© 2005-2012 American Society of Clinical Oncology (ASCO). All rights reserved worldwide.
Listen to the Cancer.Net Podcast: Cancer and Depression, adapted from this content.
- Depression is a common, treatable side effect among people with cancer.
- It is important to talk with your health care team if you are experiencing symptoms of depression.
- Depression is most often managed by counseling, medication, or a combination of these two treatments.
- Getting involved in a support group may also help relieve symptoms of depression.
Depression is a distressful disorder characterized by feelings such as sadness, apathy, guilt, hopelessness, and irritability that persists consistently for more than two weeks and negatively affects one’s daily activities and relationships.
Depression and cancer
Approximately 10% of Americans experience depression. However, depression is more common among people with cancer who often struggle to cope with uncertainty, fear, grief, physical changes, treatment-related challenges, relationship changes, and financial burdens. In addition, some cancer treatments may cause sleep and mood changes, contributing to and/or making the depression worse. As many as 15% to 25% of people with cancer experience depression.
Although depression is more common among people with cancer, it should not be considered an acceptable part of living with cancer. Identifying it and then managing it are important for improved quality of life during the cancer process. For those who are depressed, a variety of treatment options are available.
Symptoms of depression
Depression may occur near the time of diagnosis or anytime during or after treatment. The diagnosis of depression is based on mood-related, cognitive, physical, and behavioral symptoms. For example, people with depression may experience the following:
Mood-related symptoms. These include feelings of sadness, hopelessness, irritability, numbness, or worthlessness.
Cognitive symptoms. These include a decreased ability to concentrate, indecision (difficulty making decisions), memory problems, and negative thoughts (including thoughts of suicide, in extreme situations).
Behavioral symptoms. These include frequent crying, social withdrawal, loss of interest in activities that you previously enjoyed, and loss of motivation.
Physical symptoms. These include fatigue, appetite loss, insomnia (the inability to fall asleep and stay asleep) or hypersomnia (excessive sleepiness), and sexual problems, such as decreased libido (sexual desire).
However, having these physical symptoms does not necessarily mean that you are depressed; they may be side effects of the cancer or cancer treatment. Similarly, cancer and cancer treatment may cause cognitive symptoms such as decreased ability to concentrate and memory problems. As a result, more emphasis is placed on mood-related and behavior symptoms when diagnosing depression in people with cancer.
Clinical depression ranges from mild (with a few of the depressive symptoms described above) to severe. Severe depression, also called major depression, interferes with a person's relationships and ability to fulfill responsibilities. People with milder forms of depression are better able to carry out daily activities, but they may not recognize depression or seek treatment. Instead, they may blame themselves because they cannot improve their mood.
It is important to recognize that most people with depression find it difficult to improve their mood without treatment and support.
How depression affects cancer treatment
Clinical depression may worsen the physical side effects of cancer treatment. For example, fatigue caused by depression may heighten fatigue caused by cancer treatment. Meanwhile, indecision caused by depression may affect a person’s ability to make choices about cancer treatments. Depression also affects a person’s quality of life and undermines the emotional and physical strength often required to undergo treatment.
Although support from family, friends, and support groups helps many people better cope with cancer, people with depression need specialized treatment. A combination of counseling and medication is often the most effective treatment approach for people with severe depression. For people with milder depression, simply talking with a counselor may be enough to alleviate the distressing symptoms.
Just as there are diagnostic and staging tests that are necessary to diagnose cancer, specific questions and tests are used to diagnose depression and guide treatment recommendations. Your health care team will assess you with these tools to select the most appropriate treatment.
The primary goal of counseling is to enhance coping and problem-solving skills, develop a support system, and reshape negative or self-defeating thoughts. Options include individual counseling, couples or family counseling, and group counseling.
Different types of antidepressant medications are available. Your doctor will select the most appropriate antidepressant based on potential side effects, your needs, current medications, and medical history. Tell your doctor about all medications and supplements you are taking because they may interfere with some types of antidepressants.
Although some people experience improvement within a couple weeks of starting an antidepressant medication, it often takes up to six to eight weeks for the medication to have its full effect. In addition, medication may not sufficiently treat depression unless it is combined with psychological treatment.
Below is a description of each class of antidepressant medications, along with common side effects. Side effects are often managed by adjusting the dose of medication or, in some cases, switching to a different medication.
Selective serotonin reuptake inhibitors (SSRIs). These include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Prozac Weekly, Rapiflex, Sarafem, Selfemra), paroxetine (Paxil, Paxil CR, Pexeva), and sertraline (Zoloft), which increase the level of serotonin available in the brain. Serotonin is a type of neurotransmitter, which is a chemical that travels between brain cells to communicate information which helps alleviate symptoms of anxiety. Side effects of SSRIs may include dry mouth (generally with paroxetine), nausea, insomnia, headache, and sexual dysfunction and are often avoided by starting at lower doses of the medication. (Your doctor will make the judgment on the best starting dose.)
Bupropion (Aplenzin, Wellbutrin, Wellbutrin SR, Wellbutrin XL). This medication is another type of antidepressant. The most common side effects may include ringing in the ears, excitability, weight loss, and excessive sweating.
Serotonin norepinephrine reuptake inhibitors (SNRIs). These include duloxetine (Cymbalta) and venlafaxine (Effexor, Effexor XR), which increase the levels of norepinephrine (another type of neurotransmitter) and serotonin available in the brain. A drug in the same family called mirtazapine (Remeron, Remeron SolTab) may be used at low doses as a sleep aid. Common side effects include nausea, headache, dry mouth, sweating, and with duloxetine, stomach cramps. Rarely, a person may experience tremors.
Tricyclic antidepressants. These medications are generally used to treat pain or as sleep aids and not to treat depression. These include amitriptyline (Elavil, Endep, Vanatrip), clomipramine (Anafranil), desipramine (Norpramin), imipramine (Tofranil, Tofranil PM), and nortriptyline (Aventyl, Pamelor), which increase the levels of serotonin, norepinephrine, and dopamine available in the brain. Common side effects of tricyclic antidepressants include dry mouth, dizziness, a decrease in blood pressure when standing up, fatigue, and weight gain.
Monoamine oxidase inhibitors (MAOIs). These include phenelzine (Nardil) and tranylcypromine (Parnate), which block the action of monoamine oxidase, a chemical in the body that breaks down neurotransmitters. However, MAOIs are rarely used for people with cancer because this class of drug often interacts with other drugs and foods. Common side effects of MAOIs include a decrease in blood pressure when standing up and insomnia, both of which may not develop until three to four weeks after beginning the medications.
Learn more about specific medications by searching drug databases.