In the view of some health care providers, clinical depression may be the most underdiagnosed and undertreated side effect in all of cancer care. Depression can affect anyone who has cancer, including adults, teens, and children. Estimates suggest that about 1 in 4 people with cancer experience depression at some point after diagnosis, yet relatively few receive treatment. This is unnecessary suffering.

Barriers. Unfortunately, many people with cancer who experience the classic symptoms of clinical depression don't seek help. They and their caregivers think that feeling very sad and exhausted is to be expected when coping with cancer, and they don't report these feelings to their health care team. Some think the depression they feel is just part of the expected side effects of treatment. Additionally, the health care team caring for cancer patients may not be expert in recognizing the symptoms of depression. As experts in oncology, their focus is on treating your cancer.

Severe depression can be overwhelming — and it has been known to cause some patients to stop treatment before completion. This can have tragic consequences, as interrupted treatment jeopardizes the odds of success.

The key to eliminating barriers to care is awareness. The more you know, the better off you will be to care for yourself and seek the help you need.

Types of depression. Depression is usually categorized in two ways:

• Situational depression — this more common condition is usually short-lived, and is often triggered by grief and an extreme emotional event, such as that experienced by a person receiving a diagnosis of cancer. As everyone who has had this experience understands, there is a period of time immediately following diagnosis when the world seems to stop. Heart and mind are filled with anxiety about death, about a future that cannot be imagined. Depression is often accompanied by a range of other emotions, including anger, fear and anxiety, and symptoms like sleeplessness. Generally, this is followed by a period of adjustment as a new reality emerges, and we move forward into coping with it. People with these feelings respond to support, comfort, encouragement and assistance, and usually do not require additional ongoing assistance from health care professionals.
  
  
• Clinical depression — or Major Depressive Disorder as it is sometimes called — is more than a basic response to very bad news. This is a biologic event that impacts almost all of a person's life functions, even routine tasks. In the words of writer William Styron, who himself experienced depression, it feels like "darkness visible." Interest in life is gone, replaced by a flat, empty feeling. Psychologists call this anhedonia — a lack of joy — and it is a key diagnostic symptom. Sadness colors everything, and no hope for the future is seen. Sometimes it is almost impossible to function in any normal way, and exhaustion takes over. People experiencing clinical depression do not respond to support, comfort or encouragement.

Causes & Risk Factors

While there is no definitive research as yet showing the exact cause of clinical depression in cancer patients, there is growing belief in the medical community that some cancers themselves, as well as some treatments, may trigger clinical depression in some patients. A biologic basis for depression is being explored by researchers. What is important for patients to remember is that having risk factors and experiencing depression does not mean nothing can be done. Medications and treatment are effective in managing depression.

Risk factors include:

• A past history — personal or family, of depression, drug or alcohol abuse, and/or a past suicide attempt
  
  
• Some cancers themselves seem to trigger more depression than others, including pancreas, brain, gynecologic, lung and head and neck
  
  
• Some medications are associated with depression in some people:
  
  
  • Corticosteroids, such as prednisone (Deltasone) and dexamethasone (Decadron). These medications are often given to combat the side effects of treatment and to reduce inflammation. They can cause extreme anxiety, as well. Depression sometimes occurs if these medications are stopped abruptly, without tapering off the medication gradually.
    
    
  • Tamoxifen. This is an estrogen-blocking medication used in the treatment of breast cancer. Although a possible side effect in some people is depression, you do not necessarily have to stop this potentially beneficial medicine. Rather, the depression can be treated and you can continue to take Tamoxifen.
    
    
  • Interferon, used sometimes for cancer treatment, can cause depression.
    
    
  • Chemotherapy medications — notably vincristine, vinblastine, methotrexate and procarbazine — may trigger depression in some patients.
    
    
  • Other medications can also be factors in depression. The list includes opioid medications to relieve pain, some antihypertensives (like beta-blockers to relieve high blood pressure), anticonvulsant medications, drugs used to treat Parkinson's Disease, and medications intended to treat certain mental illness.
    
    
• Chemopause — a not-so-affectionate name women have given to the condition that results when cancer surgery and/or treatment triggers "instant" menopause — is also identified as a possible cause of depression. Estrogen is abruptly eliminated from a woman's body, causing numerous side effects, including, in some instances, clinical depression.

Symptoms

Depression usually does not happen all at once. You will probably not wake up one morning with great depression. More often, it develops slowly, sometimes so slowly that the gradual erosion of the quality of life is subtle. You may notice you are feeling sadder, less involved, less engaged in the world, and dismiss these early feelings as probable side effects of the treatment you're receiving. Another common early symptom is disturbed sleep patterns.

A key element in recognizing the presence of clinical depression is the measurement of how long you have been feeling significant symptoms, such as those listed below. Feeling these things, or some combination of them for two weeks or longer is a strong indicator that you may have depression, and that you need medical help to combat this.

The symptoms below are both mental and physical. Please note that almost no one has all of these symptoms — but you should seek help if you are experiencing five or more. If suicidal feelings are one symptom you feel, please seek help immediately by talking with someone, calling your doctor or a suicide hotline.

Symptoms include:

• A persistent depressed mood, most of the time
  
  
• Persistent thoughts about suicide
  
  
• Feeling you are "not yourself"
  
  
• Loss of interest and pleasure in life — an "empty" mood that does not lift
  
  
• Feelings of hopelessness and pessimism
  
  
• Difficulty or inability to concentrate*
  
  
• Frequent crying, or feeling close to tears
  
  
• Fatigue — extreme in some cases, inability to function normally*
  
  
• Feeling worthless or guilty
  
  
• Sleep problems — insomnia or oversleeping*
  
  
• Weight issues — decreased appetite, or overeating*
  
  
• Anxiety
  
  
• Aches and pains in joints and other parts of the body*

The symptoms above with asterisks (*), can also be side effects of cancer treatment. This fact can mask the presence of depression, if they are combined with other symptoms listed above. You may find some help by just asking yourself, "Am I depressed?" You should discuss ALL of your side effects with your health care team so they can see a complete picture of how you are feeling — and raise the issue of the possibility of depression. Don't assume that the presence of side effects is all just a routine part of having cancer.

Diagnosis

There is no simple lab test for depression. Your health care team may wish to consult with a psychiatrist or psychologist for assistance in assessing your symptoms. Particular attention will be paid to your moods, such as loss of interest in life and things that gave pleasure, sadness, and feelings of worthlessness and guilt. You'll need to provide information about the physical symptoms you are experiencing, such as your appetite, how well you are sleeping, fatigue levels and your overall sense of how you are feeling.

The diagnostic process, with your full cooperation and assistance, will help your health care providers assess the severity level of your depression, and develop recommendations for treatment.

Treatment

The good news is that treatment for depression works. In recent years, great strides have been made in successfully treating depression.

Most depression, including depression in people with cancer, responds to treatment. Treatment for most people will include consultation with a mental health professional, such as a psychologist or psychiatrist, and as needed, the use of medications.

Working with a mental health professional usually involves a series of private conversations to discuss your feelings. These individuals will work to help you find ways to manage your emotions effectively.

Medications are an important part of managing depression for many people. Your health care professional will select a medication course for you, based on all the factors involved in your health, medical history and treatment.

However, you should be aware that in some cases, it may be necessary to try more than one medication before finding the treatment that is most effective for you. Medications used to treat depression have many different ways of acting on the body — and what works well for one person may not be effective for another. It's best to be prepared to give each medication a fair trial, and to change if need be. This process can be frustrating, but don't lose hope and don't give up!

Most medications used to treat depression do not become effective immediately. Most people feel no improvement for several days, at the earliest, and many of these medicines don't reach their maximum effectiveness for several weeks. Understanding that it may take some time for your medications to work can be helpful and comforting while you wait for results.

Most of these medications have side effects, and they will affect people in different ways. Your health care team can discuss the most common side effects with you for the medicine you are prescribed.

There are several different types of medications that are generally prescribed for people with cancer experiencing depression:

• Selective Serotonin Reuptake Inhibitors (SSRIs). Serotonin is a neurotransmitter in the blood that affects mood; more serotonin usually means less depression. These drugs, and others that also act to reduce the dissipation of serotonin from the body, work to keep serotonin in your blood. Some of the most-prescribed are:
  
  
  • Fluoxetine (Prozac)
  • Paroxetine (Paxil)
  • Sertraline (Zoloft)
    
    
• Serotonin Norepinephrine Reuptake Inhibitors (SNRIs). These medications boost levels of norepinephrine as well as serotonin. The medication in this category often prescribed is venlafaxine (Effexor).
  
  
• Seratonin Antagonist Reuptake Inhibitors (SARIs) — yet another formulation that acts on serotonin to increase amounts in the body:
  
  
  • Nefazodone (Serzone)
  • Trazodone (Desyrel)
    
    
• Tricyclic Antidepressants. These medications and others like them have been around for many years:
  
  
  • Amitriptyline (Elavil)
  • Imipramine (Tofranil)
  • Nortriptyline (Pamelor)
    
    
• Norepinephrine Dopamine Reuptake Inhibitor (NDRI). The one medication in this category used for cancer patients is bupropion (Wellbutrin).
  
  
• Noradrenergic Specific Serotonergic Antidepressant (NaSSAs). The medication in this category used with cancer patients is mirtazapine (Remeron).

Helping Yourself

Helping yourself can be an important part of coping with depression. Here are some ideas to consider:

• Get the help you need. The first one is the most important: if feelings of depression do not lift within two weeks, seek help at once. You must be your greatest advocate and expert on how you are feeling. Don't be argued out of seeking help by anyone — not caregivers, not your oncology health care team. A significant depression that lasts two weeks or longer is not likely to just go away by itself, nor is there anything you can do by yourself to alleviate it. Life is precious, and you have a right to feel as good as you can to enjoy it.
  
  
• Support groups. Once your depression is being treated, consider becoming part of a cancer support group if you have not already done so. Support groups are not for everyone, yet many patients find that having a time to be with others in circumstances similar to their own is beneficial.
  
  
• Relaxation techniques. Some people find that even simple relaxation methods, like deep breathing, can be helpful. Other relaxation approaches to consider include massage, imagery and meditation. For more information on each of these, see the section on Alternative and Complementary Medicine in the NCCS Resource Guide.
  
  
• Exercise. Even a little exercise can be both stimulating to the spirit and relaxing for the mind. Movement, research has shown, stimulates body chemicals that help to combat depression.
  
  
• Be in the world. As is possible, and as suits your spirit, be out and about in the world, as opposed to sitting alone. Contact and interaction with others can help lift the spirits — especially if you can spend time doing something you enjoy.

For Caregivers

If you are reading about depression because you believe a loved one with cancer is depressed, here are some steps you can take to help:

• If you suspect depression, act at once (the loved one has been very depressed for two weeks or more, or has discussed suicide)
  
  
  • Don't wait for your loved one to decide on getting help. Severe depression can be so overwhelming and exhausting that the energy to seek help may be more than can be mustered. You can be enormously helpful in encouraging that help be sought, and take the lead in making arrangements for it.
    
    
• Steel yourself a bit. Sometimes people with depression are so "down" that it can be exhausting for others. Don't try to persuade your loved one to feel better if she or he is resistant to hearing this, and try to remain even-tempered, affectionate and patient. Remember that depression is caused by a chemical imbalance in the brain and is not the "fault" of your loved one.
  
  
• Patience with medications is important. Bear in mind — and remind your loved one — that the medications used to treat depression don't work overnight, and that sometimes more than one medication must be tried to find one that works well. Be encouraging and supportive of experimentation if that proves necessary, and remind her or him that treatment does work for most people.
  
  
• Call the doctor at once if your loved one:
  
  
  • Is actively speaking of suicide and ways to do it
  • Has not seen the doctor lately and the depression is getting worse
  • Is unable to sleep or eat for several days
  • Has difficulty breathing
  • Is experiencing extreme restlessness or agitation
    
    
• Care for yourself, too. It is not uncommon for caregivers to also experience depression. Cancer impacts everyone in a family, and perhaps the frontline caregiver almost as much as the patient. If you or another person in your family is experiencing symptoms of depression, seek help and treatment.
  

Questions for Your Doctor

1. How can I recognize the symptoms of depression?
   
   
2. Could my kind of cancer or my treatments be causing or contributing to my feelings of depression?
   
   
3. How will you determine if I am depressed and need help?
   
   
4. If I am depressed, what help will be available to me? Who will oversee my care?
   
   
5. Will treating depression interfere with my cancer treatment?
   
   
6. I have been feeling pretty sad for the last few days. Does this mean I am clinically depressed?
   
   
7. If I am depressed and need treatment, how long will it last?
   
   
8. Lately I've been gaining weight. Does this mean I might be depressed?
   
   
9. The medication given to me for depression has done nothing for more than a week. I don't feel better. Is it time to try something else?
   
   
10. I have been upset and sad that my cancer has recurred, but I figured these feelings were normal for the situation. Is it possible I am depressed and need assistance?
    
    
11. Can you refer me to a social worker or other reliable source of information about support groups and other forms of assistance?

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