Intended for healthcare professionals

Practice 10 Minute Consultation

Exploring low mood in a person with cancer

BMJ 2018; 361 doi: (Published 25 April 2018) Cite this as: BMJ 2018;361:k1488
  1. Alexandra Pitman, Macmillan consultant liaison psychiatrist, senior clinical lecturer in psychiatry1 2,
  2. Sahil Suleman, Macmillan consultant clinical psychologist, honorary research associate1 2,
  3. Nicholas Hyde, consultant head and neck surgeon1,
  4. Andrew Hodgkiss, consultant liaison psychiatrist, honorary clinical senior lecturer3 4 5
  1. 1St George’s University Hospitals NHS Foundation Trust, London, UK
  2. 2UCL Division of Psychiatry, London, UK
  3. 3Central & North West London NHS Foundation Trust, London, UK
  4. 4The Royal Marsden NHS Foundation Trust, London, UK
  5. 5Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, UK
  1. Correspondence to: A Pitman a.pitman{at}

What you need to know

  • Psychological, rather than biological, symptoms of depression, such as anhedonia and pronounced helplessness, hopelessness, guilt, and suicidal ideation, tend to be key diagnostic pointers to depression in patients with cancer

  • Anxiety is regarded as pathological in a patient with cancer when it is disproportionate to the level of threat and disrupts usual functioning

  • Investigate and address reversible causes, such as vitamin deficiency or hypercalcaemia, and perpetuating factors, such as pain

A 54 year old man asks his doctor for a sleeping tablet. He has recently been diagnosed with a Dukes B adenocarcinoma of the rectum and seems low in mood. Although he has been given a good prognosis, has completed neoadjuvant chemotherapy, and is booked for curative surgery shortly, he expresses doubts that he will live much longer. His doctor wonders if he might be depressed or anxious, and how best to address this.

Depression and anxiety are more common in patients with cancer, and they are associated with poorer quality of life and cancer survival.12 This article offers advice on how to recognise these disorders, and when to offer referral for specialist advice.

During the assessment, form an impression about whether the patient has depression:

  • Is this pathological low mood or anxiety, or is this a normal response to the threat posed by cancer?

  • Could this be a direct effect of a medication or the disease?

What you should cover


Explore current mood and difficulties with sleep. Facilitate disclosure by acknowledging that some patients may feel depressed or anxious after a cancer diagnosis, even when receiving lifesaving treatment.

  • Ask about:

    • Specific psychological symptoms. These are the key diagnostic pointers of depression in patients with cancer. Ask about anhedonia (loss of pleasure or interest in previously enjoyable activities), and pronounced feelings of helplessness, hopelessness, guilt, or suicidal ideation causing severe distress or …

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