全科醫(yī)學中的心理健康病案研究(二十六)
——抑郁與惡性腫瘤

Sasha Fehily，Grant Blashki，F(xiàn)iona Judd，Leon Piterman，Hui Yang，Shane Thomas

在世界范圍內(nèi)，抑郁是首要的患病因素之一，6個人中就有1個人在生命過程中患過抑郁[1]。腫瘤是抑郁發(fā)生和發(fā)展的危險因素。腫瘤病人的抑郁發(fā)生率比一般人群高出3～5倍[2]。盡管有大量的科學文獻報道了腫瘤病人的抑郁流行情況，但對其流行率的估計卻相差很大。Couper等[3]的研究結(jié)果顯示，腫瘤病人中的重性抑郁障礙(major depressive disorder)的流行率為10%～25%。國際上對腫瘤診療服務(wù)的研究一致認為，腫瘤病人的抑郁問題通常沒有得到診斷，并很少得到治療。

1 病史

李贊(化名)女士，兩個孩子的母親，58歲時被診斷為乳腺癌。診斷前2個月，她洗澡的時候在左側(cè)乳房觸摸到一個腫塊。她到你的診所來看病，你安排她做乳腺X線檢查，然后再做超聲檢查，最后進行活組織檢查。你把她的檢查結(jié)果轉(zhuǎn)到乳腺外科專家那里，請專家做進一步診斷。

今天她再次來到你的診所看病，目的是討論乳腺外科專家的診斷結(jié)果。李贊女士的診斷結(jié)果是浸潤性導管癌(3度)，Nottingham總評分為8分；腫塊直徑2 cm，雌激素和孕激素受體呈陽性。她昨天去看了乳腺外科專家，專家建議做乳房切除術(shù)、淋巴結(jié)切除術(shù)，并接受為期5年的他莫昔芬(tamoxifen，三苯氧胺)治療。此外，腫瘤學專家的會診建議是輔助化療和放療。專家還告訴她，如果她想要做乳房再造手術(shù)，可以考慮在做乳房切除術(shù)的同時做再造術(shù)。

在與李贊女士討論的過程中，你發(fā)現(xiàn)她的情緒和上次來看病時很不一樣。你再進一步詢問她怎樣應(yīng)對自己現(xiàn)在發(fā)現(xiàn)的病情，她開始眼中含淚，說自己這些日子心境一直很差。她說最近不愿意去見任何親近的朋友。她的媽媽一直在努力地支持她，跟她進行過一次嚴肅的談話，告訴她怎樣克服當前的困難。不過李贊認為這種談話更讓她灰心喪氣，所以她回避跟她媽媽談?wù)撨@個話題。她掙扎著與腦海中不斷涌現(xiàn)的有關(guān)死亡的想法做斗爭，不過她否認自己有自殺想法。她還說自己的食欲不振，自從第一次發(fā)現(xiàn)乳房腫塊后，體質(zhì)量一直下降，現(xiàn)在體質(zhì)量減少了3 kg。

2 體檢

對病人進行心理健康狀態(tài)檢查：她穿著干凈整潔并且寬松的衣服。她留著長發(fā)，但看上去頭發(fā)不太干凈。她很少和你目光接觸，偶爾自言自語，而且她說話的聲音很輕。她的情緒是憂郁的。沒有發(fā)現(xiàn)她有明顯的思維障礙，她自己也否認自己有任何妄想和幻覺。她對時間、地點和人物有定向力。她對自己最近的心境變化表現(xiàn)出較好的洞察力。

對病人進行體檢：這是一位正常和身材苗條的婦女。她的生命體征正常，沒有甲狀腺機能減退的征象。所有身體檢查中惟一發(fā)現(xiàn)是左乳房下外四分之一處的一個無壓痛的小硬結(jié)。沒有觸摸到淋巴結(jié)腫大。

3 提問

3.1 提問1：腫瘤病人每天要應(yīng)對哪些困難？

3.2 提問2：應(yīng)該考慮哪些重要的鑒別診斷？在闡明正確診斷的時候，會面臨哪些困難？

3.3 提問3：抑郁和惡性腫瘤之間有因果聯(lián)系嗎？

3.4 提問4：為什么要認識到治療腫瘤病人抑郁的重要性？

3.5 提問5：針對惡性腫瘤病人的抑郁，有哪些治療選擇？

4 解答

4.1 解答1：腫瘤病人每天要應(yīng)對的困難 當一個人接受癌癥診斷的時候，必須面對很多情感上的困難。腫瘤病人會有一些自然的情感反應(yīng)，比如自己問自己一些不合理的和無助的問題，如“為什么是我得癌癥？”、“是不是我做錯了什么事情？”。病人還可能對疾病的不確定性感到迷茫，對不得不面對死亡感到束手無策。這些情感困難使病人處于焦慮狀態(tài)，影響他們的健康，需要進行治療。就李贊的病例而言，大約40%的乳腺癌病人有抑郁和焦慮癥狀[4]。病人常見的壓力是與朋友和家人談?wù)撟约旱牟∏?。大多?shù)病人對別人的同情、支持和幫助感到不舒服，認為這是自己給別人平添了麻煩。

在患癌癥這樣的疾病過程中，需要應(yīng)對很多現(xiàn)實中的問題。病人不可避免地要打亂自己原來的生活計劃。在病人進入治療過程時，不可能持續(xù)原來那樣的家庭生活，也不可能繼續(xù)實現(xiàn)原來的工作承諾。由于長期處于生病狀態(tài)，并由于治療的副作用使人感到虛弱無力，病人很可能無法行使社會和家庭責任，這需要改變家庭其他成員的責任分工。從更大的范圍看，需要改變工作場所和社會的責任分工。

除了情感和現(xiàn)實中面臨的問題外，病人還可能患其他的腫瘤相關(guān)疾病，并可能患因為治療而造成的疾病。

4.2 解答2：應(yīng)該考慮的重要的鑒別診斷以及在闡明正確診斷時面臨的困難 當接受腫瘤診斷的時候，病人會出現(xiàn)悲傷或害怕等正常反應(yīng)，因此你必須要考慮到的一個問題是確定病人所經(jīng)歷的情感變化是不是對壓力的正常反應(yīng)。為了能給病人提供正確的治療措施，一定要把這些正常的情感反應(yīng)與綜合征性心境障礙(syndromal mood disorder，如重性抑郁)相鑒別。

對患軀體疾病的病人，比如癌癥病人，明確地診斷出抑郁性障礙可能是比較困難的。首先，病人的抑郁癥狀可能被錯誤地歸因于腫瘤，因為抑郁的軀體化癥狀與腫瘤直接導致的心理癥狀是難以鑒別開來的。這些癥狀通常包括：疲勞、體質(zhì)量降低、缺乏食欲、睡眠紊亂、精力下降等。通常某些認知癥狀，如缺乏興趣、集中力差、記憶紊亂、容易激惹、做決定困難等，對診斷和治療檢測來說更有價值[3]。

此外，化療或放療等治療措施可能導致某些軀體化抑郁癥狀(如疲勞感)，或許不是抑郁的問題。反過來看，有很多抑郁癥狀可能被錯誤地認為是治療措施的副作用導致的，從而導致識別不出來抑郁障礙。還有必要指出的是，有很多因素可以影響腫瘤病人的心境，比如疼痛、無法活動、虛弱無力、對死亡的恐懼等。

最后一點，特別是在治療階段的后期，很多腫瘤病人表達出“寧愿去死”的想法。非常重要的是，要明確病人的這個想法是抑郁性疾病的一部分，還是病人對腫瘤的心理反應(yīng)。如果是抑郁性疾病的一種表現(xiàn)，我們可以改變治療抑郁的策略，選擇那些更可能有益于改善病人生活質(zhì)量的治療方法。需要提醒的是，對腫瘤的診斷是眾所周知的自殺危險因素。

4.3 解答3：抑郁和惡性腫瘤之間的聯(lián)系 各科研文獻對腫瘤病人抑郁障礙的流行率報道并不一致，即便如此，流行率的估計范圍已經(jīng)高到足以讓研究者努力地探討兩者的關(guān)系。首先，有個別類型的腫瘤可以直接對人的心境產(chǎn)生生物學效應(yīng)，比如顱內(nèi)腫瘤可以對大腦造成直接的占位效應(yīng)，造成心境變化。還有越來越多的證據(jù)表明，某些腫瘤影響下丘腦-垂體-腎上腺軸，其作用機制是全身皮質(zhì)醇激素分泌受到了影響[5]。人們認為某些腫瘤，如胰腺癌和小細胞肺癌，會通過尚不明確的激素效應(yīng)造成病人抑郁。此外，很多腫瘤治療藥物(如皮質(zhì)類固醇激素)和化療藥物(如長春堿、環(huán)磷酰胺、干擾素)[3]也能造成心境紊亂。其他藥物以及某些外科措施(如卵巢切除術(shù)或抗雄激素治療)可能造成激素失衡，繼而影響病人心境。

對于患乳腺癌的女病人來說，使用他莫昔芬(一種雌激素受體拮抗劑)經(jīng)常會導致更年期癥狀。在用他莫昔芬的女病人中，大約有2/3的人有血管舒縮癥狀(潮熱和夜間出汗)。這些癥狀往往伴隨焦慮、睡眠紊亂以及社交和工作能力變差，并可能加劇抑郁癥狀。

某些人口學特征與抑郁的高流行率有關(guān)，如診斷腫瘤時比較年輕、女性、腫瘤部位、腫瘤轉(zhuǎn)移、以往手術(shù)情況等。另外的一些因素則可能影響抑郁的發(fā)展，如經(jīng)濟狀況、人格特質(zhì)、社會支持、種族和文化背景等。某些腫瘤與抑郁的相關(guān)性更大，特別是口咽癌、胰腺癌、乳腺癌、肺癌。

4.4 解答4：認識到治療腫瘤病人的抑郁的重要性 研究結(jié)果表明，患抑郁的腫瘤病人住院時間長、治療結(jié)果差、生活質(zhì)量下降。此外，抑郁能使治療的副作用(如疼痛強度和疲勞感)更加明顯[4]。抑郁癥狀可以導致病人對治療的依從性差，這可能是由于抑郁病人缺乏動機和集中力受損造成的。因此，雖然腫瘤病人都會正常地出現(xiàn)輕度或不穩(wěn)定的抑郁癥狀，但腫瘤卻不會必然地導致持續(xù)的心境低落、認知障礙或軀體化癥狀(如抑郁性障礙)。之所以很多腫瘤病人的抑郁得不到診斷和治療，最常見的原因是醫(yī)務(wù)人員認識不到這一點。

4.5 解答5：針對惡性腫瘤病人的抑郁治療選擇 有強有力的證據(jù)表明，采用心理療法治療腫瘤病人的抑郁可以讓病人獲得各種收益。心理教育(psychoeducation)、認知行為療法(CBT)、人際治療法(IPT)都能夠改善病人的心境紊亂，提高他們的自信心。有證據(jù)表明，采用小組式的干預(yù)方法，能夠起到特別的效果，這些方法包括認知行為療法、支持-傾述療法(supportive-expressive therapy，SET)、正念減壓法(mindfulness-based stress reduction，MBSR)、非正式支持小組法(informal support groups)[4]。

如果病人出現(xiàn)中度或嚴重的抑郁，則提示應(yīng)該采用藥物治療。選擇性5-羥色胺再攝取抑制劑(SSRIs)是一線的藥物干預(yù)。臨床隨機對照研究證據(jù)表明，氟西汀(fluoxetine，百憂解)、帕羅西汀(paroxetine)和安定(sertaline)都是有效的。有些病人使用SSRIs可能出現(xiàn)惡心癥狀；如果使用化療藥物也可能加重惡心癥狀。另外，還可以使用文拉法辛(一種5-羥色胺去甲腎上腺素受體抑制劑，SNRI)，不過它可能有一些額外的鎮(zhèn)靜作用。有證據(jù)表明三環(huán)類抗抑郁藥(TCAs)對抑郁是有效的；不過要限制這類藥物的使用，因為它有明顯的副作用，并在過量服用時有中毒的危險。

重要的是要意識到某些抗抑郁藥與化療藥物的相互作用。最常見的藥物相互作用是通過CYP450同工酶系統(tǒng)產(chǎn)生的代謝作用。這是抗抑郁藥的常見代謝途徑，而抗腫瘤藥物可以造成這些抗抑郁藥在血清中的蓄積。需要注意的是，抗抑郁藥(特別是SSRIs)與他莫昔芬有相互作用[6]。帕羅西汀以及其他SSRIs在較小的程度上拮抗CYP450同工酶2D6。因此，如果要使用SSRIs的話，要選擇對2D6代謝作用最小的藥物，比如西酞普蘭(citalopram)[4]。另外一個例子是蒽環(huán)類化療藥物(anthracycline-based chemotherapies)，該藥物經(jīng)常用于乳腺癌化療，它會與三環(huán)類抗抑郁藥發(fā)生相互作用，導致心電圖上的QT延遲，使病人容易發(fā)生尖端扭轉(zhuǎn)型室性心動過速(心動過速的一種特殊類型)[4]。對于所有的臨床病例來說，要根據(jù)具體病人的具體臨床問題，選擇恰當?shù)闹委煼椒?。同時，在治療策略中要考慮到更廣泛的心理學問題以及家庭和社會因素[7]，因為這些因素可能造成病人心境紊亂的反彈，也是心境紊亂的危險因素。

1 Depression[EB/OL].http://www.beyondblue.org.au/the-facts/depression.

2 Chan A,Ng TR,Yap KY.Clinically relevant anticancer antidepressant drug interactions[J].Expert Opin Drug Metab Toxicol,2012,8(2):173-199.

3 Couper JW,Pollard AC,Clifton DA.Depression in cancer[J].MJA Open,2012,1(Suppl 4):13-17.

4 Agarwala P,Riba MB.Tailoring depression treatment for women with breast cancer[J].Current psychiatry,2010,9(11):39-49.

5 Pasquini M,Biondi M.Depression in cancer patients:A critical review[J].Clin Pract Epid Ment Health,2007,3:21-30.

6 Desmaris JE,Loopers KJ.Managing menopausal symptoms and depression in tamoxifen users:Implications of drug and medicinal interactions[J].Maturitas,2010,67:296-308.

7 Blashki G,Judd FK,Piterman L.General practice psychiatry[M].North Ryde(NSW):McGraw-Hill Australia,2006.

·WorldGeneralPractice/FamilyMedicine·

【IntroductionoftheColumn】 The Journal presents the Column of Case Studies of Mental Health in General Practice;with academic support from Australian experts in general practice,psychology and psychiatry from Monash University and the University of Melbourne.The Column′s purpose is to respond to the increasing need for the development of mental health services in China.Through study and analysis of mental health cases,we hope to improve understanding of mental illnesses in Chinese primary health settings,and to build capacity amongst community health professionals in managing mental illnesses and psychological problems in general practice.A patient-centred whole-person approach in general practice is the best way to maintain and improve the physical and mental health of residents.Our hope is that these case studies will lead the new wave of general practice and mental health service development both in practice and research.A number of Australian experts from the disciplines of general practice,mental health and psychiatry will contribute to the Column.Professor Blashki,Professor Judd and Professor Piterman are authors of the text General Practice Psychiatry;the Chinese version of the book to be published in 2014.The Journal cases are helping to prepare for the translation and publication of a Chinese version of the book in China.We believe Chinese mental health in primary health care will reach new heights under this international cooperation.

Depression is one of the leading causes of morbidity worldwide with the lifetime rate of 1 in 6 people[1].Cancer is a risk factor for the development of depression,with the incidence being three to five times more than that of the general population[2].Despite the wealth of literature,the prevalence of depression in this subgroup widely varies in its estimation.According to Couper et al the prevalence of defined major depressive disorder in people who have cancer is estimated to be 10%-25%[3].International cancer services are united in recognising that depression often goes undiagnosed and undertreated depression in patient′s suffering from cancer.

1 History

Mrs Li Than,a single mother of two,was 58 when she was diagnosed with breast cancer.Two months previously,while Li was taking a shower,she felt a lump on her left breast.After presenting to your practice,she was sent for a mammogram,then an ultrasound and finally a biopsy.You referred her to a breast surgeon to discuss the diagnosis.

She has presented to your practice today to discuss the recommendations made to her by the surgeon.Li′s diagnosis was invasive ductal carcinoma grade 3 with a total Nottingham score of 8.The mass was two centimetres in diameter and was positive for oestrogen and progesterone receptors.She saw a breast surgeon yesterday who recommended a mastectomy,lymphadenectomy and five years of tamoxifen treatment,in addition to a consultation with an oncologist for likely adjuvant chemotherapy and radiotherapy.She was informed that if she wanted breast reconstruction surgery,it would be possible for it to be performed at the same time as the mastectomy.

On discussion with Li,you discover that her affect is markedly different from her last presentation.Upon further questioning about how she is coping,she becomes teary and describes a persistently low mood.She has noticed a recent reluctance to see any of her close friends.Her mother has been trying to support her emotionally and to have a serious discussion about what she is going through,but Li just finds this frustrating and avoids the discussion.Li is struggling with overwhelming thoughts about death,but denies suicidal ideation.She has noticed a reduction in her appetite and has consequently lost three kilograms since she first noticed the breast lump.

2 Examination

On mental status examination,she is neatly dressed in loose-fitting clothes.Her hair is long and not particularly tidy.She maintains poor eye contact,has minimal spontaneous speech and is softly spoken.Her affect is depressed.No formal thought disorder is evident and she denies any delusional thinking or hallucinations.She is oriented to time,place and person.She displays a good degree of insight into her recent change in mood.

Her physical examination reveals a normal,thin woman.Her vital signs are normal and she has no signs of hypothyroidism.All that is remarkable throughout the rest of the physical examination is a small firm non-tender breast mass in the lower outer quadrant of the left breast.There is no palpable lymphadenopathy.

3 Questions

3.1 Question1:What are the common day to day hardships that someone with cancer would have to deal with?

3.2 Question2:What are the key differential diagnoses to consider and what difficulties are faced when delineating the correct diagnosis?

3.3 Question3:Is there a causal link between depression and malignancy?

3.4 Question4:Why is it important to recognize and treat depression in patients with cancer?

3.5 Question5:What are the options available for treating depression in patients with malignancy?

4 Answers

4.1 Answer1:What are the common day to day hardships that someone with cancer would have to deal with? There are many emotional difficulties a person must face on receiving a diagnosis of cancer.It is natural to respond by asking oneself irrational and unhelpful questions such as "why me?" and "is this my fault?".Patients may also find difficulty in coming to terms with the uncertainty of the illness and having to face the possibility of death.This causes an anxiousness surrounding one′s health and required treatments.Of relevance to Li′s case,approximately 40% of patients with breast cancer suffer from depression and anxiety symptoms[4].A common area of stress is communicating the news to friends and family.Many feel uncomfortable with receiving sympathy,support and assistance,seeing it as a burden on other people.

Similarly many practical issues have to be dealt with during the course of an illness such as cancer.An interruption of life plans is inevitable.It is hard to continue coordinating family and work commitments around regular treatment.Patients are likely to face an inability to fulfill their social and familial responsibilities due to associated periods of being unwell or suffering from treatment side effects that cause debilitation.This can also require a change of other people′s roles in the family,at work and in society at large.

In addition to coping with these emotional and practical issues,cancer patients might also be suffering from physical ailments associated with their illness and its treatment.

4.2 Answer2:What are the key differential diagnoses to consider and what difficulties are faced when delineating the correct diagnosis? Feelings of sadness and fear are normal responses to receiving a cancer diagnosis,so an essential consideration is to determine whether the patient is experiencing what can be regarded as a normal response to stress.In order to provide appropriate medical treatment,it is crucial to differentiate these normal feelings from a syndromal mood disorder (major depression).

It can be difficult to be clear about the diagnosis of a depressive disorder in patients with physical illnesses such as cancer.First,symptoms of depression can be misattributed to cancer due to the difficultly in differentiating between somatic symptoms of depression and the direct physiological symptoms associated with cancer.Some of these commonly include;fatigue,loss of weight and appetite,sleep disturbance and decreased energy.Cognitive symptoms such as loss of interest,poor concentration,memory disturbance,irritability,difficulty making decisions are generally more useful in making a diagnosis and monitoring treatment[3].

Additionally,somatic depressive symptoms such as fatigue can be caused by treatments such as chemotherapy and radiotherapy,rather than being due to untreated depression.Conversely,a number of depressive symptoms can be mislabeled as treatment side effects leading to risk of under-recognition of a depressive disorder.It is also necessary to note the multiple factors that are likely to be contributing to a patient′s mood in the setting of malignancy including pain,immobility,debilitation and fear of death.

Finally,particularly in the later stages of treatment,many patients with cancer express the thought that they would rather be dead.It is important to be clear whether such thinking is part of a depressive illness,and so may be changed by treatment with potentially significant benefits for the person′s quality of life,or whether this is a thought expressed in the absence of a depressive disorder.Of note,a diagnosis of cancer is a well-known risk factor for suicide.

4.3 Answer3:Is there a causal link between depression and malignancy? While the prevalence of depressive disorders in patients with cancer varies throughout the literature,the estimated ranges are high enough to warrant the search for a link between the two.Firstly,a small number of cancers may have direct biological effects on mood.For example,intracranial lesions can have a direct mass effect in the brain,causing mood alteration.There is also increasing evidence to suggest that some cancers influence the Hypothalamic-Pituitary-Adrenal axis.The mechanism of mood alteration here is postulated to be due to a change in systemic cortisol secretion[5].Some cancers,such as pancreatic cancer and small cell lung cancer are thought to cause depression by a yet to be clarified hormonal effect.Additionally,many of the oncological therapeutic agents,such as corticosteroids and chemotherapies including vinblastine,cyclophosphamide and interferon[3]are known to cause mood disturbance.Other agents and some surgical interventions,such as oophorectomy or androgen ablation,can result in hormone imbalance,which in turn may affect mood.

For women with breast cancer,the use of tamoxifen,an oestrogen receptor antagonist,often induces menopausal symptoms.Vasomotor symptoms (hot flushes and night sweats) occur in around two thirds of women treated with tamoxifen.These symptoms are often associated with anxiety,sleep disturbance and poorer social and occupational functioning,and may exacerbate depressive symptoms.

Some demographic variables have been associated with a higher prevalence of depression,including younger age of diagnosis,being female,location of the cancer,metastases and prior surgery.Other variables are also likely to influence the development of depression,such as economic status,personality traits,social support and ethnic and cultural background.Similarly,depression is more commonly associated with certain cancers,particularly oropharyngeal,pancreatic,breast and lung cancer.

4.4 Question4:Why is it important to recognize and treat depression in patients with cancer? Research has demonstrated that depression in individuals with cancer is linked to prolonged hospital stays,worse clinical outcomes and a reduction in quality of life.Additionally,depression can lead to worsened side effects,such as pain intensity and fatigue[4].Depressive symptoms can contribute to non-compliance with treatment;this may be secondary to a lack of motivation or impaired concentration.Thus,it is important to be clear that whilst mild and fluctuating depressive symptoms can be normal in patients with cancer,sustained low mood accompanied by cognitive and somatic symptoms (i.e.a depressive disorder) is not.Failure to recognize this is one of the most common causes of patients being undiagnosed and untreated.

4.5 Answer5:What are the options available for treating depression in patients with malignancy? Strong evidence surrounds the benefits of psychotherapy in treating depression in patients with cancer.Psychoeducation,Cognitive Behavioural Therapy (CBT) and Interpersonal Therapy (IPT) have all been shown to improve mood disturbance and self-esteem.Several group interventions particularly shown to be effective include;CBT,supportive-expressive therapy (SET),mindfulness-based stress reduction (MBSR),as well as informal support groups[4].

Pharmacological therapy is indicated for individuals with moderate or severe depression.Selective Seratonin Receptor Inhibitors (SSRIs) are used as first-line pharmacological intervention.Fluoxetine,paroxetine and sertaline all have supporting evidence in RCTs.In some patients the SSRI′s may cause nausea,or exacerbate nausea due to chemotherapeutic agents.Venlafaxine,a Seratonin Noradrenaline Receptor Inhibitor (SNRI) is also used,and may have some additional analgesic benefit.Tricyclic antidepressants (TCAs) have demonstrated effectiveness;however,use is limited due to side effects and the danger of toxicity in overdose.

It is important to be aware of some interactions between antidepressant medication and chemotherapeutic agents.The most frequent interaction is due to the metabolism via the CYP450 isoenzyme system.This common metabolic pathway for antidepressants and anti-cancer drugs can cause a disturbance in the plasma concentration of these medications.Of note,Antidepressants,particularly some SSRIs interact with Tamoxifen[6].Paroxetine and to a lesser extent some other SSRIs inhibit the CYP450 isoenzyme,2D6.So if using an SSRI,choose an agent with minimal effect on the 2D6 metabolism such as citalopram[4].Another example is anthracycline-based chemotherapies,which are frequently used in breast cancer patients,can interact with TCAs and lead to QT prolongation on ECG,predisposing the patient to the development of torsades de pointes,a particular type of tachycardia[4].As in all clinical encounters,it is important to choose the appropriate treatments based on the specific clinical issues in the patient and to ensure that treatment includes consideration of broader psychological issues,family and social factors which may act as both resilience and risk factors for the patient′s mood disturbance[7].

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4 Agarwala P,Riba MB.Tailoring depression treatment for women with breast cancer[J].Current psychiatry,2010,9(11):39-49.

5 Pasquini M,Biondi M.Depression in cancer patients:A critical review[J].Clin Pract Epid Ment Health,2007,3:21-30.

6 Desmaris JE,Loopers KJ.Managing menopausal symptoms and depression in tamoxifen users:Implications of drug and medicinal interactions[J].Maturitas,2010,67:296-308.

7 Blashki G,Judd FK,Piterman L.General practice psychiatry[M].North Ryde(NSW):McGraw-Hill Australia,2006.