Depression related to cancer
Depression often goes unrecognized and untreated in the physically healthy and even more so in those with life-threatening illnesses. At least 1 in 4 people with advanced cancer has some degree of depression and about 13% has severe depression. However, this is often not recognized due to the commonly held belief that depression is a normal response to cancer. "Wouldn't you be depressed if you had cancer and were dying?" is the way the mood disorder is often rationalized.
When cancer is diagnosed most patients experience a short period of shock and disbelief followed by symptoms such as sadness, depressed mood, anxiety, anorexia, insomnia, and irritability that may last up to 2 weeks. These normal feelings will cause some people to have trouble carrying out daily activities. However, by 2 or 3 weeks most people have adapted to their new life and they return to almost normal function although symptoms of sadness and anxiety can recur intermittently.
If the disease progresses or relapses, these same feelings tend to occur again. At these transition phases of the illness, a person is more susceptible to prolonged feelings of low mood, insomnia, and sadness that cause significant dysfunction. This is described as an adjustment disorder and generally resolves with support and counseling. If the depressed mood is severe and the person has hopeless feelings and persistent suicidal thoughts then a major depression is present.
Neither an adjustment disorder or a major depression is an expected response to cancer. Neither of these disorders are normal in a patient with a terminal illness.
Depression is more difficult to diagnose in those with cancer, as many of the physical signs associated with depression can also be caused by the cancer. Loss of appetite, poor sleep, fatigue, and pain can all be caused by cancer or its treatment.
The diagnosis of depression relies more on mental symptoms and suicide risk, and is often a difficult judgment especially in end-stage cancer when physical weakness is present with depression.
Some risk factors for depression with cancer are:
- male sex (in the general population depression is twice as common in women as in men)
- younger age
- past history of depression
- physical disability
- psychological factors such as seeing oneself as the victim or negative self-identity
- limited family and friend support
Causes of mood alterations
There are several complications of cancer and its treatment that can cause or exacerbate an alteration in mood.
Uncontrolled pain: This can cause the person to be anxious, despairing of relief of their suffering, and at times suicidal. The suicide risk is genuine and can be interpreted as the person seeking "death with dignity." Good palliative care can relieve pain and other kinds of suffering leading to resolution of the depressive symptoms and an improved quality of life. The presence of depression also amplifies pain.
Metabolic disturbances: Hypercalcemia (high calcium level in the blood), anemia and liver failure caused by the cancer can cause mood alterations.
Medications: Medications such as prednisone and dexamethasone that are given with chemotherapy as well as several chemotherapy medications given for cancer treatment can cause depressive symptoms. Tamoxifen, a medication commonly used in breast cancer, can trigger depression secondary to shutting off the body's normal production of estrogen.
Physical changes: Changes in physical form due to the cancer or its treatment, such as mastectomy, can have a large impact on the psyche. The person who is ill will often wonder if they are still attractive to their partner and may feel a disabling self awareness. Often people who lose their physical independence may feel a burden to others or fear that they are no longer meaningful to their loved ones.
Psychological and social changes: Changes in the life of the person with cancer, like being away from work or not being able to do the usual roles at home, may affect the person's self-esteem. As well, the spiritual side of a person may be deeply affected by their illness. If much of the meaning in life was placed in their work and they are no longer able to be there, they will suffer a great loss of meaning.
How to help
Supportive listening is often all that is necessary to help someone through the initial stages of shock and sadness. Indeed sometimes this can be difficult because the person seems to return to the same issues many times. However, patience is usually rewarded and the person improves after several weeks. If these feelings of shock and sadness persist for weeks on end and the person is not able to function in their usual way, it is time to seek help.
In someone who has advanced illness and eats little and has very little activity it is more difficult to determine if they are depressed. Loss of appetite, sleep and activity may be due to the symptoms of the illness. However, loss of interest in things that always interested them, feelings of hopelessness, worthlessness and thoughts of suicide are good indicators of depression. Even those who are at the end of their life can take pleasure in many things, providing their physical symptoms are well controlled. Do not assume that these are the natural thoughts of one who is dying. Help should be sought even in the last days or weeks as treatment is available and can improve the person's quality of life.
The goal of treatment is to have people living full quality of life. Treatment of depression is one way in which we can improve the lives of those who have cancer.
Romayne Gallagher, MD
in association with the MediResource Clinical Team