Depression in men on ADT


Depression is relatively common among men with prostate cancer. Indeed, it may be a lot more common than we can currently document.

Why?

Because men tend to avoid admitting to disorders like depression until the disorder reaches the point of being seriously debilitating — unless, of course, their spouses, partners, or children are able to drag them to the doctor earlier.

Critical problems, therefore, in assessing the risk for depression in men with prostate cancer — and the association of risk for depression with a specific type of treatment — include a host of other complicated factors, including:

  • How are we defining “depression”? (The definitions can vary.)
  • How are we measuring levels of depression?
  • Had the patient been diagnosed with depression prior to his diagnosis with prostate cancer?
  • Had the patient been diagnosed with depression after his diagnosis with prostate cancer but before he started on the treatment being evaluated (androgen deprivation therapy or ADT in this case)?
  • How long after the patient started the ADT was he diagnosed with depression?

And these are only some of the key issues!

A large, new analysis of data from nearly 40,000 US veterans, all being treated at VA institutions around the country, has recently be reported by Deka et al. in the journal Cancer. Their report is accompanied by an editorial (by Polacek and Nelson). In addition, there is commentary on this new study on the Healio web site. Your sitemaster has had the opportunity to review the full texts of all three of these documents.

Deka et al. looked very specifically at the incidence of depression in veterans who had received treatment for their prostate cancer that comprised radiation therapy with ADT within 1 year of their initial diagnosis. All of the patients were initially diagnosed with their prostate cancer between January 1, 2001, and October 31, 2015. The primary study outcome was new development of depression after initiation of treatment with radiation therapy + ADT.

We should be clear that this was not a prospective clinical trial. This was a retrospective analysis of data over the near to 15-year period from 2001 to 2015.

The core findings of the study were as follows:

  • 39,965 veterans were diagnosed with prostate cancer during the study period and received definitive radiation therapy as their first-line treatment
    • The average (median) age of the patients was 66.8 years.
    • 68.6 percent of the patients were white.
    • Average (median) follow-up for these patients was 6.8 years.
  • 14,843/39,965 of these patients (37.1 percent) were also started on ADT within 12 months of their initial diagnosis.
  • Average (median) time on ADT was 243 days or about 8 months.
  • Of these 14,843 patients
    • 943 (6.4 percent) were newly diagnosed with depression after starting ADT.
    • 7,825 (52.7 percent) took advantage of outpatient psychiatric services.
    • 358 (2.4 percent) required inpatient psychiatric services.
    • 54 (0.4 percent) committed suicide.
  • Use of ADT was associated with
    • The development of depression (subdistribution hazard ratio [SHR] = 1.50)
    • Outpatient psychiatric utilization (SHR = 1.21)
  • Use of ADT was not associated with either inpatient psychiatric utilization or suicide.

Now this study still does not tell us what percentage of the 39,965 patients actually had depression. It only tells us the percentage who were diagnosed with this condition or took advantage of psychiatric services for some other reason. And of course many veterans of this generation could have had all sorts of reasons for seeking psychiatric services. Depression may not have been high on the list for at least some of them.

What the study does tell us, however, is that there seems, finally, to be a clear relationship between risk for depression and initiation of treatment with ADT. This will not come as a surprise to most prostate cancer advocates.

In their editorial commentary, Polacek and Nelson state clearly that:

As research such as that of Deka et al … continues to provide robust support for the causal relationship between ADT use and depression in patients with prostate cancer, it is imperative that clinicians be vigilant in their screening for and treatment of depression in this population.

We trust that ASTRO and the AUA will join ASCO in making clear to their members the importance of this piece of guidance in the management of prostate cancer patients being treated with ADT.

We would also take this opportunity to remind patients that there should be no shame associated with depression after a diagnosis of prostate cancer (regardless of how you may get treated or managed). Prostate cancer can be a highly debilitating condition for all sorts of physiological and emotional reasons. If it makes you depressed and that depression is affecting your quality of life, talk to your doctor(s) about this — whether it is your primary care physician or a specialist who is managing your prostate cancer. Depression can be treated.

3 Responses

  1. Mike is so correct about his analysis of depression in men with prostate cancer with or without ADT. It is so important to know what the underlying history for depression was/is for a man before the diagnosis of prostate cancer.

    Since depression is so common in an older population (and often unrecognized) it becomes even more important to have the data documented before looking at outcome data on a specific treatment.

    Every man who has had active treatment for prostate cancer is likely to have some depression since the side effects are so impactful (especially sexual function). Since men are such deniers, it is very hard for them to admit and discuss depression, much less impotence or incontinence.

    I have been on continuous ADT for 11 years and luckily had no history of depression. I may have a “down day” but rarely two in a row.

    Thanks Mike for another good review.

  2. What are some signs and treatments for depression.

  3. Dear Kevin:

    That is an extraordinarily difficult question to answer well. The best I can really do is send you to this link (for symptoms and causes) and this link (for diagnosis and treatment) on the Mayo Clinic’s excellent educational web site. Please note in particular that signs and symptoms of depression (and the relevant treatments) can vary a great deal by age and by severity of the depression.

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