Assessment Approaches And Issues

Depression has been assessed using a variety of approaches including self-report, brief screening measures, and structured clinical interviews. Common self-report measures include the Hospital Anxiety and Depression Scale (HADS),6 the Rotterdam Symptom Checklist (RSCL),7 the Beck Depression Inventory (BDI: regular and short forms),8,9 the Brief Symptom Inventory-Depression scale (BSI-D),10-12 Center for Epidemiologic Studies Depression Scale (CES-D),13 and the Zung Self-Rating Depression Scale (ZSRDS: both full and brief forms).14,15 A major limitation of self-report measures is that they are unable to provide a diagnosis of depression, providing instead information as to the severity of depressive symptoms. An additional limitation is that the measures often include physical symptoms that may be the result of the cancer itself (e.g., feeling fatigued), and not feelings of depression.

In contrast, clinical interviews are strictly designed to provide a diagnosis of depression and other psychiatric illnesses. Indeed, structured clinical interviews have traditionally been considered the gold standard for identifying the prevalence, clinical significance, and potential treatment of depression because of their rigorous criteria. Common interviews include the Schedule for Affective Disorders and Schizophrenia (SADS),16 Structured Clinical Interview for DSM (SCID),17 Research Diagnostic Criteria (RDC),18 and the Diagnostic Interview Schedule (DIS).19 In addition, researchers and clinicians have used unstructured clinical interviews in which they diagnose depression based on DSM20,21 or Endicott22 criteria. Unfortunately, clinical interviews are not without limitations. Structured clinical interviews have been criticized for the length of time they take to administer and the amount of training that they require for proficiency in administration and scoring,23 as well as having little reliance on contextual information. Semistructured interviews presumably would allow the interviewer to ask additional questions that would help determine whether the physical symptoms endorsed are the result of cancer or its treatment, are the result of another physical malady, or are indeed the consequence of depression. Perhaps a greater limitation of structured clinical interviews, however, is the fact that they were developed and validated on a population devoid of significant comorbid medical illness. The result, as Hall et al.24 point out, is that even clinical interviews are unlikely to be completely reliable. Nevertheless, as previously mentioned, they are standard for diagnosing depression.

Having reviewed the basics of diagnosis and assessment of depression in cancer survivors, we will now turn to incidence, prevalence, and correlates of depression. Specifically, the remainder of this chapter will cover five areas. First, we will address the incidence of depression from the time of diagnosis through the end of primary treatment for cancer. Second, we will examine the research investigating the prevalence and correlates of depression after primary treatment. Third, we will provide an overview of studies of depression in long-term survivors of cancer. Fourth, we will briefly touch on psychosocial and biological theories of depression in cancer survivors. Finally, we will touch on directions for future research.

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