Distinguishing Depressive Symptoms From Similar Cancer-Related Somatic Symptoms

Implications for Assessment and Management of Major Depression After Breast Cancer

Lora M.A. Thompson, PhD; Margarita Bobonis Babilonia, MD


South Med J. 2017;110(10):667-672. 

In This Article

Abstract and Introduction


Prevalence rates of major depressive disorder (MDD) following breast cancer diagnosis are estimated to be ~5% to >20%, and these rates range from slightly below to somewhat above the expected prevalence rate for MDD in the general population of women in the United States. Women with a history of MDD are at increased risk for recurrence of MDD after breast cancer and need to be monitored closely. To properly diagnose and treat MDD, healthcare providers must be able to recognize depressive symptoms and distinguish them from similar somatic symptoms that are associated with breast cancer and breast cancer treatment. The National Comprehensive Cancer Network and the American Society of Clinical Oncology have published guidelines for the screening, assessment, and care of adult cancer patients with depressive symptoms. Use of a standardized and validated screening measure may help healthcare providers identify patients in need of further assessment or treatment. Evidence-based nonpharmacological interventions such as cognitive behavioral therapy and antidepressant medications are recommended treatment options.


Research-validated diagnostic criteria for a major depressive disorder (MDD) commonly require the presence of 5 symptoms for at least 2 weeks, and 1 symptom must be depressed mood or loss of interest in usual activities. Other symptoms include feelings of worthlessness or guilt, sleep disturbance, weight or appetite changes, psychomotor agitation or retardation, fatigue, difficulty concentrating or making decisions, and recurrent thoughts of death or suicidal ideation.[1] Symptoms must be distressing to the individual or affect the individual's ability to function. Furthermore, they may not be attributed to the physiological effects of another medical condition or substance. This final requirement often poses a challenge to healthcare providers attempting to identify MDD in women with breast cancer because MDD-related somatic symptoms are difficult to distinguish from the somatic symptoms related to cancer or cancer treatment. For example, fatigue could be caused by nonpsychological factors such as tumor burden, treatment, pain or nausea, medication use, immobility, and other cancer-related physiological conditions.[2] Similarly, patients may experience weight loss caused by anorexia-cachexia syndrome[3] or sleep disturbance caused by pain, menopausal symptoms, medication use (eg, corticosteroids), or hospitalization.[4] Difficulty concentrating or making decisions could indicate chemotherapy-related cognitive dysfunction.[5] There also is the possibility of hypoactive delirium, in which the observed apathy may be related to cognitive disturbance rather than depression.[6]

Knowledge of MDD prevalence rates and risk factors in women with breast cancer and of clinical practice guidelines can facilitate appropriate screening, assessment, and care of MDD in the presence of confounding somatic symptoms. As such, the objective for this review was to summarize the existing knowledge on MDD in women with breast cancer, to describe best practices for depressive symptoms screening using validated scales, to present modified diagnostic schema that take into consideration confounding somatic symptoms, and to describe applicable treatment options based on the severity of MDD.