It appears that increased pain and decreased performance in terminal cancer were more closely correlated with depression, rather than terminal cancer itself. Increased pain, and specifically increased pain with metastasis (which occurs with stage 4 disease), may play a causal role, as individuals with high levels of pain reported significantly lower previous episodes of depression (Spiegel et al., 1994). Based on similar findings, Ciaramella and Poli (2001) hypothesized that depression follows pain and metastasis. This argues the need to integrate pain assessment in evaluation of depression, especially in metastatic cancer.