Supportive Care Clinic
What is depression?
Many cancer patients experience times of sadness and emotional turmoil. Since sadness is common, it is important to understand the difference between sadness and depression. Depression occurs in about 15-25% of cancer patients and is characterized by the following symptoms which have lasted for two weeks or more:
- Depressed mood for most of the day on most days
- Decreased interest and pleasure in most activities
- Feelings of worthlessness or excessive guilt
- Recurrent thoughts of death or suicide
- Significant change in appetite and sleep patterns (may be due to disease or treatment)
- Psychomotor agitation or slowing (may be due to disease or treatment)
- Fatigue (may be due to disease or treatment)
- Poor concentration (may be due to disease or treatment)
Sometimes it is difficult to determine if a patient’s symptoms are due to cancer and cancer treatment, or to depression. Many cancer patients can experience fatigue, changes in sleep or appetite, changes in speed of movement or thinking, or poor concentration without being depressed. But they may experience repeated guilty thoughts (example: “I deserve this punishment”), worthlessness (example: “I have failed my family”), or hopelessness (example: “I know I’ll never make it, even though the doctor says my prognosis is excellent”). They may experience a loss of interest or enjoyment in most activities, a sad or blue mood, or a preoccupation with death, with or without suicidal thoughts. If so, they are probably depressed.
What can help?
Depression generally improves with treatment, and any patients experiencing these symptoms for two or more weeks should be treated in order to improve their quality of life. Both psychotherapy and medication have been shown to be useful in treating depression in cancer patients.
The Vanderbilt Psychological Oncology Team uses cognitive-behavioral therapyto treat depression. This therapy focuses on the thoughts and mental images that the person has which contribute to feelings of guilt, worthlessness, hopelessness and helplessness. The patient learns to identify these dysfunctional thoughts and replace them with more helpful or more realistic thoughts. Other techniques include increasing activity levels and scheduling pleasant events.
For example, John’s family reported that since he was diagnosed, John had been waking up at 3 a.m. and staying awake, and had been losing weight because he was eating much less. He did not want to participate in any family get-togethers, and had stopped playing his guitar with friends. When we talked to John, he shared that he felt worthless and guilty because he was temporarily unable to work. He also had a negative expectation about his cancer outcome, even though he actually had a very good prognosis. Therapy focused on changing his dysfunctional thoughts and increasing his rewarding experiences. He began reminding himself that he was valuable whether he worked or not, and that his family and friends did not judge him based on his ability to work. He also learned to stop blaming himself for having cancer and to focus instead on the things that he could do to cope with treatment and promote better health. When he had a negative thought about his cancer outcome, he learned to replace it with the thought that he might actually have a good outcome, and that he would find a way to cope with issues as they arose, and spent much less time focusing on the negative “what-ifs”. In addition, John began going to family events, and invited friends to his house again to play music. He found that he enjoyed these activities and that his mood improved. He began to get more restful sleep and returned to a more normal sleep pattern. He did, however, find that the cancer treatment reduced his appetite, and met with the dietician to find ways to improve his nutrition and stabilize his weight.
There are many different types of antidepressants, and the choice of which to use depends on the patient’s medical history and current medical problems, depressive symptoms, side effects of antidepressants, and past response to antidepressants. These medicines must be taken regularly, and do not have immediate effect. Generally, patients should notice improvement in some depressive symptoms in 14-21 days, but full therapeutic effect may take up to 6 weeks. If no improvement is seen, the dosage may be increased or a different antidepressant may be tried. These drugs are not addictive, but SHOULD BE TAPERED when treatment is discontinued. Sometimes these drugs produce side effects, which are typically mild, and which may improve over time or with a reduction in dosage.
Certain antidepressants may also be prescribed to reduce pain or improve sleep.