Introduction
Diagnostic Issues
Major Depression
Etiologic approach (ICD-DSM): based on the nine traditional symptoms of major depression (depressed mood, anhedonia, appetite or weight change, sleep disturbance, fatigue, psychomotor disturbance, feelings of worthlessness or guilt, impaired concentration, and suicidal thoughts) to be present (at least five—of which either depressed mood or anhedonia are mandatory—for at least 2 weeks of duration), but symptoms that are clearly and fully attributable to the cancer (as a general medical condition) are excluded, otherwise depression due to a general medical condition is diagnosed. |
Inclusive approach (modified ICD-DSM): as above, but symptoms are counted regardless whether or not they might be attributable to cancer. |
Substitutive approach (Endicott’s criteria) [12]: in Criterion A, neurovegetative/somatic symptoms are substituted by cognitive/affective symptoms (specifically: diminished ability to think or concentrate or indecisiveness replaced by fearfulness or depressed appearance in face or body posture; weight loss or gain or a decrease in appetite replaced by social withdrawal or decreased talkativeness; insomnia or hypersomnia replaced by brooding, self-pity or pessimism; fatigue or loss of energy replaced by “cannot be cheered up, doesn’t smile, no response to good news or funny situations). These substitute symptoms should be used if the medical condition is likely to affect/cause the somatic symptoms. |
Exclusive approach (Cavanaugh’s criteria) [13]: in Criterion A, hopelessness, helplessness, and not caring anymore are added to either depressed mood or anhedonia as mandatory (plus three other symptoms) for at least 2 weeks of duration; significant weight loss or weight gain, psychomotor agitation or retardation, insomnia or hypersomnia, and fatigue or loss of energy are excluded, unless temporarily related to cognitive/affective symptoms. In Criterion B, one extra item (not participating in medical care, in spite of ability to do so, he is not progressing despite improved medical condition and/or is functioning at a lower level than the medical condition warrant) is added. |
Alternative approach (Akechi’s criteria) [15]: as in inclusive approach plus other items do be fulfilled in order to diagnose mild major depressive episode (fearfulness or depressed appearance in face or body posture; brooding, self-pity or pessimism), moderate major depressive episode (not participating in medical care in spite of ability to do so, not progressing despite improving medical condition and/or in functioning at a lower level than the medical condition warrants; social withdrawal or decreased talkativeness) and severe major depressive episode (cannot be cheered up, doesn’t smile, no response to good news or funny situations).
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Persistent Depressive Disorder
Dysthymia |
Based on the presence of depressed mood for the last 2 years (criterion A) plus at least two of the six traditional symptoms of dysthymia (Criterion B), defined in DSM5 as Persistent Depressive Disorder (i.e., poor appetite or overeating; insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, feelings of hopelessness), but after having ascertained that (a) hopelessness is not demoralization or discouragement related to the reality of the medical illness; (b) low self-esteem is feeling bad about oneself, not the situation; and (c) all the somatic symptoms are not easily explained by physical illness, treatments, or hospital environment. |
Adjustment disorders (with depressed mood) |
In Criterion A, The development of depressed mood in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s) should include illness (e.g., cancer) or treatment, as stressor(s). |
In Criterion B, the fact that there is a marked distress reaction in excess of what would be expected from exposure to the stressor should consider that rarely with medical illness is the distress considered in excess of the stressor. Also, a further item (treatment is recommended) is added. |
Adjustment Disorder and Other Depressive Disorder
Demoralization
Demoralization/subjective incompetence (De Figueiredo) [34] |
A combination of distress (anxiety, sadness, discouragement, and resentment) and subjective incompetence (a feeling of being trapped or blocked because of a sense of inability to plan and initiate concerted action toward one or more goals) |
Persistent failure of coping with internally or externally induced stress |
Feelings of impotence, isolation, and despair |
Individual’s self-esteem damaged |
Feelings of rejection by others because of his or her failure to meet their expectations |
Diagnostic Criteria for Psychosomatic Research (DCPR Criteria)—demoralization module (Fava et al.) [35] |
A. A feeling state characterized by the patient’s consciousness of having failed to meet his or her own expectations (or those of others) or being unable to cope with some pressing problems; the patient experiences feelings of helplessness, or hopelessness, or giving up |
B. The feeling state should be prolonged and generalized (at least 1 month duration) C. The feeling closely antedated the manifestations of a medical disorder or exacerbated its symptoms |
DCPR Criteria - demoralization module -Revised (Fava et al.) [38••] |
A. A feeling state characterized by the perception of being unable to cope with some pressing problems and/or of lack of adequate support from others (helplessness); the individual maintains the capacity to react |
B. The feeling state is prolonged and generalized (duration of at least 1 month) C. A feeling state characterized by the consciousness of having failed to meet expectations associated with the conviction that there are no solutions for current problems and difficulties (hopelessness) |
[criteria A and B are required; criterion C is a specifier for the presence of hopelessness] |
Encompassing hopelessness or loss of meaning and purpose in life |
Cognitive attitudes of pessimism, helplessness, sense of being trapped, personal failure |
Absence of drive or motivation to cope differently |
Associated features of social alienation or isolation and lack of support |
Fluctuation in emotional intensity |
Persistence of above-mentioned phenomena across two or more weeks (and a major depressive or other psychiatric episode should not be present as the primary condition) |