Antidepressant Use in Children With Cancer What We Now Know (and Need to Know) About the Use of Antidepressants

In 2007, cancer was diagnosed in 10,400 children and adolescents under the age of 15 years.1 While cancer remains the second leading cause of death in children, increasing numbers of children with cancer are surviving into adulthood.2 Over the past 30 years, 5-year survival rates for children with cancer have significantly improved, from 59% in 1975 to 1977 to 80% in 1996 to 2004.3 Pediatric cancer, increasingly considered a chronic rather than an acute condition, is an intense emotional and physical experience for patients and their families.4

Comprehensive psychiatric assessment of these children is complicated by symptoms of medical comorbidities that overlap mental health conditions. Few resources exist to guide clinicians in the psychiatric treatment of children with cancer. This article describes the sparse research from small clinical studies on the extent of psychiatric treatment in children with cancer and evidence from outcome studies of medication use in these children. Minimal knowledge on the role of antidepressants in such children motivated us to examine the question in a broad population-based approach.

Psychopathology

One area of interest in caring for children with cancer is the prevalence of psychiatric diagnoses. Assessment of psychiatric disorders in these children from either research or community settings is difficult because of the complex medical and emotional presentation of illness.5,6 DSM-IV criteria for mood disorders, for example, include both somatic and cognitive symptom criteria, and clinicians must decide which symptoms are caused by the illness and treatment and which are related to a separate psychiatric diagnosis.7

In addition, doctors and nurses may overestimate psychosocial distress and symptoms in children and adolescents with cancer.6 Assessment tools for psychiatric disorders are not often validated in children with medical illnesses, which may lead in part to the varying research prevalence of psychiatric disorders in this population.8

Reports of psychiatric illness in children with cancer range from a high of 17% to rates that do not differ significantly from those for the general population.9 Specific cancers and their treatments may also contribute to the variable rates of depression. Without more precise estimates that generalize to large youth populations, it is unclear whether children with cancer are at higher risk for a psychiatric disorder than children who are not medically ill.

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Comorbidity in Bipolar Disorder The Complexity of Diagnosis and Treatment

The central tenet of clinical comorbidity, the occurrence of 2 syndromes in the same patient, presupposes that they are distinct categorical entities. By this definition, 2 or more coexisting syndromes do not negate one another, nor paradoxically does this coexistence negate the potential for one to influence the course, outcome, and treatment response of the other. Isolating a syndrome by characterizing it through a unique pathogenic process allows for diagnostic fidelity even while acknowledging overlapping phenotypes.

Bipolar disorder (BPD) is highly prevalent and heterogeneous. Its increasing complexity is often caused by the presence of comorbid conditions, which have become the rule rather than the exception. Lifetime prevalence of psychiatric comorbidity has been reported in community and clinical studies. Most (95%) of the respondents with BPD in the National Comorbidity Survey met criteria for 3 or more lifetime psychiatric disorders.1 In a Stanley Foundation Bipolar Treatment Outcome Network study of almost 300 patients, 65% met DSM-IV criteria for at least 1 comorbid Axis I disorder.2

Analogous to models in medicine (eg, cardiovascular disease), BPD incorporates psychiatric and medical comorbidities (Table) whose simultaneous treatment is equally pressing to the core mood disturbance.3 Checks and balances must be used to address the distressing comorbid condition (eg, anxiety) whose treatment with an SSRI or serotonin norepinephrine reuptake inhibitor (SNRI) may catalyze a round of mood cycling in an otherwise stable patient; a greater degree of protection via mood stabilizers may be warranted in such an individual to reduce this possibility.

Overall, the presence of comorbidities in BPD has negative prognostic implications for psychological health and for medical well-being and longevity.4-6 The most common comorbid conditions are reviewed below to help guide the clinician through this diagnostic maze and associated treatment considerations.

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