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Depression in Cancer: Does it come with the territory?
People often expect that having cancer would make anyone depressed, that it is “normal,” but clinical depression is anything but normal and is imminently treatable. The challenge is that cancer can often cause the same symptoms that are seen in depression, so that depression is under-recognized and consequently undertreated.
What is depression? It is a clinical condition that is marked by one of two major symptoms, depressed mood and loss of interest in most activities (called anhedonia), as well as at least 4 other symptoms. These could include feelings of hopelessness, helplessness, worthlessness, guilt, and thoughts of suicide as well as physical symptoms such as fatigue, anorexia (loss of appetite), sleep problems (too little or too much), and weight loss. If those physical symptoms sound familiar, it’s because they can also occur due to cancer itself; as a result, the physical symptoms are not as helpful in identifying clinical depression.
To complicate things further, both patients and clinicians often mistake clinical depression as a “normal” emotional reaction to the cancer. There is indeed an expected emotional response to this diagnosis, including sadness, and while patients with cancer may have initially difficulty with their normal functioning and social interactions, patients who aren’t depressed are able to adapt. A patient with clinical depression won’t be able to do normal daily functioning on an ongoing basis. They will also persistently not be able to enjoy activities or experience pleasure. Their thought processes will be affected and consumed by helplessness, guilt and low self-esteem as well as hopelessness. A despondency accompanies the hopelessness, as opposed to a patient who feels hopeless due to discovering their cancer is incurable but can re-direct hope to something else (life prolongation, good quality of life). Actively seeking an early death is more indicative of clinical depression, in the absence of poorly controlled symptoms or inadequate social support.
Who’s at risk for depression?
The incidence of depression amongst cancer patients is thought to be 15-25% based on a systematic review of the literature. Certain types of cancers have an increased incidence of clinical depression, including lung, pancreas, breast, and head & neck. Risk factors include a prior history of depression or suicide attempt, a family history of depression, history of drug or alcohol abuse, and poorly controlled symptoms, particularly pain. This underscores the importance for managing and controlling symptoms, both from the cancer itself as well as from treatment side effects. Young age at diagnosis is also considered a risk factor for depression. Interestingly, these risk factors vary somewhat from those for suicide; a recent 2008 Harvard study found that older aged patients with cancer had an increased risk for suicide.
Treatment
In general, the most effective treatment strategy is a combination of psychotherapy and medication. There is a larger body of literature looking at this combination approach that demonstrates its superiority in the general population and smaller studies in cancer-specific trials. I will also comment here that social support (family, friends, patient-only networks) has not been studied in formal trials (hard to randomize patients to social support vs. no social support), but lack of social support and social isolation is a considerable risk factor for suicide in depressed patients.
Psychotherapy
Psychotherapy alone has been demonstrated to improve depressive symptoms in multiple studies, though the number of randomized control trials is small. It can occur either in individual sessions or in professionally led groups; both have demonstrated efficacy. In general, this therapy focuses on crisis intervention and cognitive behavioral therapy. Crisis intervention aims to alleviate the immediate distress of stressful situations, i.e. the cancer diagnosis, life changes due to the cancer, etc. Cognitive behavioral therapy works to provide new coping skills and strategies for correcting the irrational thoughts in depression.
Medications
Antidepressants are the primary group of medications used; I know this sounds like a no-brainer, but there are other classes of medications that are used as well. There are two main categories of antidepressants used: the tricyclic antidepressants, or TCAs, and the selective serotonin reuptake inhibitors, or SSRIs.
The TCAs are much older but better studied—these include elavil (amitriptyline), pamelor (nortriptyline), tofranil (imipramine), and norpramin (desipramine). They are also used in the treatment of neuropathic pain and can be of added benefit for patients suffering from pain. However, they tend to have more side effects than some of the newer antidepressants and more drug interactions, which are important factors to consider with ongoing cancer treatment. Their side effects include sedation, dry mouth, constipation, and nausea, among others. You can see why they are not considered the most ideal for patients with cancer if there are better alternatives.
The SSRIs include medications like prozac (fluoxetine), paxil (paroxetine), zoloft (sertraline), and celexa (citalopram). They do not have as many side effects as the TCAs and are better tolerated; they are the preferred antidepressant to initially treat depression in cancer patients. However, their onset of action is quite slow; it usually takes 3-6 weeks for the full therapeutic benefit.
Other antidepressants include wellbutrin (bupropion), effexor (venlafaxine), remeron (mirtazapine), and trazodone. These are not as commonly used as first-line in cancer patients with depression, and they each have a different mechanism of action. I would highlight that remeron has the particular side effect of weight gain and can be particularly helpful for a patient who has depression and weight loss. One of the newest antidepressants is cymbalta (duloxetine); it has garnered attention for its use in the treatment of pain as well as depression and is being used instead of TCAs for patients with both depression and pain.
Psychostimulants are an additional class of medication to consider for depression and are more “activating.” They include ritalin (methylphenidate), dexedrine (dextroamphetamine), and provigil (modafinil). They are used to promote alertness and improve energy and mood; they’re also used to mediate the sedating effects of opioids for some patients. One of their main advantages is their rapid onset of action—they work quickly and are short-acting (dosed multiple times during the day). This is particularly helpful if 3-6 weeks will be too long for a patient to wait for relief or if their prognosis is limited to weeks.
This post is certainly not exhaustive, but rather is a broad overview of a big and important topic. I welcome your comments and questions.
4 Responses to Depression in Cancer: Does it come with the territory?
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Dr. Harman -
Thank you for another informative post! So far, I’m combatting my cancer-induced depression mostly behaviorally. I still work full time at a job I love, which gives me a reason to get up each weekday morning. Appetite still good. Worthwhile social interactions, WONDERFUL family support, good pain control, and ability to function on my own (e.g., driving, buying groceries) — except during days when maintenance chemo (Alimta and Zometa) side effects are bad. I’ve seen counselors at my HMO, but both of the counselors I really liked have now retired or moved on, so I need to find another good one and that’s not easy. The one thing I wish I could do is exercise. I used to love it (pre-diagnosis); just cannot get motivated any more. But in many ways, I am very, very fortunate.
I do cry frequently and still get very angry occasionally about having lung cancer then I move on for awhile. On rare occasion, I consider the “turning point” at which I would want to end my life (e.g., severe brain mets) and how I might do so, but don’t dwell on this. I understand that these are mostly normal reactions to a life-threatening illness and will probably occur in some form throughout the course of this disease.
My oncologist has prescribed Ativan, as needed, for anxiety and it also helps relax/open blood vessels just before IV treatment every 3 weeks. I’m pretty judicious about taking it, but could it be considered a useful drug in handling depression as well? Is there a “best” way to be using it?
Though I’ve been pretty much able to cope and redirect hope (as you mention in your post), are there specific symptoms that would indicate discussing antidepressant medications with my oncologist or primary care MD? I don’t want to take any more drugs than necessary, or anything BEFORE I really need it, but I also want to take advantage of worthwhile drugs that might be available to make my life a little easier.
- Catharine
Dear Catharine,
I’m sorry for the delay in my reply. Thank you for the feedback on my post.
Ativan is generally not thought of as a stand-alone treatment for depression, but as depression and anxiety are often co-existing, it can be helpful for some of the cognitive symptoms of depression. In terms of its “best” usage, I think it’s important to keep in mind that it is a short-acting drug so it’s better for episodes of anxiety. If a patient is taking ativan multiple times daily for anxiety for a prolonged period of time, a more long-acting anti-anxiety medication would work better.
In terms of specific symptoms that would trigger an evaluation for depression, I would have a low threshold if you begin to have feelings of worthlessness, hopelessness, and/or guilt that invade your normal functioning; thoughts of actively hastening death; or if your mood is depressed the majority of the time. It sounds like you have had success with the behavioral approach to your symptoms and as you said, your reactions have been normal. Planning for end-of-life care as you mention is NOT the same as thinking of hastening death. Another way to describe some of your reactions is that there is often normal grief after the diagnosis of cancer–grief for the loss of what your life had been before the cancer, grief for the loss of your exercising, for example. I understand that your reluctance to add a medication to your regimen.
I applaud you for being proactive about your symptoms and your coping–that can be hard to do when dealing with cancer.
-Dr. Harman
Dr. Harman -
No problem with the timing of your response. I sincerely appreciate your feedback. Will continue to use the Ativan only for episodic anxiety and at the time of Alimta infusions. The oncology RNs comment that they like when patients come to the infusion clinic as relaxed as possible (e.g., Ativan and meditation in my case) and also try to have veins available as “targets”, e.g., applying heating pad on the way to clinic, etc. I don’t have prominent veins and every little bit helps to make their job easier — and less poking and prodding is better for me too. If it appears that I’ll be on Alimta long term, we will consider a port.
Thank you for pointing out those threshold feelings as well and what to watch for.
This is not the way I’d planned to live this part of my life, but my choice is to cope and do the best I can for as long as I am able. Thankfully, I have wonderful resources to draw upon (family, friends, some of the medical professionals at my HMO, Internet sites like GRACE). Going through this without those assets would be hell on earth.
I’m kind of where you are Catharine – despite a crappy diagnosis, everything is pretty much ok. The crybaby episodes were really problematic at first, but the doctor told me I was also going through “chemo-pause”. If you had asked me in July if I would miss my period if it went away, I would have laughed. I think I’m just tired of having things taken away. So the crybaby stuff is probably hormonal. I’ve NEVER been a cryer – unless I was manipulating my husband – so it’s hard to get used to. And yeah – cancer qualifies as a trigger for reactive depression. I also have set a baseline for terminating treatments and completing my journey. May be years from now, but I think a little planning puts things back in my control. I feel better knowing that things can’t get any worse than I choose to allow them to. Thank you Dr. Harman for a helpful list of medications in case things get worse.