Jessie, a 69-year-old retired health visitor, who was known to have an 8-year history of breast cancer with bone metastases (diagnosed 2 years ago), presented to the palliative care outpatient clinic with increasing bone pain that was not responding to conventional analgesia, and her husband who accompanied her reported that for last 3 months, Jessie had become increasingly withdrawn and was reluctant to visit friends or attend the weekly craft group which she greatly enjoyed and which she had help set up. On examination, Jessie sat slumped in the chair and made little eye contact during the consultation, she was frequently tearful and when asked what she thought may be the problem and what could be done to help, she replied ‘I know you are trying to help doctor, but you are wasting your time, nobody and nothing can help me...’ Jessie’s current medication included letrozole and co-codamol as an analgesic – she had received radiotherapy to the left hip 18 months previously with a very good effect and total pain relief. A letter from her oncologist revealed that a recent bone scan revealed stable disease and that the disease had been stable for over 12 months. The oncologist also reported that a recent CT scan showed no evidence of any other metastases but noted that Jessie had appeared ‘disinterested during the clinic consultation, which is not like, her as she usually asks a lot of questions.’ Recent bloods test revealed full blood count, urea and electrolytes, calcium and liver function tests to all be within normal limits.
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1. What do you think is likely to be cause of Jessie’s symptoms?
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Correct answer:
Jessie’s symptoms of being increasingly withdrawn and not taking part in activities, together with the lack of eye contact and disengagement during the consultation suggest that Jessie is depressed.
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2. What is the relevance of her past history?
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Correct answer:
Jessie is known to have breast cancer and bone metastases, that is, she has advanced cancer; however, her disease is currently stable. We do know that approximately 25% of patients with advanced cancer will have symptoms of depression but that these are frequently not assessed or diagnosed – note the recent clinic letter from the oncologist who, although noting a change in Jessie’s mood, did not carry out an assessment for depression.
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3. Why do you think Jessie complains of having increased pain?
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Correct answer:
Jessie is known to have bone metastases and has had radiotherapy in the past and was currently taking co-codamol as analgesia - she was known to have received radiotherapy in the past with good effect. There are two possible explanations for Jessie’s increased pain. It is known that patients who are depressed have increased symptom burden including pain possibly due to the fact that they limit their external activities and have more time to focus on what previously may have been thought of as trivial physical symptoms. There is also a belief that patients who are depressed do not take regular analgesia, as they feel so hopeless and see no point in doing so. When asked directly, Jessie admitted that co-codamol 4 times daily had given her total pain relief; however, over last 6 weeks, she had not taken any co-codamol, as she could not see the point in doing so.
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4. What would help decide on the correct diagnosis?
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Clearly, in a patient like Jessie, it is important to exclude any physical cause - the recent letter from the oncology and scan results suggest stable disease as do blood tests. In a patient with known bone metastases, it would be appropriate to re-check serum calcium levels and also to screen for thyroid disease. Asking the patient to complete the BEDS and PHQ-9 to screen for depression is also important.
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5. Jessie scores 11/18 on BEDS and 14/21 on PHQ-9 - what does this suggest?
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Correct answer:
Both scores suggest that Jessie is depressed. The BEDS is a screening tool and a cut-off of 6/18 suggests patients may be depressed and require further evaluation. The score of 14 on PHQ-9 suggests that Jessie is suffering from moderate depression (10--15 is the threshold for moderate depression) and that she requires an intervention.
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6. Would anti-depressant medication be appropriate for Jessie?
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Correct answer:
It is vital to speak to Jessie and her husband and explain the findings - Jessie tearfully states that she is so glad somebody has taken notice of how depressed she is and that they are trying to help her. She agrees to a prescription of mirtazapine 15 mg at night and to be reviewed again in the clinic in a week’s time (to check compliance and also to review blood results and pain). Jessie feels at present that she cannot attend her craft group but agrees to attend the hospice day care for a 12-week assessment period. This helps Jessie re-engage within a supportive environment, provides support for Jessie and her husband and the variety of diversional activities available help Jessie to re-engage with her previous activities.
