Depression in cancer patients

There is some variance in the emotional reactions of people diagnosed with cancer. 

  • For instance, it is perfectly normal for most, if not all cancer patients to experience some degree of sadness and grief.  
  • However reactions can vary along a spectrum of mild, moderate or severe experience, which can last for a short period or seem un-ending. 
  • The seriousness and level of debility caused by a persons’ reaction will dictate what level of treatment may be recommended. 
  • For mild cases, joining a support group or learning to utilize a few coping skills can help. 
  • For moderate to severe cases counseling or medications may be indicated. 

 

Normative Depressive Reactions (Grief)
When people find out they have cancer it is normal to experience some degree of disbelief or despair.

  • They may also experience difficulty sleeping, loss of appetite, and a preoccupation with worries about the future. All of these reactions make sense. 
  • After all cancer is not just a medical condition; it can be impactful in terms of self-image and relationships. 
  • Cancer can also give rise to financial issues and less productivity.
  • The severity of these normative depressive symptoms usually lessens over the six months following diagnosis.
  • A good indicator that a person has adjusted to cancer diagnosis is the ability to continue functioning as a spouse, parent, employee, or other roles by incorporating treatment into one’s life.

 

Other Depressive Reactions
Depression affects approximately 15% to 25% of all cancer patients and it affects men and women equally. For the sake of simplicity we categorize depressive reactions as falling into two categories, reactive depression and major depression. 

 

Reactive Depression
Reactive depression is the most common type of depression experienced by cancer patients.  

  • As the name suggests, this type of depression is the result of an identifiable psychosocial stressor, such as a diagnosis of cancer. 
  • With this type of depression, most people notice mood changes such as increased irritability or pronounced sadness that can lead to an inability to perform usual activities.
  • Symptoms of reactive depression last longer than anticipated and are more pronounced, but do not meet criteria for major depression. 

 

Major Depression
People often use the word “depression” in day-to-day language to mean the normal ups and downs of life.

  • Major depression differs greatly from this, in that it is severely debilitating and often is a distinct change from previous functioning. 
  • A person who cannot adjust to cancer diagnosis after a long period of time, and who loses interest in usual activities, may be experiencing major depression.
  • Major depression is a severely debilitating clinical syndrome that often requires medical intervention. 
  • If you notice changes in your mood but are unsure about the severity of those changes, it is recommended that you speak with your health care team for guidance.

 

Symptoms of Major Depression include five or more of the following:

  • Persistent irritable, sad or “empty” mood often accompanied by excessive crying
  • Loss of interest in ordinary activities
  • Fatigue or loss of energy nearly every day
  • Sleep disturbances
  • Difficulty concentrating   
  • Feelings of guilt, worthlessness
  • Significant weight changes
  • Feeling wound up or slowed down
  • Recurrent thoughts of death or suicide

 

Why is depression important to address?
Depression can be a serious health concern. It is extremely important that serious depression be identified and treated as early as possible so that individuals with cancer can have the best outcomes possible.

  • Severe depression can lower immune functioning and thereby impact cancer treatment and day-to-day functioning directly. 
  • Of course, as previously stated, it is nearly impossible to be diagnosed with cancer and not experience some degree of sadness. 
  • Realistic treatment goals that center around reducing the impact of depression rather than abolishing it all together (which may not be realistic) can also be vastly helpful in improving ones’ functioning. 
  • It is not helpful, however, to beat yourself up about experiencing depression or to add to your stress level by feeling guilty for having this emotion.

 

Just as patients need to be evaluated for depression throughout their treatment, so do family caregivers.

  • Caregivers have been found to experience a good deal more anxiety and depression than people who are not caring for patients with cancer.
  • Children are also affected when a parent with cancer develops depression.
    • A study of women with breast cancer showed that children of depressed patients were the most likely to have emotional and behavioral problems themselves.

What increases the risk of depression?
The following factors may increase the risk of depression:

  • Depression at the time of cancer diagnosis
  • Poorly controlled pain
  • An advanced stage of cancer
  • Increased physical impairment or pain
  • Pancreatic cancer
  • Being unmarried and having cancer
  • Treatment with some anti-cancer drugs
  • History of depression
  • Lack of family support
  • Other life events that cause stress
  • Family history of depression or suicide
  • History of alcoholism or drug abuse
  • Having many coinciding illnesses (such as stroke or heart attack)

 

Treatment of Depression in Cancer Patients
Several psychiatric therapies have been found to be helpful in the treatment of depressive reactions related to cancer.  

  • Talk therapy and medication management are the most common and effective treatments. Both are available at Kaiser Permanente Santa Clara Medical Center.
  • Specific goals of these therapies are to reduce depressed mood, improve overall functioning, and improve immune functioning.   

 

Talk therapy for Depression
Engaging in professional counseling is typically recommended for mild to moderate cases of depression. 

  • Talk therapy alone would not be indicated if depression is severe or suicidal thoughts are present. 
  • Talk therapy, especially a form of therapy called cognitive behavioral therapy, has been shown to be effective for many persons experiencing depression. 

Generally, talk therapy is helpful because it provides cancer patients with:

  • Education
  • Problem solving skills
  • Enhanced communication and identification of emotions
  • Healthy coping skills
  • Diminished stress
  • Added emotional support
  • Boundary setting
  • Enhanced hope and optimism
  • Increased spiritual awareness

Peer or professionally led cancer support groups may be helpful in treating depression in patients with cancer, especially adolescents.

    • Support groups have been shown to improve mood, encourage the development of coping skills, improve quality of life, and improve immune response.
    • Talk to your cancer care team about referrals for support groups or talk therapy.

Medication Management for Depression
Major depression may be treated with a combination of talk therapy and medications such as antidepressants. A primary care doctor may prescribe medications for depression and refer the patient to a psychiatrist or psychologist for the following reasons:

  • A physician or oncologist is not comfortable treating the depression (for example, the patient has suicidal thoughts)
  • The symptoms of depression do not improve after 2 to 4 weeks of treatment
  • The symptoms are getting worse
  • The side effects of the medication keep the patient from taking the dosage needed to control the depression
  • The symptoms are interfering with the patient's ability to continue medical treatment

 

Antidepressants are usually effective in the treatment of depression and its symptoms.

    • Unfortunately, antidepressants are not prescribed often for patients with cancer.
    • If 25% of all patients are depressed, only about 16% will receive medication for the depression.
    • The choice of antidepressant depends on the patient's symptoms, potential side effects of the antidepressant, the person's individual medical problems, and previous response to antidepressant drugs if any.

Most antidepressants take 3 to 6 weeks to begin working.

  • The side effects must be considered when deciding which antidepressant to use.
  • If an antidepressant improves symptoms, it is usually recommended that treatment continue for 6-12 months or longer depending upon severity.

 

Dietary Supplements for Depression
St. John's wort (hypericum perforatum) has been used as an over-the-counter supplement for mood enhancement.

  • In the United States, dietary supplements are regulated as foods, not as drugs. The FDA does not require that supplements be approved before being putting them on the market. Because there are no standards for product manufacturing, consistency, dose, or purity, the safety of St. John's wort is not known.
  • Patients with symptoms of depression are encouraged to avoid self-treatment with St. John's wort and instead should be evaluated by a health care professional.
  • St. John's wort is not recommended for major depression in patients who have cancer.

 

Exercise and depression:
Regular exercise 30 minutes a day was recently found to reduce rate of depression.

  • A regular exercise program can help reduce weight gain, improving energy level, reducing stress level and therefore improving physical and mental function.

 

Following are the links to online support resources:

 


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