Depression

Often a patient does not know if he or she is depressed, or if the depression is related to being diagnosed with cancer. The following information explains what depression is, what the symptoms are, and how it can be treated.

How common is depression?

It is estimated that close to 10% of Americans will experience depression sometime in the course of their lifetime. Depression is more common for people with cancer—as many as 15% to 25% of people with cancer experience depression at some point during treatment.

What is depression?

Depression is defined as having a low mood and/or feeling numb consistently for more than two weeks—every day and pretty much all day long—so that activities that used to interest you no longer do, your concentration is affected, your sleep and appetite are affected, and you feel nothing you do can make you feel better. Crying every day for two consecutive weeks is another common symptom of untreated depression.

Although depression is more common among people with cancer, there are many misconceptions about cancer and depression. Not all people with cancer are depressed. Similarly, depression is not considered a normal part of living with cancer. Although it is common to be sad, frustrated, or even angry, depression is a treatable, biologic disorder—just like cancer.

Depression can occur around the time of diagnosis or anytime during or after treatment. People with milder forms of depression usually respond well to support and reassurance from friends, family, and support groups. Cancer is typically associated with multiple losses and often leads to grieving. Grief is common for people with cancer; they often have a period of grieving for their health and for the multiple losses they experience as a result of the diagnosis and treatment. Examples include emotional losses, such as security about the future; physical losses such as those that may occur from cancer surgery or hair loss from chemotherapy; and financial losses due to the expense of cancer treatment.

People with more serious or clinical depression typically do not respond to encouragement and often have a loss of ambition or interest in things that were once enjoyable. It affects mood (such as happiness, sadness), thinking (such as decreased concentration or negative thoughts, including thoughts of suicide), behavior (such as the loss of motivation), and physical functions (such as sleep and appetite). Clinical depression is treatable with psychological treatment, medication, or a combination of these treatments.

What causes depression?

People living with cancer deal with an enormous amount of uncertainty and fear, changes in family and relationships, economic challenges, and the difficulties of treatment. This stress may trigger mood changes or depression. Some treatments for cancer can cause changes in sleep and a person’s mood, contributing to depression.

What are the symptoms of depression?

Many people who experience depression feel sad; however, not all people with clinical depression experience sadness. Other symptoms of depression include:

Group 1: Mood symptoms

• Feelings of sadness, helplessness, or hopelessness
  
  
• Irritability
  
  
• Feelings of guilt or worthlessness

Group 2: Cognitive (thought-process) symptoms

• Decreased ability to concentrate (for example, inability to read the newspaper)
  
  
• Decreased memory (for example, inability to remember basic and useful facts)
  
  
• Suicidal thoughts, in extreme cases (for example, thoughts or plans to end one's life)

Group 3: Physical symptoms

Some of the physical symptoms listed below are difficult to recognize because they can also be caused by the cancer or the treatment of cancer.

• Fatigue or low energy
  
  
• Poor appetite
  
  
• Feeling slowed down
  
  
• Inability to experience pleasure

Group 4: Behavioral symptoms

• Social withdrawal
  
  
• Crying spells
  
  
• Loss of interest
  
  
• Decreased sex drive

How is depression diagnosed?

Diagnosing clinical depression relies mostly on several core symptoms, including low mood, loss of interest in usual activities, inability to experience pleasure, sleep disturbance, fatigue, and frequent and repeated crying. Because the physical symptoms can also be caused by cancer treatments, there is more emphasis on the psychological symptoms, such as loss of interest, crying spells, and hopelessness, in diagnosing depression for people with cancer.

Clinical depression can range from mild (with a few of the depressive symptoms described above) to more severe, called major depression. Major depression interferes with a person's relationships and ability to carry out their usual responsibilities. People with milder forms of depression are better able to carry out daily activities, but they may not recognize depression or seek treatment, which makes it harder to diagnose. Some people with milder forms of depression are reluctant to ask for help because they may blame themselves for not being able to improve their mood. It is important to recognize that most people cannot improve their mood without treatment and support.

How can depression affect cancer treatment?

Clinical depression can worsen the physical effects caused by cancer, sometimes increasing the losses experienced by the patient. For example, fatigue caused by depression can worsen the fatigue caused by treatments. Indecision is often a symptom of depression that affects a person’s ability to make choices about cancer treatments. In addition, depression affects a person’s quality of life and undermines the emotional and physical strength often required to undergo treatment. However, depression does not cause cancer to grow or spread unless the person has difficulty making treatment decisions or does not follow treatment recommendations.

How is depression treated?

Emotional and social support helps people to better cope with cancer, but depression and anxiety need specialized treatment. Before selecting the most appropriate treatment option for depression, a doctor needs to make a proper assessment. Just as there are staging and diagnostic tests that are necessary for diagnosing cancer, there are specific questions and tests used to diagnose depression and guide treatment recommendations.

Counseling

Combined psychological treatment and medication is the primary treatment option for people with severe depression. For people with milder depression, talking with a therapist may be helpful. The primary goal of psychological treatment is to enhance coping and problem-solving skills, help find support, and help reshape negative or self-defeating thoughts. Types of psychological treatments include individual psychotherapy and cognitive-behavioral therapy (recognizing and reducing negative thoughts that contribute to depression).

Medications

Although nearly 15% to 25% of people with cancer experience depression, only 2% receive treatment with antidepressants. Antidepressants usually take up to six weeks to start working, and may not be able to effectively treat depression unless combined with psychological treatment.

If medication is recommended, the doctor will select the most appropriate antidepressant based on the patient’s needs and medical history. The possible side effects and interactions with other medications are also considered.

There are different types of antidepressant medications available. Below is a description of each type, along with common side effects. Side effects can usually be managed by adjusting the doses of medications or, in some cases, switching to a different medication.

Selective serotonin reuptake inhibitors (SSRIs). SSRIs such as fluoxetine (Prozac) and a combination of fluoxetine and olanzapine (Symbyax), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), and paroxetine (Paxil, Pexeva) allow the body to build up serotonin (a neurotransmitter) levels, and make the best use of the limited amount it has at the time. The most common side effects include nausea, insomnia (inability to fall asleep or stay asleep), headache, and sexual dysfunction.

Serotonin norepinephrine reuptake inhibitors (SNRIs). Similar to SSRIs, SNRIs such as venlafaxine (Effexor), duloxetine (Cymbalta), and mirtazapine (Remeron) increase levels of norepinephrine (a neurotransmitter) and serotonin. Potential side effects of SNRIs include nausea, headache, dry mouth, drowsiness, and tremors.

Serotonin antagonist reuptake inhibitors (SARIs). SARIs such as nefazodone (Serzone) and trazodone (Desyrel) block serotonin from attaching to the receiving nerve or neuroreceptor, increasing the level of serotonin. Side effects of nefazodone include dry mouth, dizziness, sedation, stomach upset, and a decrease in blood pressure when standing up. Trazodone is infrequently associated with a condition that causes a painful, continued erection in men.

Tricyclic antidepressants. Tricyclic antidepressants include amitriptyline (Elavil, Endep), imipramine (Tofranil), nortriptyline (Aventyl, Pamelor), desipramine (Norpramin), and clomipramine (Anafranil). These antidepressants raise serotonin and norepinephrine levels in the brain. Some of the possible side effects of tricyclic antidepressants include dry mouth, dizziness, decrease in blood pressure when standing up, tiredness, and weight gain.

Monoamine oxidase inhibitors (MAOIs). MAOIs such as phenelzine (Nardil) and tranylcypromine (Parnate) are rarely used for people with cancer, since this class of drug often interacts with other drugs and foods. MAOIs block the action of monoamine oxidase, a chemical in the body that breaks down neurotransmitters. The most common side effects of MAOIs include a decrease in blood pressure when standing up and insomnia, both of which may not develop for three to four weeks after beginning therapy.

Stimulants. Stimulant medications such as methylphenidate (Concerta, Metadate, Methylin, Ritalin) and dextroamphetamine (Dexedrine, Dextrostat) are sometimes used to treat depressive symptoms for people with cancer. These medications increase a certain type of neurotransmitter. Stimulants may be used because they work more quickly than antidepressants and may improve energy and appetite. Common side effects of stimulants include nervousness, headache, appetite changes, insomnia, constipation, and changes in blood pressure and heart rate.

Over-the-counter drugs and herbal supplements. People with cancer should avoid over-the-counter drugs and herbal remedies, such as St. John's wort. Read the National Center for Complementary and Alternative Medicine (NCCAM) Fact Sheet on St. John's Wort and Depression.

Learn more about medications through Cancer.Net’s Drug Information Resources, which provides links to searchable drug databases.

Last Updated: September 26, 2008

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