The Value of Fatigue Severity to Rule Out Depression in Older Adult Patients With Cancer

Laura Deckx, PhD; Marjan van den Akker, PhD; Denise Vergeer, MD; Doris van Abbema, RN, MSc; Franchette van den Berkmortel, MD, PhD; Loes Linsen, PhD; Eric T. de Jonge, MD, PhD; Bert Houben, MD; Mieke van Driel, MD, PhD, FRACGP; Frank Buntinx, MD, PhD


Oncol Nurs Forum. 2015;42(4):E302-E309. 

In This Article

Abstract and Introduction


Purpose/Objectives: To evaluate whether fatigue severity can serve as a cue to investigate the presence of depression in older adult patients with cancer.

Design: Cross-sectional observational cohort study.

Setting: Seven hospitals and general practices in Belgium and the Netherlands.

Sample: 205 older adult patients with cancer and 436 older adults without cancer (aged 70 years or older).

Methods: The diagnostic accuracy of fatigue as a proxy for depression was evaluated using sensitivity, specificity, and predictive values.

Main Research Variables: Fatigue was measured with a visual analog scale, and depression was measured with the 15-item Geriatric Depression Scale.

Findings: Fifty-six percent of the population experienced fatigue, and 13% were depressed. For fatigue as a cue for depression, sensitivity was 82%, specificity was 47%, positive predictive value was 18%, and negative predictive value was 95%.

Conclusions: The data confirm that fatigue is a valuable cue to investigate the presence of depression because 82% of depressed participants were correctly identified by fatigue. The assessment of fatigue severity is intuitive, quick, straightforward, and usually already implemented.

Implications for Nursing: Identification of depression is difficult in older adult patients with cancer. Instead of experiencing affective symptoms of depression, older adult patients are more likely to disclose somatic symptoms, such as fatigue, which often overlap with cancer-related symptoms. Nurses should be aware of this problem and should be alert for the possibility of depression in older adult patients presenting with fatigue.


The prevalence of depression among patients with cancer is high. Results from a comprehensive meta-analysis estimated the prevalence of depression, as defined by the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV), to be 21% among patients with cancer (Mitchell et al., 2011). Particularly in older adult patients with cancer, depression is identified as an important concern and is more prevalent compared to younger patients with cancer and older adults (aged 70 years or older) without a history of cancer (Mohile et al., 2011; Nelson et al., 2009). Because the number of older adult patients with cancer is rising, the psychosocial consequences of cancer and its treatment, such as depression, will become an important problem that requires attention (Stanton, 2012).

Depression has a negative impact on quality of life, cognitive functioning, and survival (Ensinck et al., 2002). A study confirmed that, after adjustment for major clinical predictors of mortality, patients with cancer and depressive symptoms had a two-fold risk for all-cause mortality compared to patients with cancer without depressive symptoms (Mols, Husson, Roukema, & van de Poll-Franse, 2013). Therefore, the accurate identification and treatment of depression is an essential public health issue.

However, identification of depression in older adult patients with cancer is challenging, and depression is often unrecognized and untreated (Nelson, Cho, Berk, Holland, & Roth, 2010; Warmenhoven, van Weel, Vissers, & Prins, 2013; Weinberger, Bruce, Roth, Breitbart, & Nelson, 2011; Weinberger, Roth, & Nelson, 2009). Several reasons account for the under-recognition of depression. First, older adult patients less commonly disclose affective symptoms, such as sadness, and instead tend to present with trouble concentrating, fatigue, and lack of initiative (Nelson et al., 2010). Second, patients and healthcare providers often assume that depressive symptoms are normal symptoms of aging (Nelson et al., 2010). Third, the overlap between diagnostic criteria of depression and cancer-related symptoms and treatment side effects may account for the under-recognition of depression in patients with cancer (Nelson et al., 2010). When confronted with a diagnosis of cancer, feelings of sadness, distress, and grief are normal, and there is only reason for concern when these feelings last for a long time or limit daily functioning (Warmenhoven et al., 2013).

In this context, Weinberger et al. (2009, 2011) showed that older adult patients are less likely to endorse the two gateway symptoms of depression—depressed mood and loss of interest—and emphasized the importance of evaluating additional symptoms of depression. Fatigue is an additional symptom that may prove to be a useful cue to further investigate the presence of depression.

Fatigue is a common symptom in older adult patients with cancer (Rao & Cohen, 2004), and numerous studies have shown that fatigue and depression are related and occur concurrently (Fox & Lyon, 2006; Hofman, Ryan, Figueroa-Moseley, Jean-Pierre, & Morrow, 2007; Rhondali et al., 2012). A cross-sectional study in breast cancer survivors showed that fatigue was a significant predictor of depression (Galiano-Castillo et al., 2014). For this reason, the National Comprehensive Cancer Network (NCCN) has recommended that "the possibility of depression should be carefully considered in patients with cancer who report fatigue" (Lawrence, Kupelnick, Miller, Devine, & Lau, 2004, p. 47). Fatigue might serve as a cue for nurses and physicians to investigate the presence of depression; however, the added value of this strategy has not been evaluated empirically. Therefore, the aim of this study was to assess whether self-reported severity of fatigue can be used as a cue to identify patients who might benefit from further assessment of depression. This strategy has the advantage of being quick and straightforward and is already standard practice for oncology nurses. In addition, oncology nurses are often aware of the wide scope of emotions and feelings, including fatigue, patients with cancer go through. Results of this study will enhance nurses' awareness of the difficulties associated with identifying depression in older adult patients with cancer and provide them with a tool to enhance identification of patients at risk.

This strategy was evaluated in a population of older adult patients with cancer and in an older primary care population without a history of cancer because several of the reasons that account for under-recognition of depression in older adult patients with cancer could also apply to older adults in general.