is possible that they may be less suitable in this setting because of their relatively late onset of action. The use of psychostimulants which have a rapid onset of action therefore deserves more attention.

Is it time to act? The potential of acceptance and commitment therapy for psychological problems following acquired brain injury

Behaviour therapies have a well-established, useful tradition in psychological treatments and have undergone several major revisions. Acceptance and Commitment Therapy (ACT) and mindfulness-based approaches are considered a third wave of behavioural therapies. Emerging evidence for ACT has demonstrated that this paradigm has promising effectiveness in improving functionality and well-being in a variety of populations that have psychological disturbances and/or medical problems. In this review we first evaluate traditional cognitive behavioural therapy (CBT) interventions used to manage psychological problems in distressed individuals who have sustained an acquired brain injury (ABI). We provide an overview of the ACT paradigm and the existent evidence base for this intervention. A rationale is outlined for why ACT-based interventions may have potential utility in assisting distressed individuals who have sustained a mild to moderate ABI to move forward with their lives. We also review emerging evidence that lends preliminary support to the implementation of acceptance and mindfulness-based interventions in the rehabilitation of ABI patient groups. On the basis of existent literature, we recommend that it is an opportune time for forthcoming research to rigorously test the efficacy of ACT-based interventions in facilitating ABI patient groups to re-engage in living a valued and meaningful life, in spite of their neurocognitive and physical limitations. The promising utility of testing the efficacy of the ACT paradigm in the context of multimodal rehabilitation programmes for ABI populations is also addressed.

A biobehavioral perspective on depressive symptoms in patients with cerebral astrocytoma

More than 51,000 individuals are diagnosed with a primary brain tumor in the United States each year, and for those with the most common type of malignant tumor, an astrocytoma, almost 75% will die within 5 years of diagnosis. Although surgery, radiation, and chemotherapy have improved length of survival, mortality remains high, which underscores the need to understand how other factors affect the disease trajectory. Several recent studies have shown that depressive symptoms are independently associated with reduced quality of life and survival time after controlling for other variables in patients with an astrocytoma. Thus, depressive symptoms represent a significant risk factor for adverse outcomes in this patient population. A growing body of evidence indicates that depressive symptoms are linked to underlying biological phenomena, particularly inflammatory activation modulated through increased peripheral levels of proinflammatory cytokines. Recent research has shown that neoplastic astrocytes respond to elevated proinflammatory cytokine levels by secreting immune mediators within the central nervous system, including cytokines and glial fibrillary acidic protein that promote astrogliosis and angiogenesis and may increase tumor growth and metastasis. However, because these biological factors have not as yet been measured in conjunction with depressive symptoms in these patients, little is known about the interactions that potentially influence the treatment trajectory. To guide future research and to provide a deeper understanding of the factors that may influence depressive symptoms and length of survival in patients with an astrocytoma, a review of the literature was undertaken. Publications over the past 10 years were analyzed to examine the theoretical models and measures of depressive symptoms used in previous research. Although numerous studies have documented the relationship between depression and reduced length of survival, there were several methodological concerns identified, and there were no studies that included biological variables. Yet, research in the basic sciences provides compelling evidence of specific neuroendocrine-immune interactions orchestrated by astrocytes that can cause depressive symptoms and alter the tumor microenvironment so that standard treatments are not as effective. These findings support the need for clinically based research so that we can begin to understand the potentially modifiable biobehavioral mechanisms underlying depressive symptoms in patients with an astrocytoma. Grounded in the biobehavioral research paradigm of psychoneuroimmunology, a novel research program is presented that may provide a new level of understanding regarding the high prevalence of depressive symptoms in patients with an astrocytoma and lead to new treatment strategies, with possible implications for improved symptom management and quality of life in patients with brain tumors.

Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies

BACKGROUND

Substantial uncertainty exists about prevalence of mood disorders in patients with cancer, including those in oncological, haematological, and palliative-care settings. We aimed to quantitatively summarise the prevalence of depression, anxiety, and adjustments disorders in these settings.

METHODS

We searched Medline, PsycINFO, Embase, and Web of Knowledge for studies that examined well-defined depression, anxiety, and adjustment disorder in adults with cancer in oncological, haematological, and palliative-care settings. We restricted studies to those using psychiatric interviews. Studies were reviewed in accordance with PRISMA guidelines and a proportion meta-analysis was done.

FINDINGS

We identified 24 studies with 4007 individuals across seven countries in palliative-care settings. Meta-analytical pooled prevalence of depression defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria was 16·5% (95% CI 13·1-20·3), 14·3% (11·1-17·9) for DSM-defined major depression, and 9·6% (3·6-18·1) for DSM-defined minor depression. Prevalence of adjustment disorder alone was 15·4% (10·1-21·6) and of anxiety disorders 9·8% (6·8-13·2). Prevalence of all types of depression combined was of 24·6% (17·5-32·4), depression or adjustment disorder 24·7% (20·8-28·8), and all types of mood disorder 29·0% (10·1-52·9). We identified 70 studies with 10,071 individuals across 14 countries in oncological and haematological settings. Prevalence of depression by DSM or ICD criteria was 16·3% (13·4-19·5); for DSM-defined major depression it was 14·9% (12·2-17·7) and for DSM-defined minor depression 19·2% (9·1-31·9). Prevalence of adjustment disorder was 19·4% (14·5-24·8), anxiety 10·3% (5·1-17·0), and dysthymia 2·7% (1·7-4·0). Combination diagnoses were common; all types of depression occurred in 20·7% (12·9-29·8) of patients, depression or adjustment disorder in 31·6% (25·0-38·7), and any mood disorder in 38·2% (28·4-48·6). There were few consistent correlates of depression: there was no effect of age, sex, or clinical setting and inadequate data to examine cancer type and illness duration.

INTERPRETATION

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.

FUNDING

None.

Depression in cerebral glioma patients: a systematic review of observational studies

BACKGROUND

Depression is a common and important complication of primary cerebral glioma. However, observational studies of this relationship have not been systematically reviewed.

METHODS

We searched MEDLINE, EMBASE, and PsycINFO for all English-language cross-sectional, case-control, and cohort studies of depression in adults with primary glioma published between January 1, 1980, and September 16, 2009. We identified 42 eligible studies that recruited 4089 individual glioma patients. We conducted a narrative review of these studies regarding the heterogeneity in diagnostic methods, the frequency of depression and its clinical associations, and the quality of study reporting.

RESULTS

Most studies of depression in adults with glioma were small, cross-sectional, or retrospective. Depression was most often measured using the Hospital Anxiety and Depression Scale (HADS; n = 10 studies). The Beck Depression Inventory, another frequently used screening instrument, returned a higher frequency of depression (median = 39%, range = 38%-42%) than the Hospital Anxiety and Depression Scale (median = 16%, range = 0%-21%). At clinical interview, the median frequency of depression in glioma was 15% (range = 6%-28%). Depression was consistently associated with reduced physical function, cognitive impairment, and reduced quality of life. It may be associated with reduced survival, although evidence for this association was modest. There was an absence of clear associations between depression and many tumor-related variables. Few observational studies examined the treatment of depression in glioma patients. Multivariable analyses were rare, and study reporting was of variable quality.

CONCLUSIONS

In glioma, mild to moderate depressive symptoms may only rarely be due to tumor-associated structural or functional disruption of neuronal emotional networks. Improved methodological reporting would help clinicians better evaluate future studies, and facilitate improved evidence-based care of depressed glioma patients.

Effect of massage therapy on stress levels and quality of life in brain tumor patients--observations from a pilot study

BACKGROUND

Patients with brain tumors report experiencing elevated levels of stress across the disease continuum. Massage therapy is a commonly used complementary therapy and is employed in cancer care to reduce psychological stress and to improve quality of life (QoL). The purpose of this pilot study was to obtain a preliminary assessment of the efficacy of massage therapy on patient reported psychological outcomes and QoL.

MATERIALS AND METHODS

The design of the study was a prospective, single-arm intervention. Participants were newly diagnosed primary brain tumor patients who reported experiencing stress and who received a total of eight massages over a period of 4 weeks. Participants completed the Perceived Stress Scale (PSS-10) and the Functional Assessment of Cancer Therapy-Brain to assess their stress level and QoL.

RESULTS

As a group, levels of stress dropped significantly between weeks 2 and 3 (M = 12.3, SD = 3.09, P ≤ 0.010). A trend for the reduction in stress continued through week 4 (P ≤ 0.063). At the end of week 4, PSS-10 scores of all participants were below the threshold for being considered stressed. By the end of the intervention, participants reported significant improvements in three test domains, emotional well-being, additional brain tumor concerns, and social/family well-being.

CONCLUSION

This study indicates that participation in a massage therapy program is both feasible and acceptable to newly diagnosed brain tumor patients experiencing stress. Furthermore, participants in this study reported improvements in stress and their QoL while receiving massage therapy.

Pharmacological treatment of depression in patients with a primary brain tumour

BACKGROUND

Patients with a primary brain tumour often experience depression, for which drug treatment may be prescribed. However, these patients are also at high risk of epileptic seizures, cognitive impairment and fatigue, all of which are potential side-effects of antidepressants. The benefit, or harm, of pharmacological treatment of depression in brain tumour patients is unclear.

OBJECTIVES

To assess the benefits and harms of pharmacological treatment of depression in patients with a primary brain tumour.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 3), MEDLINE (1950 to July 2009) and EMBASE (1980 to July 2009). We searched PsycINFO, the British Nursing Index, LILACS, Psyndex, the NHS National Research Register, the NHS Centre for Reviews and Disseminations' Database of Abstracts of Reviews of Effectiveness (DARE) and Web of Knowledge (covering Science Scisearch, Social Sciences Citation Index and Biological Abstracts) (up to July 2009). We handsearched Neuro-oncology, the Journal of Neuro-oncology, the Journal of Neurology, Neurosurgery and Psychiatry and the Journal of Clinical Oncology (July 1999 to June 2009) and wrote to all the pharmaceutical companies manufacturing antidepressants for use in the UK.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs), controlled clinical trials, cohort studies and case-control studies of any pharmacological treatment of depression in patients with a histologically diagnosed primary brain tumour.

DATA COLLECTION AND ANALYSIS

No studies met the inclusion criteria for this review.

MAIN RESULTS

We found no eligible studies evaluating the benefits or harms of any pharmacological treatment of depression in brain tumour patients suffering from depression.

AUTHORS' CONCLUSIONS

No high-quality studies have examined the value of any drug treatment of depression in patients with primary brain tumours. Detailed prospective studies and RCTs are needed to inform the safe and effective treatment of this common and important complication of brain tumours.

Proper information during the surgical decision-making process lowers the anxiety of patients with high-grade gliomas

PURPOSE

We aim to analyse the relationship between the quality of information during the decision-making process regarding surgery to treat high-grade gliomas and the level of anxiety of the patients.

METHODS

This is a transversal, descriptive and correlational study on 26 patients with a clinical and radiological diagnosis of high-grade glioma. They scored the quality (in terms of comprehension and satisfaction) of information received about the treatment options and prognosis during the surgical decision-making process, and the Hospital Anxiety and Depression Scale questionnaire (HADS) was applied immediately afterward.

RESULTS

Lower levels of anxiety were observed in patients who showed a desire to receive information regarding their illness, those with a higher degree of comprehension, and those with a higher level of satisfaction with the information provided.

CONCLUSIONS

An improvement in the communication process contributes to a decrease in the levels of anxiety, and consequently to enhancement of the well-being of these patients.

The relationships between depression and brain tumors

Depression is a common complication/co-morbidity in patients with brain tumors. Better understanding of the relationships between brain tumors and depression should lead to improvement in patient care. This paper reviews these relationships in order to direct further study to improve patient care, and hopefully, outcome. Both anatomic and physiological perturbations in the brain are likely involved in the associations between depression and brain tumors. Tumor treatments are also associated with depression. Depression has a significant negative impact on outcome in brain tumor patients. The role of treatment of depression in brain tumor patients has been scantly studied. Further investigation directed to these areas of knowledge deficit should benefit depressed patients with brain tumors.

Quality of life in adults with brain tumors: current knowledge and future directions

Quality of life is an important area of clinical neurooncology that is increasingly relevant as survivorship increases and as patients experience potential morbidities associated with new therapies. This review of quality-of-life studies in the brain tumor population aims to summarize what is currently known about quality of life in patients with both low-grade and high-grade tumors and suggest how we may use this knowledge to direct future research. To date, reports on quality of life have been primarily qualitative and focused on specific symptoms such as fatigue, sleep disorders, and cognitive dysfunction, as well as some symptom clusters. However, the increasing interest in exploring quality of life as a primary end point for cancer therapy has established a need for prospective, controlled studies to assess baseline and serial quality-of-life parameters in brain tumor patients in order to plan and evaluate appropriate and timely interventions for their symptoms.

State and trait anxiety and depression in patients with primary brain tumors before and after surgery: 1-year longitudinal study

Object

The aim in this study was to assess the state and trait types of anxiety as well as current depression before and after surgery in patients affected by brain tumors. The relationships between these affective disorders and the patient's sex, tumor histology, and laterality of the tumor were also evaluated.

Methods

A total of 72 patients affected by a primary brain tumor were enrolled in the study. Histological grades were assigned according to the World Health Organization classification. State and trait anxiety were assessed using the State and Trait Anxiety Inventory; current depression was assessed using the Zung Self-Rating Depression Scale. Cognitive impairment was assessed using the 10-item Short Portable Mental Status Questionnaire. Psychometric evaluation was assessed before surgery and at 1, 3, 6, and 12 months after surgery.

Results

Before brain surgery, 62.5% of patients showed state anxiety, 50% of patients showed trait anxiety, and 9.7% of patients showed current depression. During the follow-up period there was no significant variation in the percentage of patients with state anxiety (p = 0.416) and trait anxiety (p = 0.7), whereas a significant increase in the percentage of those with current depression was found (p < 0.0001), in particular at 1 month (p = 0.002) and 3 months (p = 0.039) after surgical treatment. The tumor's laterality and histology showed no correlation with psychometric variables, whereas a relationship between the presence of trait anxiety at the enrollment and current depression after surgery (p < 0.0001) was found.

Conclusions

Patients affected by brain tumors frequently experience affective disorders. After brain surgery, a depressive state can develop. The psychometric assessment could be useful in these patients for quick recognition of psychological disorders.

The interdependence of behavioral and somatic health: implications for conceptualizing health and measuring treatment outcomes

PURPOSE

The interdependence of behavioral and somatic aspects of various health conditions warrants greater emphasis on an integrated care approach.

THEORY

We propose that integrated approaches to health and wellness require comprehensive and empirically-valid outcome measures to assess quality of care.

METHOD

We discuss the transition from independent to integrated treatment approaches and provide examples of new systems for integrated assessment of treatment outcome.

RESULTS

Evidence suggests that support for an independent treatment approach is waning and momentum is building towards more integrated care. In addition, research evidence suggests integrated care improves health outcomes, and both physicians and patients have favorable impressions of integrated care.

CONCLUSIONS

As treatment goals in the integrated perspective expand to take into account the intimate relationships among mental illness, overall health, and quality of life, clinicians need to develop outcome measures that are similarly comprehensive.

DISCUSSION

Increased recognition, by researchers, providers, and insurers, of the interdependence between behavioral and physical health holds great promise for innovative treatments that could significantly improve patients' lives.

Depression in relation to survival among neurosurgical patients with a primary brain tumor: a 5-year follow-up study

OBJECTIVE

The adverse impact of depression in relation to survival among cancer patients is currently a subject of great interest in research. In a 5-year follow-up study, we investigated the association of depression with survival of patients with a primary brain tumor.

METHODS

The study population consisted of 75 patients with a solitary primary brain tumor treated surgically at the Oulu Clinic for Neurosurgery, Oulu University Hospital, in Northern Finland. The patients were interviewed during admission to the hospital for the tumor surgery. Assessment of depression was made using the Beck Depression Inventory and the Crown-Crisp Experiential Index. Information on all deaths within 60 months after tumor operation was collected from the Cause of Death Register, provided by Statistics Finland.

RESULTS

The patients with a high-grade glioma had a survival time of 22.5 months (standard deviation, 21.4 mo), whereas the corresponding time was 50.2 months (standard deviation, 19.9 mo) for patients with a low-grade glioma and 58.2 months (standard deviation, 9.4 mo) for the patients with a histologically benign tumor (P < 0.001, difference between groups, Kruskal-Wallis test). In the subgroup of patients with low-grade gliomas, depressive patients had a significantly shorter survival time compared with nondepressive subjects (P = 0.031, Kaplan-Meier survival analysis). A corresponding difference was not found in patients with high-grade gliomas or benign tumors. Tumor location in one hemisphere compared with bilateral location and wider extent of tumor surgery was associated with better survival in patients with low-grade gliomas and benign tumors but not in patients with high-grade gliomas.

CONCLUSION

Preoperative depression seemed to be a significant prognostic factor for worse survival in low-grade glioma patients. In clinical practice, an evaluation of depression among brain tumor patients by structured and standardized diagnostic methods is needed to distinguish the patients whose depression actually needs treatment. The effective treatment of clinical depression among brain tumor patients and the impact of treatment on the patients' chances of survival should be a focus of future research.

Marital status, treatment, and survival in patients with glioblastoma multiforme: a population based study

BACKGROUND

Social factors influence cancer treatment choices, potentially affecting patient survival. In the current study, the authors studied the interrelations between marital status, treatment received, and survival in patients with glioblastoma multiforme (GM), using population-based data.

METHODS

The data source was the Surveillance, Epidemiology, and End Results (SEER) Public Use Database, 1988-2001, 2004 release, all registries. Multivariate logistic, ordinal, and Cox regression analyses adjusted for demographic and clinical variables were used.

RESULTS

Of 10,987 patients with GM, 67% were married, 31% were unmarried, and 2% were of unknown marital status. Tumors were slightly larger at the time of diagnosis in unmarried patients (49% of unmarried patients had tumors larger than 45 mm vs. 45% of married patients; P = 0.004, multivariate analysis). Unmarried patients were less likely to undergo surgical resection (vs. biopsy; 75% of unmarried patients vs. 78% of married patients) and were less likely to receive postoperative radiation therapy (RT) (70% of unmarried patients vs. 79% of married patients). On multivariate analysis, the odds ratio (OR) for resection (vs. biopsy) in unmarried patients was 0.88 (95% confidence interval [95% CI], 0.79-0.98; P = 0.02), and the OR for RT in unmarried patients was 0.69 (95% CI, 0.62-0.77; P < 0.001). Unmarried patients more often refused both surgical resection and RT. Unmarried patients who underwent surgical resection and RT were found to have a shorter survival than similarly treated married patients (hazard ratio for unmarried patients, 1.10; P = 0.003).

CONCLUSIONS

Unmarried patients with GM presented with larger tumors, were less likely to undergo both surgical resection and postoperative RT, and had a shorter survival after diagnosis when compared with married patients, even after adjustment for treatment and other prognostic factors.

Depression and functional outcome in patients with brain tumors: a population-based 1-year follow-up study

Object. The authors analyzed changes in depression and contemporary functional states by using valid tools in a population-based study sample during a 1-year follow-up period.

Methods. The study population consisted of 77 patients with a solitary primary brain tumor treated surgically at the Oulu Clinic for Neurosurgery. Each patient's depressive status, according to the Beck Depression Inventory (BDI), and functional outcome, based on the Karnofsky Performance Scale (KPS), were evaluated before the tumor was surgically treated as well as 3 months and 1 year after surgery. Before surgery 27 patients (35%) had BDI scores indicating the presence of depression. These scores were significantly higher in patients with a history of depression (p = 0.017) and in those with a lower functional outcome (p = 0.015). In the entire study sample the severity of depression decreased statistically significantly (p = 0.031) at 3 months postsurgery. A lower functional status (KPS score ≤ 70) in patients was significantly associated with high depression scores at the 3-month (p = 0.000) and 1-year (p = 0.005) assessments. The decrease in the level of depression was significant in patients with an anterior tumor (p = 0.049) and those with a pituitary adenoma (p = 0.019).

Conclusions. Affective disorders among patients with brain tumors must be considered immediately after surgery, especially in persons with a depression history and in those with a coincident physical disability.

Management of cancer-related fatigue

Fatigue is among the most commonly reported symptoms of patients with cancer, with prevalence exceeding 60% in many studies. It is among the most distressing symptoms associated with cancer and cancer treatments because it substantially disturbs patients' quality of life and ability to function optimally on a daily basis. Although the development of this condition has been associated with a number of factors, its etiology remains poorly understood. Important elements to include in any definition of cancer-related fatigue include its pervasiveness, persistence, detrimental effect on quality of life, and its inability to be relieved by rest or sleep. Several validated questionnaires can be used to measure fatigue in patients with cancer, and research efforts are currently focused on ways to distinguish it from depression with which it shares many symptoms. All patients with cancer should be evaluated for fatigue, and treatment options should be considered for those who are experiencing excessive levels of fatigue. Treatment should be individualized according to the underlying pathology when a specific cause has been identified (e.g., anemia, sleep disorder, depression, or metabolic disorder). Nonspecific therapies may be useful in short- and long-term cancer-related fatigue management in many patients. In addition to older therapies, such as hematopoietics, antidepressants, corticosteroids, and psychostimulants, the effectiveness of the new wake-promoting agent modafinil is currently being studied. A more thorough evaluation of the various therapeutic options is required to better define their efficacy and safety profiles in this patient population.

A critical review of the clinical effects of therapeutic irradiation damage to the brain: the roots of controversy

We critically examined the damaging affects of therapeutic irradiation by comparing results from cross-disciplinary studies of early- and late-delayed radiotherapy effects. Focus is attained by concentrating on clinical treatment issues (volume of brain, dose, timing of effects, age, modality types, and stereotactic treatment techniques), rather than on methodological means or problems, which is necessary to understand the mechanisms and characteristics of radiotherapy-induced behavioral dysfunction including cognition. We make observations and hypotheses about the actual risks from radiotherapy that could be informative in the treatment decision process, and which may lessen the concerns of some patients and their families about the risks they take when receiving radiation. Conditions that predispose to radiation injury are reviewed: (1) higher doses even to part of the brain versus lower doses to the whole brain, (2) combined treatment modalities, (3) malignancy itself, (4) radiation early during postnatal brain development, and (5) late-delayed effects (more than 3 years posttreatment). Current neurocognitive frameworks for understanding cognitive change over time in children and adults are summarized, along with the literature on effects of brain tumors and treatment on depression. No studies have as yet identified candidate brain regions that are more sensitive to radiotherapy. Two studies have provided early, preliminary evidence for a specific vulnerability of visual attention/memory to the early stage of late radiation damage. Furthermore, radiation effects appear severe only in a minority of patients. Risk is related to direct and indirect effects of cancer type, concurrent clinical factors, and premorbid risk factors.

Depression in patients with high-grade glioma: results of the Glioma Outcomes Project

OBJECTIVE

To study the incidence of depression among patients undergoing surgery for high-grade glioma, document factors associated with the presence of depression, and examine the relationship between depression and patient outcome.

METHODS

Physician and patient reports of depression were analyzed immediately postoperatively and again 3 and 6 months after surgery for high-grade glioma. Physician-reported depression was defined according to the Diagnostic and Statistical Manual of Mental Disorders, ed 4. Patient self-assessment of depression was based on responses to questions contained in two validated functional status surveys. Concordance of physician- and patient-reported depression was examined, along with the extent of use of pharmacological treatment for depression. Additional outcomes examined included quality of life, survival, patient satisfaction, and posttreatment complications.

RESULTS

Data from 598 patients were analyzed. In the early postoperative period, physicians reported depression in 15% of patients, whereas 93% of patients reported symptoms consistent with depression. The incidence of patient self-reported depression remained similar at 3- and 6-month follow-up, whereas physician reported depression increased from 15% in the early postoperative period to 22% at both 3- and 6-month follow-up. Concordance between physician recognition of depression and treatment of depression was low initially (33%) and increased at 3 and 6 months (51 and 60%, respectively). As compared with patients who were not depressed, survival was shorter and complications were more common among depressed patients.

CONCLUSION

Symptoms of depression were common immediately after surgery for glioma, and they increased throughout the 6-month period after surgery. These findings support the hypothesis that clinically important depression is a common complication in patients with high-grade glioma. Concordance between physician recognition of depression and self-reports of depression by patients was low. Concordance between physician recognition of depression and initiation of pharmacological antidepressant therapy was fair in the early postoperative period and improved somewhat over the subsequent 6-month period; however, within the 6-month period after surgery for glioma, antidepressant therapy was provided for only 60% of patients in whom the physician recognized depressive symptoms and in only 15% of patients who self-reported symptoms of depression. Findings from this observational study suggest the need for a controlled trial that is designed to test the hypothesis that more attention to the identification of postoperative depression and aggressive treatment of depressive symptoms can improve the quality of life and survival of patients after surgery for high-grade glioma.