Editor—In the ABC of psychological medicine Peveler et al discuss depression in medical patients.1 As a haematologist I often have to respond to depressive reactions in patients with malignant disease who are confronted with a poor prognosis and difficult decisions about treatment. Some degree of this reactive demoralisation is normal and has to be acknowledged. It is psychological in nature and different from major depression as a disease of the brain.2 Sometimes the problem is distinguishing depressed patients with tumours from patients who are depressed because of tumours.
Most of the studies included in the meta-analysis of drug treatment taken from the Cochrane review by Gill and Hatcher had to struggle with this distinction.3 This analysis did not compare tricyclic antidepressants with selective serotonin reuptake inhibitors, as stated in the caption of the table; rather it compared drug treatment (tricyclic antidepressants, tetracyclic antidepressants, and selective serotonin reuptake inhibitors) with placebo. The reflected benefit is therefore neither the benefit of antidepressive treatment in major depression (with medical comorbidity) nor the benefit in patients with reactive symptoms. The first two lines of the table should not be taken as evidence that every symptom of depression in a patient with cancer warrants drug treatment.
Meta-analyses of selective serotonin reuptake inhibitors versus other antidepressants are also available in the Cochrane Library and show no major difference in efficacy and only a modest advantage for selective serotonin reuptake inhibitors in terms of fewer dropouts.4,5
Fortunately, most patients with cancer and depressive adjustment disorders respond to a supportive environment and counselling and do not need drug treatment. The observed depressive reaction—for example, after the disclosure of malignancy—should not be taken as an excuse to withhold the truth from patients or to overmedicalise the condition. I sometimes wonder whether patients who seem to show no emotional reaction at all to bad news are in fact the more abnormal.
References
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