Cancer Pain and Depression:
Management of the
Dual-diagnosed Patient
Alan D. Valentine, MD
Address
The University of Texas M.D. Anderson Cancer Center, Psychiatry
Section, Department of Neuro-Oncology, 1515 Holcombe Blvd,
Unit 431, Houston, TX 77030, USA.
E-mail: avalenti@mdanderson.org
Current Pain and Headache Reports 2003, 7:262–269
Current Science Inc. ISSN 1531-3433
Copyright © 2003 by Current Science Inc.
Depressive disorders and pain syndromes are very com-
mon in the experience of cancer patients and may be expe-
rienced simultaneously. There is an intuitive association
between cancer pain and cancer depression, both of which
are multidimensional entities. Research has suggested, but
not conclusively proven a cause-effect relationship. Suicidal
ideation is a common concern in cancer patients with
severe depression or pain. Antidepressant therapy is a
mainstay of management of depression. That some antide-
pressants have use in the management of cancer pain may
influence choice of drug selection in depressed patients.
Antidepressant side effects and the patient’s drug history
are relevant variables. Because antidepressants that are
effective as coanalgesics may not be tolerated at doses
effective for depression, the clinician must be familiar with
newer classes of antidepressants and psychostimulants.
Combination drug therapy may be required. Psychotherapy
also is common to the treatment of cancer pain and
depression. With or without the intervention of pain and
mental health specialists, ongoing supportive therapy from
the primary clinician is essential.
Introduction
Cancer, with notable exceptions, is not a curable disease.
However, with commitment of massive effort and resources,
remarkable progress is being made such that is reasonable to
begin to look at cancer as a chronic disease that patients may
expect to live with for years while curative therapies are being
developed. It follows that patients may expect to live longer
with morbidities associated with the disorder. There is an
intuitive relationship between cancer pain and depression,
each of which would reasonably exacerbate the other. Taken
by themselves, each is a major obstacle to effective supportive
care of the cancer patient. Taken together, they can present
even greater challenges, but also some opportunities in
attempts to palliate suffering and improve quality of life.
Depression in Cancer
Psychiatric illness is a common, but by no means obligate
part of the cancer experience. In the often-cited Psychoso-
cial Collaborative Oncology Group study of ambulatory
and hospitalized cancer patients [1], 47% met the criteria
for a psychiatric disorder. Adjustment disorders with
depressive or anxious features and major depression were
the diagnoses made most often (Table 1).
Depression is a term that has different meanings in differ-
ent settings, ranging from the emotional state of sadness com-
monly experienced in life, to a maladaptive psychologic
response to a stressor (adjustment disorder, or reactive depres-
sion; Table 2), to a persistent disorder with characteristic psy-
chologic and physical symptoms (major depression; Table 3)
[2]. Adjustment disorders with depressed mood and major
depression are associated with levels of distress that warrant
intervention. In both of these depressive disorders, the patient
experiences significant dysphoria or anhedonia and often
other psychologic and physical symptoms.
The 1-month prevalence of major depression in the gen-
eral population has been estimated to be between 1.8% and
4.9% [3]. The reported prevalence of major depression in can-
cer patients varies from less than 5% to more than 50% [4].
Many factors appear to contribute to differences in preva-
lence. In their review, DeFlorio and Massie [4] attributed most
of the variance to differences in study methodology and diag-
nostic criteria. Higher rates of depression generally are seen in
studies using less stringent diagnostic criteria. Other factors
influencing prevalence include use of observer v self-report
rating scales and the sensitivity and specificity of those scales.
Increased rates of depression are seen with advanced disease
[1,5–7], decreased performance status [7], and with involve-
ment of different organ systems and treatment modalities (eg,
interferon, corticosteroids). In the discussion that follows, the
influence of pain on cancer-related depression is developed in
detail. When all of the factors are considered, Massie and Pop-
kin [8] have concluded that approximately 25% of all cancer
patients experience significant depression.
 Cancer Pain and Depression: Management of the Dual-diagnosed Patient • Valentine 263

Table 1. Rates of Diagnostic and Statistical Manual-III psychiatric disorders and prevalence of pain observed
in 215 patients with cancer from three cancer centers*
Patients with
Diagnostic class significant pain
Psychiatric
Diagnostic category n % diagnoses, % n %
Adjustment disorders 69 32 68 N/A N/A
Major affective disorders 13 6 13 N/A N/A
Organic mental disorders 8 4 8 N/A N/A
Personality disorders 7 3 7 N/A N/A
Anxiety disorders 4 2 4 N/A N/A
Total with psychiatric diagnoses 101 47 N/A 39 39
Total with no psychiatric diagnoses 114 53 N/A 21 19
Total patient population 215 100 N/A 60 28
*Score higher than 50 mm on a 100-mm visual analogue scale for pain severity.
Adapted from Deragotis et al. [1] and Breitbart and Passik [19], with permission.

Table 2. Criteria for adjustment disorders

A. The development of emotional or behavioral symptoms in response to an identifiable stressor occurring within 3 months of
the onset of the stressors
B. These symptoms or behaviors are clinically significant evidenced by either of the following:
1. Marked distress that is in excess of what would be expected from exposure to the stressor
2. Significant impairment in social or occupational (academic) functioning
C. The stress-related disturbance does not meet the criteria for another specific Axis 1 disorder and is not merely an
exacerbation of a pre-existing Axis I or Axis II disorder
D. The symptoms do not represent bereavement
E. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months
Reprinted from the Diagnostic and Statistical Manual of Mental Disorders, edn 4, with permission [2].

Suicide chosocial Oncology Group study, 39% of patients who

The most serious potential consequences of unrelieved
depression and cancer pain are suicide and a wish for
death among cancer patients. The role and influence of
pain and depression figure prominently in the ongoing
debate on euthanasia and physician-assisted suicide. The
known suicide rate among cancer patients is thought to be
approximately twice that of the general population [9,10].
Suicides are more likely to occur in cancer patients with
advanced disease who also are more vulnerable to depres-
sion and severe pain than in patients with earlier stage dis-
ease [7,11,12]. Breitbart and Krivo [11] have argued that
cancer pain’s role in suicidal ideation is more a function of
associated psychologic suffering and hopelessness than it is
pain intensity. Hopelessness also may be more important
than depression as a factor in suicidal ideation [13].
Cancer Pain
Pain is one of the most feared consequences of a cancer
diagnosis [14]. It is an extremely common problem; up to
70% of cancer patients experience severe pain at some
point in the disease process [15]. In the cancer setting, pain
has repeatedly been associated with increased levels of psy-
chologic distress, including depression [1,16]. In the Psy-
received a psychiatric diagnosis reported significant pain,
compared with 19% of patients who did not have a psychi-
atric diagnosis [1] (Table 1). Adjustment disorders were the
most common diagnoses in patients with pain, but 15% of
pain patients had major depression.
Association does not necessarily imply causality. There
could be a relationship between pain and depression or
they could exist as independent entities in the same
patient. Pain is a multidimensional construct, with emo-
tional/cognitive variables that are thought to contribute to
perception and intensity of pain [17–19]. This reasonably
suggests that patients with increased levels of psychologic
distress (including depression) would experience more
pain. Because pain is, by definition, a noxious (ego dys-
tonic) state, one also may conclude that, on general princi-
pal, pain makes depression worse.
Several studies have examined aspects of the rela-
tionship between cancer pain and depression, with data
leading to different conclusions. In a study of 120 cancer
patients with moderate to severe pain, Cleeland [14]
found no differences in perceived pain intensity and
function status in those who were identified as
depressed compared with those who were not. In the
same study, depressed patients felt that pain interfered
264 Cancer Pain

Table 3. Criteria for a major depressive episode

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from a
previous functioning (at least one of the symptoms is depressed mood or loss of interest or pleasure*)
1. Depressed mood most of the day nearly every day indicated by a subjective report (eg, feelings of sadness or emptiness)
or observations made by others (eg, tearfulness)†
2. Markedly diminished interest or pleasure in all, or almost all activities most of the day nearly every day (indicated by
subjective account or observations made by others)
3. Significant weight loss when not dieting, weight gain (eg, a change of more than 5% of body weight in a month), or a decrease
or increase in appetite nearly every day‡
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day (not merely subjective feelings of restlessness or slowing down, but
observable by others)
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely
self-reproach or guilt about being sick)
8. Diminished ability to think or concentrate or indecisiveness nearly every day (by subjective account or as observed
by others)
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt
or a specific plan for committing suicide
B. The symptoms do not meet criteria for a mixed episode
C. The symptoms cause clinically significantly distress or impairment in social, occupational, or other important areas
of functioning
D. The symptoms are not a result of the direct physiologic effects of a substance (eg, an abusive drug, a medication) or a general
medical condition (eg, hypothyroidism)
E. The symptoms are not accounted for better by bereavement (ie, after the loss of a loved one, the symptoms persist for more
than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal
ideation, psychotic symptoms, or psychomotor retardation)
*Do not include symptoms that result from a general medical condition, mood-incongruent delusions, or hallucinations.
†Can be irritable mood in children and adolescents.
‡In children, consider failure to make expected weight gains.
Reprinted from the Diagnostic and Statistical Manual of Mental Disorders, edn 4, with permission [2].

more with activity and mood than did nondepressed
patients. Depression also did not predict response to
treatment of pain. Using research diagnostic criteria,
Spiegel et al. [20] found higher rates of depressive disor-
ders and anxiety, but a significantly lower history of
depression in patients with severe pain than in those
with less severe pain, suggesting a relationship in which
pain is more likely to cause depression than the con-
verse. Ciaramella and Poli [21] found increased rates of
depression in pain patients compared with those not in
pain, but they found increased intensity of pain (using a
visual analog scale) in those who were depressed.
Depressed patients did not have higher lifetime rates of
depression, leading to an argument for pain as the more
causal entity [21].
Spiegel and Bloom [22] found that level of mood distur-
bance, use of analgesics, and belief about the meaning of
pain were major factors contributing to variance in pain
experienced by women with metastatic breast cancer.
Observing bone marrow transplant patients, Syrjala and
Chapko [23] found that psychologic distress (although not
frank depression) contributed (to some extent) to the experi-
ence of mucositis pain. A bidirectional relationship in which
depression could be a cause and effect of cancer also has
been suggested [24].
Although study designs, assessment instruments, and
study results have not been consistent, the evidence for the
existence of a relationship between cancer pain and depres-
sion is sufficient to suggest that clinicians should always
consider pain as a contributing factor in the depressed can-
cer patient. The possible presence of depression (and psy-
chologic distress in general) should always be considered
in a cancer patient in pain.
Management
The cancer patient who is depressed and in pain can
present significant management challenges. Some difficul-
ties are practical, others may be more philosophic.
Although the goal of adequate pain relief for all cancer
patients has not been achieved, few would argue that the
goal is inappropriate. With regard to depression, this may
not be the case. Some clinicians assume that depression is
a “normal” part of the cancer experience and thus need not
be addressed. Chochinov [25] describes this as “therapeu-
tic nihilism,” which absolves the caregiver for failing to
respond to the patient’s suffering. The stigma associated
with mental illness is such that patients may not volunteer
that they are in distress because of shame or fear of com-
promising treatment. Failure of the clinician to inquire or
 Cancer Pain and Depression: Management of the Dual-diagnosed Patient • Valentine
screen for psychologic distress can serve as an unfortunate
reinforcement to such beliefs.
The question of order of treatment also can cause diffi-
culties. Some authors assert that the psychiatric symptoms
of patients in pain must first be considered consequent to
unrelieved pain and that this must be addressed first with
re-evaluation of mental state after pain control is achieved
[12,26]. Others assert that patients who meet diagnostic
criteria for depression should be treated concurrently with
pain management [23]. As a practical point, patients in
severe pain are likely to be in such distress that they cannot
be engaged, making adequate pain control a prerequisite
to psychiatric evaluation and treatment. In unfortunate,
but not uncommon cases in which adequate pain control
is difficult to achieve, it is not reasonable to defer treatment
of depression and attempted management of both prob-
lems should be simultaneous.
Antidepressants
Antidepressants are used frequently to treat moderate to
severe depression in cancer patients. Clinical and
research experience is such that they are now a recom-
mended component of the management of cancer
patients who meet diagnostic criteria [27]. Antidepres-
sants are effective coanalgesics that are recommended for
use against pain of all levels of intensity and appear to be
especially useful for management of neuropathic pain
[26,28,29•,30]. Oncologists and supportive care special-
ists who take care of cancer patients need to have a
working knowledge of these medications. Their pharma-
cology, especially with regard to the management of
pain, has been thoroughly reviewed [31•].
No antidepressant or class of antidepressants has been
shown to have superior efficacy in the management of the
depressed cancer patient. Variables relevant to the selection
of an antidepressant include the drug’s side-effect profile,
the patient’s clinical status and particular depressive symp-
toms, a history of response to antidepressants, and poten-
tial drug interactions. The considerable data on the efficacy
of antidepressants as analgesics may make drug selection
easier when the depressed cancer patient also is in pain
(Table 4).
Tricyclic antidepressants
The introduction of these drugs began the modern era of
pharmacotherapy of depression. They are the most well-
studied antidepressants with regard to analgesia [29•,31•].
In oncology, they are used most often as coanalgesics with
opioids. There are several possible mechanisms contributing
to analgesia, including the variable effects of tricyclic antide-
pressants (TCAs) on norepinephrine and serotonin levels.
Although equally efficacious against depression, the TCAs
with more serotoninergic effects (eg, amitriptyline, doxepin)
appear to be the most effective analgesics and amitriptyline
is generally considered the adjuvant analgesic of first choice
265
[29•]. These drugs have been employed effectively against
several different pain syndromes, but especially neuropathic
pain, making them of considerable potential value in the
cancer setting. Unlike mood-elevating effects, the initial
analgesic effects of TCAs occur rapidly, often within a few
doses. Antidepressant effects of TCAs can be correlated with
serum levels, which generally is not true of other antidepres-
sants. There are data indicating that TCA-induced analgesia
also can be correlated with serum levels [32]. These drugs
have the added advantage of modest cost, compared with
newer antidepressants.
The side-effect profile of TCAs can make their use
problematic, especially in cancer patients who are seri-
ously ill. The anticholinergic, antihistaminic, and α-adr-
energic blockade effects of TCAs are greatest for the tertiary
amines (eg, amitriptyline, doxepin, imipramine), which
are more potent analgesics than secondary amines
(nortriptyline, desipramine). Sedation, constipation, uri-
nary retention, and orthostatic hypotension can be caused
by these medications or exacerbated in the setting of use
with opioid analgesics and other drugs. In seriously ill
patients, this can make the use of TCAs difficult even at
low doses let alone at doses necessary for therapeutic
serum levels. In such cases, the use of secondary amines is
preferred. These drugs must be used cautiously, if at all, in
cardiac patients, especially those who have had postmyo-
cardial infarction. They are potentially lethal in overdose
and thus must also be used cautiously in patients with
unstable or severe psychiatric disorders.
Selective serotonin reuptake inhibitors
The drugs in this class are likely the antidepressants pre-
scribed most often in clinical practice for the manage-
ment of depression. Selective serotonin reuptake
inhibitors (SSRIs) specifically influence reuptake of sero-
tonin at different receptor-binding sites. Within the class,
differences in effects on 5-HT binding may provide some
guidance in the selection of a drug. However, similar to
other antidepressants, the side-effect profile of the SSRI
is matched most often against particular symptoms (eg,
severe insomnia, fatigue) of the patient’s depression. The
SSRIs have been studied for treatment of several types of
pain, including that associated with diabetic neuropathy,
fibromyalgia, and migraine headache [31•]. Although
SSRIs have demonstrated significant relief of pain in
some studies compared with placebo, they do not per-
form well when compared with TCAs. The review of stud-
ies by McQuay et al. [30] of antidepressant treatment of
neuropathic pain revealed a rate of SSRI-induced major
side effects 50% that of TCAs.
Side effects of the SSRIs include nausea, anxiety,
insomnia (especially with the use fluoxetine), weight loss
or gain, and sexual dysfunction (especially, but not exclu-
sively fluoxetine). Thrombocytopenia is not common,
but does occur and is of obvious concern in patients
undergoing chemotherapy or who have undergone a
266 Cancer Pain

Table 4. Selected antidepressants for the management of depression and pain

Drug Starting dose, mg Dose range, mg Adverse effects
Tertiary tricyclics*
Amitriptyline 10 to 25 50 to 200 Moderate to severe weight gain,
Clomipramine 25 25 to 250 sedation, orthostatic hypotension,
Doxepin 10 to 25 30 to 200 sexual dysfunction, anticholinergic
Imipramine 10 to 25 50 to 200 effects, cardiac conduction effects
Trimipramine 50 50 to 200
Secondary tricyclics*
Desipramine 10 to 25 75 to 200 Moderate to severe weight gain,
Nortriptyline 10 to 25 50 to 150 sedation, orthostatic hypotension,
Protriptyline 10 to 20 15 to 60 sexual dysfunction, anticholinergic
effects, cardiac conduction effects
Tetracyclics
Amoxapine 25 to 75 200 to 300 Moderate to severe weight gain,
Naprotiline 25 to 75 75 to 300 sedation, orthostatic hypotension,
sexual dysfunction, anticholinergic
effects, cardiac conduction effects;
amoxapine also is associated with
extrapyramidal effects
Selective serotonin
reuptake inhibitors
Citalopram 20 20 to 60 Common anxiety, insomnia, sexual
Fluoxetine 10 to 20 20 to 60 dysfunction, variable effects on weight,
Paroxetine 10 to 20 20 to 60 no significant cardiac effects, except with
Sertraline 25 to 50 50 to 200 serotonin syndrome toxicity
Serotonin/norepinephrine
reuptake inhibitors
Nefazodone 100 to 200 200 to 600 Significant sedation, modest
Venlafaxine* 37.5 75 to 225 sexual dysfunction
Anxiety, nausea, variable sedation;
may be useful for hot flashes
Noradrenergic/specific
serotoninergic agents
Mirtazapine 15 15 to 45 Moderate sedation, appetite stimulation,
which can be useful for cancer patients
Noradrenergic/
dopaminergic agents
Bupropion 100 to 200 200 to 450 Seizure risk in predisposed patients,
variable anxiety, insomnia; no effect on
sexual function
Psychostimulants*
d-Amphetamine 2.5 to 5.0 bid 5 to 30 Anxiety, insomnia, hyper/hypotension;
Methylphenidate 2.5 to 5.0 bid 5 to 30 pemoline is associated with elevated
Pemoline 18.75 bid 37.5 to 150 liver transaminases
*Discussed in text; all dosages are oral; elderly or seriously ill patients should be started at low dosages [7,25,28,30,32,33].

bone marrow transplant. The drugs do not affect cardiac
conduction and are relatively safe in intentional overdose
situations, which is one reason why they are so popular in
general clinical practice. Serotonin syndrome is poten-
tially dangerous and occurs with increased serum seroto-
nin levels caused by dose escalation or combination
therapy with other serotoninergic drugs. It is character-
ized by anxiety, autonomic hyperactivity, hyper-reflexia,
diaphoresis, tremor, and hypertonicity. In worst cases,
altered mental status and life-threatening hyperpyrexia
may occur. Patients who are very sensitive may experience
serotonin syndrome at normal medication doses.
Third generation and atypical antidepressants
There are few available studies of these drugs, which include
combined serotonin/norepinephrine reuptake inhibitors
(venlafaxine, nefazodone), noradrenergic/specific serotonin-
ergic antidepressants (mirtazapine), and noradrenergic/
dopaminergic agents (bupropion). All of these drugs are
potentially useful in the management of the depressed cancer
patient. Most of the few studies to date have involved ven-
lafaxine, which appears to have some use in the treatment of
neuropathic pain [35,36] and hot flashes [37]. Very early
studies of mirtazapine suggest it also may be useful against
pain in cancer patients [38].
 Cancer Pain and Depression: Management of the Dual-diagnosed Patient • Valentine
Psychostimulants
These medications, including δ -amphetamine, meth-
ylphenidate, and pemoline, are useful in the management
of depression and cognitive impairment in cancer patients
[39–42]. Methylphenidate has been proven effective in the
reduction of opioid-induced sedation and is itself a co-
analgesic [43,44].
Psychostimulants may be particularly useful in the
treatment of seriously ill or debilitated cancer patients.
Onset of antidepressant effect is more rapid than with stan-
dard antidepressants. Psychostimulants improve appetite
and can counter disease or treatment-related fatigue. Their
use may facilitate increased (and more effective) opioid
dosing schedules [45].
The direct and indirect amphetamine agonists (δ -
amphetamine and methylphenidate, respectively) are used
most often in clinical practice. Dose response for the various
effects of these drugs can be highly variable. Common side
effects include tremor, anxiety, and insomnia. Patients with
poorly controlled hypertension are not good candidates for
treatment with psychostimulants, nor are patients at high
risk for or who have recently suffered a myocardial infarc-
tion. Although potentially quite useful in the seriously ill or
debilitated, these same patients are at higher risk for
stimulant-induced delirium. The drugs should be introduced
at low doses and increased if tolerated.
Antidepressant selection
The selection of appropriate antidepressant therapy for the
cancer patient who is depressed and in pain is not a
straightforward process. Variables that influence selection
include the quality and severity of symptoms, side effects
of candidate drugs, other drugs being used, the patient’s
medication history, and the clinician’s comfort level work-
ing with psychotropic drugs. The order in which pain and
depression come to attention (sequentially or simulta-
neously) also may be a factor. Mays [31•] has described the
selection process used by the Pain Medicine/Palliative Care
Center at the Huntsman Cancer Institute. The following
section is a consideration of variables from the perspective
of an oncological psychiatrist asked to treat depression in
the cancer patient in pain.
Patient antidepressant: naïve
Ideally, an antidepressant useful for pain would be
employed. This would suggest a TCA or venlafaxine. Seri-
ously ill or debilitated cancer patients often cannot tolerate
TCAs (especially tertiary amines) at dosages therapeutic for
depression, although a trial of a secondary amine (eg,
nortriptyline, desipramine) may be attempted. If not toler-
ated, venlafaxine becomes a reasonable first choice because
of its more benign side-effect profile. Alternatively, one can
use standard practice and attempt to match antidepressant
side effects to symptoms. Patients with significant insomnia
may benefit from a sedating drug such as mirtazapine or
nefazodone. For some patients, paroxetine is sedating and
267
can be administered at night. Patients with significant anor-
exia may benefit from weight gain and appetite stimulation
associated with mirtazapine. Often, sedation is not desirable
and one should consider an SSRI that is not sedating (eg, ser-
traline, citalopram). For the patient who is oversedated or
withdrawn, an activating SSRI (fluoxetine) or bupropion
may be considered. In these cases in which antidepressants
without analgesic properties are used, it often is possible to
employ a TCA at low doses (discussed below).
Patients with recurrent depression and histories of
successful treatment with an antidepressant often will
respond to the same drug if used again. If the depression
is severe, it is likely best to start with the original drug. If
the depression is mild to moderate and the pain is severe
or poorly controlled, one could attempt a trial of an
analgesic antidepressant and switch to the original drug
if there is suboptimal response.
Patient antidepressant: exposed
The patient responding to a nonanalgesic antidepressant,
but is in pain presents a dilemma. It has been suggested
that the patient be switched to an analgesic antidepressant
[30]. Although this can be done, there is some risk that
control of depression will be lost when the patient is
placed on an antidepressant of another class.
The patient who is not responding to a nonanalgesic
antidepressant therapy is more straightforward. The antide-
pressant dose may not be adequate and, if so, it is often
simpler and faster to optimize the dose than to change
medications. If the patient is on maximum antidepressant
dosages with poor response, a change to another (analge-
sic) antidepressant is indicated.
Combination therapy
It is not unusual for a patient with good coanalgesic
response to a low-dose TCA to come to evaluation for
depression. Alternatively, the patient with well-controlled
depression may not have well-controlled pain. If single-
agent treatment with TCAs at optimum dosages is unneces-
sary, inappropriate, or has failed, it often is possible to
combine low-dose TCAs and other antidepressants, usually
SSRIs. The major risk is elevation of serum TCA concentra-
tions to toxic levels. This risk is minimized by avoiding use
of highly protein-bound SSRIs (eg, fluoxetine) and keeping
TCA dosages low (25–50 mg).
Psychostimulants
Patients experiencing opioid-induced sedation (especially
if treatment is long-term), severe depression, which com-
promises care, or disease-associated asthenia are potential
candidates for treatment with stimulants. Tolerance is a
potential problem complicating the use of these drugs over
time. In some cases, a stimulant can be administered cau-
tiously with a standard antidepressant, with intent to “buy
time” for the latter medication to take effect. The stimulant
is then withdrawn.
268 Cancer Pain
Psychotherapy
Pain and depression are multidimensional constructs. It
follows that optimal treatment for both problems is multi-
modal, with a prominent role for psychotherapeutic inter-
ventions. The shared goals of psychotherapy for pain and
depression include support and improvement of coping
skills [8,26]. These goals are especially important in the
oncology setting where new, increased, or poorly con-
trolled pain may represent a real or imagined threat of
recurrent or advancing disease. Psychotherapeutic inter-
ventions intended to relieve psychologic distress (anxiety,
depression) can result in improved ability to cope with
pain [46–48].
Psychotherapeutic interventions that may be employed
to aid the dual-diagnosed cancer patient include crisis
intervention, brief supportive therapy, cognitive-behavioral
therapy, and group therapy. Depending on available
resources, patients often are referred to mental health pro-
fessionals to provide these therapies when appropriate.
When referring a patient for therapy, the clinician should
consider the acuity of the patient’s distress, the availability
of support resources, and the patient’s ability/willingness
to learn new coping strategies or to engage in a process of
self-disclosure [49].
It should be emphasized that the relationship between
patient and medical caregiver is itself a very important and
useful psychotherapeutic device [25,49]. Supportive ther-
apy is universally appropriate in the care of cancer patients
in distress. It can and should continue in the primary treat-
ment setting, even if the emphasis of treatment is medica-
tion- or intervention-based or if referral is made for more
specialized psychotherapy. In settings where specialists are
involved, fears of abandonment may be minimized and
feelings of support reinforced by emphasis on a team
approach. It is helpful to make sure that patients know
caregivers are communicating with each other and are kept
up-to-date with all of the aspects of treatment.
Conclusions
Supportive care in oncology will routinely involve man-
agement of dual-diagnosed patients with cancer-related
pain and cancer-related depression. Separately consid-
ered, each problem can confound attempts to control the
other. At the same time, palliation of each of these com-
plications of cancer can do much to make management of
the other more effective. Knowledge of the several avail-
able treatment modalities is essential and imaginative
combination of therapies is helpful, especially in difficult
cases. Consistent communication between physician and
patient and between treating consultants increases the
likelihood that medications will be used safely and effec-
tively and that the quality of life of patients with pain and
depression will be improved.
References and Recommended Reading
Papers of particular interest, published recently, have been
highlighted as:
• Of importance
•• Of major importance
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psychiatric disorders among cancer patients. JAMA 1983,
249:751–757.
2. Diagnostic and Statistical Manual of Mental Disorders, edn 4.
Washington DC: American Psychiatric Association; 2000.
3. Wilson KG, Chochinov HM, deFaye BJ, et al.: Diagnosis and
management of depression in palliative care. In Handbook of
Psychiatry in Palliative Medicine. Edited by Chochinov HM, Breit-
bart W. New York: Oxford University Press; 2000:25–49.
4. DeFlorio M, Massie MJ: Review of depression in cancer: gen-
der differences. Depression 1995, 3:66–80.
5. Plumb MM, Holland J: Comparative studies of psychological
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